AAPC – CPB – CHAPTER 2 PRACTICAL APPLICATION – FULL QUESTIONS AND
ANSWERS – QUESTIONS 1 TO 15
QUESTION# 1
Susan wakes up this morning with sharp pain and ringing in her ears. She calls her
otolaryngologist to make an urgent appointment for later that day. The
otolaryngologist’s staff makes Susan an appointment for later than morning. Susan has
an HMO insurance and calls her primary care provider (PCP) to request a referral to the
specialist. The PCP office refuses to issue the referral and offers the patient a same-day
visit with the PCP. Which of the following statements is TRUE for a patient with an HMO
insurance?
A. The patient should not have called the PCP. She could have gone to see
the specialist without a referral and paid a higher out-of-pocket
expense.
B. The patient did not need to notify the PCP. HMO patients are able to
see any provider they choose at any time.
C. Correct: The PCP was correct to offer the patient a same-day
appointment to assess the condition before issuing a referral.
D. The PCP’s office should have issued the referral immediately since the
patient already had an appointment scheduled.
Feedback: Rationale: Susan has an HMO insurance. In an HMO, the PCP acts
as the gatekeeper to manage all of Susan’s health conditions. The PCP’s role
is to evaluate the patient, treat what they can in the office, and only refer to
specialists for conditions they are unable to manage or treat themselves.
QUESTION# 2
Mr. Jones is undergoing radiation therapy at University Hospital. Mr. Jones has
Medicare, and even though University Hospital does not participate with
Medicare, he opts to proceed with radiation treatment as the facility is the
closest to his home. Mr. Jones receives a check in the mail for $15,000. Why
would this happen?
A. Doctor marked the claim as patient pay.
B. Correct: The provider does not participate with the health plan and
filed an unassigned claim to the plan.
C. The provider filed the claim as assigned which directs the insurance
carrier to pay the patient directly.
, D. The provider participates with the plan.
Feedback: Rationale: When a provider participates with a health plan, it is
called accepting assignment, which means they will accept the health plan
fee determination for all covered services; they must write-off the difference
between their charges and the plan’s rate for the services. If a provider does
not participate with the health plan, the physician can bill the patient directly
for services rendered. The amount the plan can bill is different between
commercial insurance and Medicare; however, in both cases, a non-
participating provider can file an “unassigned” claim to the plan on the
patient’s behalf. The patient will typically receive the reimbursement directly
from the plan.
QUESTION# 3
Dr. Dean sees Mrs. Jones today for a punch biopsy of a lesion on her arm. He
does not participate with Medicare, but he files a claim for $155 to Medicare
on her behalf. Since he does not participate, he files the claim as unassigned.
The payment will be directed to Mrs. Jones by Medicare. Based on the
Medicare fee schedule below, how much can Dr. Dean charge the patient?
HCPCS MODIFIE SHORT NON- FACILITY NON- FACILITY
CODE R DESCRIPTIO FACILITY PRICE FACILITY LIMITING
N PRICE LIMITING CHARGE
CHARGE
11104 PUNCH BX $126.32 $48.53 $138.00 $53.02
SKIN
SINGLE
LESION
A. $126.32
B. Correct: $138.00
C. $155.00
D. Because he does not participate with Medicare, he is not entitled to
any payment for services. He should not be seeing the patient.
Feedback: Rationale: When a provider participates with a health plan, it is
called accepting assignment, which means they will accept the health plan
fee determination for all covered services. They must write-off the difference
between their charges and the plan’s rate for the services. If a provider does
not participate with the health plan, the physician can bill the patient directly
ANSWERS – QUESTIONS 1 TO 15
QUESTION# 1
Susan wakes up this morning with sharp pain and ringing in her ears. She calls her
otolaryngologist to make an urgent appointment for later that day. The
otolaryngologist’s staff makes Susan an appointment for later than morning. Susan has
an HMO insurance and calls her primary care provider (PCP) to request a referral to the
specialist. The PCP office refuses to issue the referral and offers the patient a same-day
visit with the PCP. Which of the following statements is TRUE for a patient with an HMO
insurance?
A. The patient should not have called the PCP. She could have gone to see
the specialist without a referral and paid a higher out-of-pocket
expense.
B. The patient did not need to notify the PCP. HMO patients are able to
see any provider they choose at any time.
C. Correct: The PCP was correct to offer the patient a same-day
appointment to assess the condition before issuing a referral.
D. The PCP’s office should have issued the referral immediately since the
patient already had an appointment scheduled.
Feedback: Rationale: Susan has an HMO insurance. In an HMO, the PCP acts
as the gatekeeper to manage all of Susan’s health conditions. The PCP’s role
is to evaluate the patient, treat what they can in the office, and only refer to
specialists for conditions they are unable to manage or treat themselves.
QUESTION# 2
Mr. Jones is undergoing radiation therapy at University Hospital. Mr. Jones has
Medicare, and even though University Hospital does not participate with
Medicare, he opts to proceed with radiation treatment as the facility is the
closest to his home. Mr. Jones receives a check in the mail for $15,000. Why
would this happen?
A. Doctor marked the claim as patient pay.
B. Correct: The provider does not participate with the health plan and
filed an unassigned claim to the plan.
C. The provider filed the claim as assigned which directs the insurance
carrier to pay the patient directly.
, D. The provider participates with the plan.
Feedback: Rationale: When a provider participates with a health plan, it is
called accepting assignment, which means they will accept the health plan
fee determination for all covered services; they must write-off the difference
between their charges and the plan’s rate for the services. If a provider does
not participate with the health plan, the physician can bill the patient directly
for services rendered. The amount the plan can bill is different between
commercial insurance and Medicare; however, in both cases, a non-
participating provider can file an “unassigned” claim to the plan on the
patient’s behalf. The patient will typically receive the reimbursement directly
from the plan.
QUESTION# 3
Dr. Dean sees Mrs. Jones today for a punch biopsy of a lesion on her arm. He
does not participate with Medicare, but he files a claim for $155 to Medicare
on her behalf. Since he does not participate, he files the claim as unassigned.
The payment will be directed to Mrs. Jones by Medicare. Based on the
Medicare fee schedule below, how much can Dr. Dean charge the patient?
HCPCS MODIFIE SHORT NON- FACILITY NON- FACILITY
CODE R DESCRIPTIO FACILITY PRICE FACILITY LIMITING
N PRICE LIMITING CHARGE
CHARGE
11104 PUNCH BX $126.32 $48.53 $138.00 $53.02
SKIN
SINGLE
LESION
A. $126.32
B. Correct: $138.00
C. $155.00
D. Because he does not participate with Medicare, he is not entitled to
any payment for services. He should not be seeing the patient.
Feedback: Rationale: When a provider participates with a health plan, it is
called accepting assignment, which means they will accept the health plan
fee determination for all covered services. They must write-off the difference
between their charges and the plan’s rate for the services. If a provider does
not participate with the health plan, the physician can bill the patient directly
