AAPC CPB Exam Questions and Answers 2023

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? - Answer- A deductible is the amount a policyholder pays for health care services before the health insurance begins to pay. Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? - Answer- Medical malpractice insurance is a type of liability insurance that covers physicians and other healthcare professionals for liability as to claims arising from patient treatment. Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. - Answer- I, IV, V, and VI, Group health insurance coverage is a type of health policy that is purchased by an employer and is offered to eligible employees of the company, and to eligible dependents of employees. With group health insurance, the employer selects the plan (or plans) to offer to employees. With an individual policy, you are the only one who can make changes to your policy and you are the only one who can cancel the coverage. You have full control over your own policy. Applicants for individual health insurance will need to complete a medical history questionnaire and have a physical exam when applying for coverage. Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? - Answer- Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan What is the deadline for filing a Medicare claim? - Answer- One year from the date of service A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? - Answer- . $60.00 What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? - Answer- Utilization Review Organization Medicaid providers are forbidden by law to: - Answer- Balance bill patients Which statement is FALSE about Local Coverage Determinations (LCDs)? - Answer- CMS develops LCDs when there is no National Coverage Determination When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered? - Answer- 10-day global period - the day of the procedure and 10 days following the procedure. View Rationale Question 11 If add-on procedure code 11103 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? - Answer- Code 11103 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? - Answer- Either 1995 or 1997 CMS documentation guidelines Select the scenario that meets the incident-to requirements - Answer- Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? - Answer- G0121 Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers - Answer- I, II, IV, V and VI According to CPT® Radiology Guidelines, if a patient is given oral contrast for a CT scan of the abdomen which code is reported? - Answer- 74150 Computed tomography, abdomen; without contrast material Which of the following is NOT in the HIPAA Privacy Rule? - Answer- Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act? - Answer- False Claims Act Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? - Answer- Fraud; the provider intentionally over-coded to gain financially What is a Qui tam relator? - Answer- A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare