CERTIFIED HEALTHCARE CONSTRUCTOR EXAM
STUDY GUIDE QUESTIONS
2025/2026 UPDATED
2.
"Incident To" services - ANS-services commonly furnished in a physician's office by a
nurse practitioner in which there is direct physician personal supervision and are billed
under the physician's provider number (does not apply in hospital setting)
physician must be present to bill (*)
Two-Midnight Rule - ANS-CMS will consider a claim as inpatient if the patient in hospital
bed over two midnights
72 Hour Rule/3 Day Window Project (*) - ANS-all diagnostic outpatient charges and
other related outpatient charges within 72 hours prior to an inpatient admission are
bundled into inpatient stay reimbursement
False Cost Reports (*) - ANS-submission of charges to Medicare which are unrelated to
medical care, such as administrative overhead
Credit Balances - Failure to Refund (*) - ANS-provider has 60 days to refund credit
balances (*)
PPS Transfer Project - ANS-PPS transfer of patient (rather than discharge) and
receiving payment
Advance Beneficiary Notice (ABN) - ANS-a written form that a provider gives to a
Medicare beneficiary that informs the beneficiary that Medicare may not pay for an item
or service
,must be provided and signed by patient before services are provided (or provider
cannot bill patient if Medicare denies)
Medicare Secondary Payer Questionnaire - ANS-used to identify the correct insurance
company that must pay health care bills first when Medicare pays second
Hospital Outpatient Cardiac Rehabilitation - ANS-physician must be present during
treatment
DRG Utilization (*) - ANS-DRG utilization should be reviewed when the number of uses
of a particular DRG is outside of the norm or average
The three components of Evaluation and Management (E&M) services (*) - ANS-1.
History
2. Examination
3. Medical Decision Making
Evaluation & Management Codes - ANS-1. subset of CPT codes
2. privileged providers
3. describe complexity of care, place of services, and type of service
Types of History or Examination - ANS-1. Problem Focused (CC & brief history)
2. Expanded Problem Focus
3. Detailed
4. Comprehensive
Complexities of Medical Decision Making - ANS-1. Straight-forward (simple, 1 problem)
2. Low complexity
3. Moderate complexity (may have some complications)
4. High complexity
Initial patient visit (*) - ANS-3 out of 3 key elements of E&M services must be met or
exceeded in order to bill for this type of visit
Established patient visit (*) - ANS-2 out of 3 key elements of E&M services must be met
or exceeded in order to bill for this type of visit
Inpatient Documentation Requirements - ANS-1. sufficient documentation to
demonstrate signs/symptoms were sever enough to warrant inpatient care
2. preexisting medical problems or extenuating circumstances
Factors to Consider When Making the Decision to Admit as Inpatient - ANS-1. severity
of signs and symptoms
2. medical predictability of something adverse happening to the patient
3. need for diagnostic studies
,4. availability of diagnostic procedures at the time and location where patient presents
Medicare Part A - ANS-Part of Medicare that reimburses primarily for inpatient services
provided by institutions such as hospitals and skilled nursing facilities
Medicare Part B - ANS-Part of the Medicare program that reimburses covered physician
and supplier services
Medicare Part C (Medicare Advantage) - ANS-Formerly known as Medicare + Choice,
government managed care program, must have Part B
Medicare Part D - ANS-part of Medicare that reimburses for outpatient prescription
drugs
Medicare Administrative Contractor (MAC) - ANS-Processes Part A and Part B claims
Focused Medical Review (FMR) - ANS-1. determine if documentation supports claim
2. reviews guidelines
Medicaid - ANS-state health insurance that helps many people who can't afford medical
care and pays for some or all of their medical bills
1500 Form - ANS-Non-institutional providers must use this form to bill Medicare,
Medicaid, CHAMPUS, and most private insurance companies
used to bill Part B claims
CMS 1450 or UB-04 - ANS-institutional providers use this form to bill Medicare,
Medicaid, CHAMPUS, and most private insurance companies
used to bill Part A claims
Fiscal Intermediary (FI) - ANS-an insurance company that contracts with CMS to
process Medicare Part A claims - replaced by MACs in 2003
a Carrier - ANS-an insurance company that contracts with CMS to process Medicare
Part B claims - replaced by MACs in 2003
Centers for Medicare and Medicaid Services (CMS) - ANS-HHS agency that establishes
payment policies for providers, conducts research, and evaluates the quality of care
provided to beneficiaries
Conditions of Participation (COP) - ANS-must be in compliance in order to be
reimbursed by CMS
, CMS Allowable - ANS-how much CMS will reimburse for a particular service or
procedure
Third Party Carrier - ANS-entity that processes the claims on behalf of CMS
Disproportionate Share Hospital (DSH) - ANS-hospital that provides larger amount of
care to indigent population
CMS provides increased reimbursement for these hospitals to cover cost of uninsured
patients
Common Working File (CWF) - ANS-information about beneficiaries
Return to Provider (RTP) Report - ANS-indication of error in the claim submitted to CMS
- must be corrected to receive reimbursement
Health Professional Shortage Area - ANS-geographic areas that have been designated
as primary medical care shortage areas where physician who furnish medical care are
entitled to a Medicare incentive payment
Participating Provider/Supplier - ANS-accepts CMS allowable as payment in full for
services
Certificate of Medical Necessity (*) - ANS-physician statement that services are
medically necessary
Assignment - ANS-agreement to accept payment in full - 20% copay, 80% Medicare
Reassignment - ANS-physician is paid a salary and entity receives payment from
Medicare
Coordination of Benefits - ANS-decides primary, secondary, and tertiary payor
Local Coverage Determination (LCD) - ANS-determination of what is a covered service
within a region,
used when there is no national coverage determination
National Coverage Determination (NCD) - ANS-determination of what is a covered
service across the country, overrides local coverage determinations
Medicare Code Editor - ANS-halts the claims process but does not correct errors in
claims
Grouper - ANS-uses all information about the claim (including complications and
comorbidities) to determine the primary DRG
STUDY GUIDE QUESTIONS
2025/2026 UPDATED
2.
"Incident To" services - ANS-services commonly furnished in a physician's office by a
nurse practitioner in which there is direct physician personal supervision and are billed
under the physician's provider number (does not apply in hospital setting)
physician must be present to bill (*)
Two-Midnight Rule - ANS-CMS will consider a claim as inpatient if the patient in hospital
bed over two midnights
72 Hour Rule/3 Day Window Project (*) - ANS-all diagnostic outpatient charges and
other related outpatient charges within 72 hours prior to an inpatient admission are
bundled into inpatient stay reimbursement
False Cost Reports (*) - ANS-submission of charges to Medicare which are unrelated to
medical care, such as administrative overhead
Credit Balances - Failure to Refund (*) - ANS-provider has 60 days to refund credit
balances (*)
PPS Transfer Project - ANS-PPS transfer of patient (rather than discharge) and
receiving payment
Advance Beneficiary Notice (ABN) - ANS-a written form that a provider gives to a
Medicare beneficiary that informs the beneficiary that Medicare may not pay for an item
or service
,must be provided and signed by patient before services are provided (or provider
cannot bill patient if Medicare denies)
Medicare Secondary Payer Questionnaire - ANS-used to identify the correct insurance
company that must pay health care bills first when Medicare pays second
Hospital Outpatient Cardiac Rehabilitation - ANS-physician must be present during
treatment
DRG Utilization (*) - ANS-DRG utilization should be reviewed when the number of uses
of a particular DRG is outside of the norm or average
The three components of Evaluation and Management (E&M) services (*) - ANS-1.
History
2. Examination
3. Medical Decision Making
Evaluation & Management Codes - ANS-1. subset of CPT codes
2. privileged providers
3. describe complexity of care, place of services, and type of service
Types of History or Examination - ANS-1. Problem Focused (CC & brief history)
2. Expanded Problem Focus
3. Detailed
4. Comprehensive
Complexities of Medical Decision Making - ANS-1. Straight-forward (simple, 1 problem)
2. Low complexity
3. Moderate complexity (may have some complications)
4. High complexity
Initial patient visit (*) - ANS-3 out of 3 key elements of E&M services must be met or
exceeded in order to bill for this type of visit
Established patient visit (*) - ANS-2 out of 3 key elements of E&M services must be met
or exceeded in order to bill for this type of visit
Inpatient Documentation Requirements - ANS-1. sufficient documentation to
demonstrate signs/symptoms were sever enough to warrant inpatient care
2. preexisting medical problems or extenuating circumstances
Factors to Consider When Making the Decision to Admit as Inpatient - ANS-1. severity
of signs and symptoms
2. medical predictability of something adverse happening to the patient
3. need for diagnostic studies
,4. availability of diagnostic procedures at the time and location where patient presents
Medicare Part A - ANS-Part of Medicare that reimburses primarily for inpatient services
provided by institutions such as hospitals and skilled nursing facilities
Medicare Part B - ANS-Part of the Medicare program that reimburses covered physician
and supplier services
Medicare Part C (Medicare Advantage) - ANS-Formerly known as Medicare + Choice,
government managed care program, must have Part B
Medicare Part D - ANS-part of Medicare that reimburses for outpatient prescription
drugs
Medicare Administrative Contractor (MAC) - ANS-Processes Part A and Part B claims
Focused Medical Review (FMR) - ANS-1. determine if documentation supports claim
2. reviews guidelines
Medicaid - ANS-state health insurance that helps many people who can't afford medical
care and pays for some or all of their medical bills
1500 Form - ANS-Non-institutional providers must use this form to bill Medicare,
Medicaid, CHAMPUS, and most private insurance companies
used to bill Part B claims
CMS 1450 or UB-04 - ANS-institutional providers use this form to bill Medicare,
Medicaid, CHAMPUS, and most private insurance companies
used to bill Part A claims
Fiscal Intermediary (FI) - ANS-an insurance company that contracts with CMS to
process Medicare Part A claims - replaced by MACs in 2003
a Carrier - ANS-an insurance company that contracts with CMS to process Medicare
Part B claims - replaced by MACs in 2003
Centers for Medicare and Medicaid Services (CMS) - ANS-HHS agency that establishes
payment policies for providers, conducts research, and evaluates the quality of care
provided to beneficiaries
Conditions of Participation (COP) - ANS-must be in compliance in order to be
reimbursed by CMS
, CMS Allowable - ANS-how much CMS will reimburse for a particular service or
procedure
Third Party Carrier - ANS-entity that processes the claims on behalf of CMS
Disproportionate Share Hospital (DSH) - ANS-hospital that provides larger amount of
care to indigent population
CMS provides increased reimbursement for these hospitals to cover cost of uninsured
patients
Common Working File (CWF) - ANS-information about beneficiaries
Return to Provider (RTP) Report - ANS-indication of error in the claim submitted to CMS
- must be corrected to receive reimbursement
Health Professional Shortage Area - ANS-geographic areas that have been designated
as primary medical care shortage areas where physician who furnish medical care are
entitled to a Medicare incentive payment
Participating Provider/Supplier - ANS-accepts CMS allowable as payment in full for
services
Certificate of Medical Necessity (*) - ANS-physician statement that services are
medically necessary
Assignment - ANS-agreement to accept payment in full - 20% copay, 80% Medicare
Reassignment - ANS-physician is paid a salary and entity receives payment from
Medicare
Coordination of Benefits - ANS-decides primary, secondary, and tertiary payor
Local Coverage Determination (LCD) - ANS-determination of what is a covered service
within a region,
used when there is no national coverage determination
National Coverage Determination (NCD) - ANS-determination of what is a covered
service across the country, overrides local coverage determinations
Medicare Code Editor - ANS-halts the claims process but does not correct errors in
claims
Grouper - ANS-uses all information about the claim (including complications and
comorbidities) to determine the primary DRG
