Chapter 1

Question 1

LCD (Local Coverage Determinations)

Answer 1

LCDs further define when an item or service will be covered. LCDs only have jurisdiction within their region

Question 2

NCD (National Coverage Determations)

Answer 2

They explain when Medicare will pay for items or services. If there isn’t an NCD for something then MACs decide the coverage.

Question 3

MAC (Medicare Administrative Contractor)

Answer 3

Are responsible for interpreting national policies. MACs may also define what codes are needed for coverage in a related billing and coding article.

Question 4

ABN (Advanced Beneficiary Notice)

Answer 4

A form that explains to a Medicare beneficiary that the procedure they requested or agreed to may not be covered by Medicare

Question 5

When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost?

Answer 5

$100 or 25 percent

Question 6

HIPAA (Health Insurance Portability and Accountability Act of 1996)

Answer 6

1. Prevents Healthcare Fraud and Abuse
2. Administrative Simplification through the use of technology
3. Medical Liability Reform
4. Defines Covered Entities
5. Defines Health Plans

Question 7

HIPAA defined Healthcare Providers (7 total)

Answer 7

1. Doctors
2. Clinics
3. Psychologists
4. Dentists
5. Chiropractors
6. Nursing Homes
7. Pharmacies

Question 8

HIPAA defined Health Plans (4 total)

Answer 8

1. Health Insurance companies
2. HMOs
3. Company Health Plans
4. Government programs that pay for healthcare such as Medicare, Medicaid, the military and veterans’ healthcare programs

Question 9

HIPAA’s “Minimum Necessary Requirement”

Answer 9

Only individuals whose job requires it may have access to protected health information

Question 10

HITECH (Health Information Technology for Economic and Clinical Health Act)

Answer 10

A part of the American Recovery and Reinvestment Act of 2009. Empowers HIPAA rules by addressing privacy and security concerns related to electronic transmission of health info.

Question 11

American Recovery and Reinvestment Act of 2009

Answer 11

Introduced HITECH

Question 12

What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?

Answer 12

OIG Work Plan

Question 13

What document assists provider offices with the development of Compliance Manuals?

Answer 13

OIG Compliance Program Guidance

Question 14

What would be defined as a medically necessary service?

Answer 14

Using the lead radical service/procedure that allows for effective treatment of the patient’s complain or condition.

Question 15

Fraud

Answer 15

An intentional deception or misrepresentation that can result in unauthorized benefits or payment

Question 16

Abuse

Answer 16

An unintentional misrepresentation that can result in unauthorized benefits or payment

Question 17

What is used to report inpatient codes?

Answer 17

ICD-10-CM and ICD-10-PCS

Question 18

What is used to report outpatient codes?

Answer 18

ICD-10-CM and CPT/HPCS Level II

Question 19

S.O.A.P.

Answer 19

Subjective, Objective, Assessment, and Plan

Order of action used to evaluate and manage patients

Question 20

What is the value of a remittance advice?

Answer 20

It states what will be paid and why any changes to charges were made.

Question 21

Healthcare providers are responsible for developing ____ _____ and policies and procedures regarding privacy in other practices.

Answer 21

Notices of Privacy Practices

Question 22

The Medicare program is made up of several parts. Which part is affected by the Centers for Medicare & Medicaid Services - Hierarchical Condition Categories (CMS - HCC)?

Answer 22

Part C. Accurate and thorough diagnosis coding is important for Medicare Advantage claims because reimbursement is impacted by the patient’s health status

Question 23

Which part of Medicare covers provider fees without the use of a private insurer?

Answer 23

Part B. Covers medically necessary provider services, outpatient care and other medical services not covered under Medicare Part A

Question 24

What is the definition of medical coding?

Answer 24

Translating documentation into numerical/alphanumerical codes used to obtain reimburshment

Question 25

Which options below is NOT a covered entity under HIPAA?

Answer 25

Worker’s Compensation

Question 26

In what year did HIPAA become law?

Answer 26

1996

Question 27

What type of insurance is Medicare Part D?

Answer 27

Prescription drug coverage available to all Medicare beneficiaries.

Question 28

The OIG releases a ____ outlining its priorities for the fiscal year ahead and beyond.

Answer 28

Work Plan

Question 29

HITECH provides a _____ day window during which any violation not due to willful neglect may be corrected without penalty.

Answer 29

30 days

Question 30

A covered entity may obtain consent from an individual to use or disclose protected health information to carry out all of the following except what?

Answer 30

Research

Question 31

What form is used to submit a provider’s charge to the insurance carrier?

Answer 31

CMS-1500

Question 32

AAPC Code of Ethics

Answer 32

1. Integrity
2. Respect
3. Commitment
4. Competence
5. Fairness
6. Responsibility

Question 33

Who is responsible for enforcing the HIPAA security rule?

Answer 33

OCR, The Office of Civil Rights