Chapter 1 Flashcards
Which statement describes a medically necessary service?
Using the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition.
Under HIPAA, what would be a policy requirement for “minimum necessary”
Only individuals whose job requires it may have access to protected health information.
According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care?
Chronic venous insufficiency
What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges?
Rationale: An Advanced Beneficiary Notice (ABN) is used when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. This form notifies the patient of potential out of pocket costs for the patient.
What document assists provider offices with the development of Compliance Manuals
OIG Compliance Program Guidance
Select the TRUE statement regarding ABNs.
Rationale: ABNs may not be recognized by non-Medicare payers. Providers should review their contracts to determine which payers will accept an ABN for services not covered.
Who would NOT be considered a covered entity under HIPAA
Rationale: Covered entities in relation to HIPAA include Health Care Providers, Health Plans, and Health Care Clearinghouses. The patient is not considered a covered entity although it is the patient’s data that is protected.
Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?
Rationale: The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as a part of the American Recovery and Reinvestment Act of 2009 (ARRA) to promote the adoption and meaningful use of health information technology. Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information.
What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?
Rationale: Twice a year, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead. Within the Work Plan, potential problem areas with claims submissions are listed and will be targeted with special scrutiny.
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?
Rationale: CMS instructions stipulate, “Notifiers must make a good faith effort to insert a reasonable estimate…the estimate should be within $100 or 25 percent of the actual costs, whichever is greater.”
What type of profession, other than coding, might skilled coders enter?
Consultants, educators, medical auditors
What is the difference between outpatient and inpatient coding
Inpatient coders use ICD-10-CM and ICD-10-PCS.
What is a mid-level provider?
Mid-level providers include physician assistants (PA) and nurse practitioners (NP).
What are the different parts of Medicare
Part A, B, C, D
Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent?
Subjective, Objective, Assessment, Plan
List and explain the tips for coding operative (op) reports?
Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body
What is medical necessity?
Relates to whether a procedure or service is considered appropriate in a given circumstance
What is NOT a common reason Medicare may deny a procedure or service when an ABN is provided to a Medicare beneficiary
Covered service
Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?
Disclosures to the individual who is the subject of the information
Which is not one of the seven key components of an internal compliance plan?
Conduct training but not perform education on practice standards and procedures.
What does the abbreviation MAC stand for
Medicare Administrative Contractor
Which CMS product describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare?
Rationale: The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare.
What does CMS-HCC stand for?
Centers for Medicare & Medicaid Services –HierarchicalCondition Centers
What will the scope of a compliance program depend on
The size and resources of the provider’s practice
Which of the following is NOT an example of an Advanced Alternative Payment Model (AAPM)
Rationale: The three Advanced APMs discussed in the chapter are Bundled Payments for Care Improvement Advanced; Comprehensive End-Stage Renal Disease Care and Comprehensive Primary Care Plus among other programs
The minimum necessary rule applies to
Covered entities taking reasonable steps to limit use or disclosure of PHI (protected health information)
Healthcare providers are responsible for developing ____ ____ and policies and procedures regarding privacy in their practices.
Notices of Privacy Practices
What type of provider goes through approximately 26 ½ months of education, after completion of a bachelor’s degree, and is licensed to practice medicine with the oversight of a physician?
Physician Assistant (PA)
What type of insurance is Medicare Part D?
Prescription drug coverage available to all Medicare beneficiaries.
Which provider is NOT a mid-level provider?
Anesthesiologist
Correct Answer:
Correctc. Anesthesiologist
The minimum necessary rule is based on sound current practice that protected health information should NOT be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. What does this mean?
Providers should develop safeguards to prevent unauthorized access to protected health information.
According to the AAPC Code of Ethics, which term is NOT listed as an ethical principle of professional conduct?
Efficiency
Response Feedback:
Rationale: It shall be the responsibility of every AAPC member, as a condition of continued membership, to conduct themselves in all professional activities in a manner consistent with ALL of the following ethical principles of professional conduct:
· Integrity
· Respect
· Commitment
· Competence
· Fairness
· Responsibility
What form is used to submit a provider’s charge to the insurance carrier?
CMS-1500
Which statement is TRUE regarding the Merit-Based Incentive Program (MIPS)?
Providers are excluded from MIPS if they are enrolled in a Qualifying APM program.
