Chapter 1 - Business of Medicine

Question 1

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

• OIG Compliance Program Guide
• OIG Security Summary
• OIG Work Plan
• OIG Investigation Plan

Answer 1

OIG Work Plan
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.

Question 2

Who would NOT be considered a covered entity under HIPAA?

-Doctors

-HMOs

-Clearinghouses

-Patients

Answer 2

Correct:
PATIENTS
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.

Question 3

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?

-LCD

-CMS-1500

-UB-04

-ABN

Answer 3

Correct:
ABN
-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.

Question 4

Select the TRUE statement regarding ABNs.

-ABNs may not be recognized by non-Medicare payers.

-ABNs must be signed for emergency or urgent care.

-ABNs are not required to include an estimate cost for the service.

-ABNs should be routinely signed by Medicare Beneficiaries in case Medicare doesn’t cover a service.

Answer 4

Correct:
ABNs may not be recognized by non-Medicare payers.
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.

Question 5

Which statement describes a medically necessary service?

*Performing a procedure/service based on cost to eliminate wasteful services.
*Using the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition.
*Using the closest facility to perform a service or procedure.
*Using the appropriate course of treatment to fit within the patient’s lifestyle.

Answer 5

Using the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition.
Medical necessity is using the least radical services/procedure that allows for effective treatment of the patient’s complaint or condition.

Question 6

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?

-Arthritis

-Chronic venous insufficiency

-Hypertension

-Muscle weakness

Answer 6

Correct:
Chronic venous insufficiency

According to the LCD, chronic venous insufficiency is a systemic condition that may result in the need for routine foot care.

Question 7

Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?

-HIPAA

-HITECH

-SSA

-PPACA

Answer 7

Correct:
HITECH
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.

Question 8

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?

-$25 or 10 percent

-$100 or 10 percent

-$100 or 25 percent

-An exact amount

Answer 8

$100 or 25 percent
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.”

Question 9

Under HIPAA, what would be a policy requirement for “minimum necessary”?

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

-Only the patient has access to his or her own protected health information.

-Only the treating provider has access to protected health information.

-Anyone within the provider’s office can have access to protected health information.

Answer 9

Correct:
Only individuals whose job requires it may have access to protected health information.
It is the responsibility of a covered entity to develop and implement policies, best suited to its particular circumstances to meet HIPAA requirements. As a policy requirement, only those individuals whose job requires it may have access to protected health information.

Question 10

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

-OIG Compliance Program Guidance

-OIG Work Plan

-OIG Suggested Rules and Regulations

-OIG Internal Compliance Plan

Answer 10

Correct:
OIG Compliance Program Guidance
The OIG has offered compliance program guidance to form the basis of a voluntary compliance program for physician offices. Although this was released in October 2000, it is still considered as active compliance guidance today. In 2023, the OIG released the General Compliance Program Guidance (GCPG). The provider’s office should refer to both of these documents when creating and updating their compliance plan.

Question 11

What type of profession, other than coding, might skilled coders enter?

• Physicians, insurance carriers, nurses
• Front desk personnel, HR dept
• Consultants, educators, medical auditors
• None of the above

Answer 11

Consultants, educators, medical auditors

Question 12

What is the difference between outpatient and inpatient coding?

• Outpatient coders use ICD-10-CM and ICD-10-PCS.
• Outpatient coders only focus on hospital services and Inpatient coders focus on physician services.
• Inpatient coders have more interaction than Outpatient coders.
• Inpatient coders use ICD-10-CM and ICD-10-PCS.

Answer 12

Inpatient coders use ICD-10-CM and ICD-10-PCS.

Question 13

What is a mid-level provider?

• Non-licensed PAs
• Physician withholder
• Mid-level providers include physician assistants (PA) and nurse practitioners (NP).
• NPs with Bachelor’s Degree

Answer 13

Mid-level providers include physician assistants (PA) and nurse practitioners (NP).

Question 14

What are the different parts of Medicare?

• Part A, B, D
• Part A, B, C, D
• Part E, F, G, H
• Part A and B

Answer 14

Part A, B, C, D

Question 15

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
• Statement, Observation, Action, Prepare
• Symptoms, Objective, Auscultation, Percussion
• Subjective, Observation, Action, Plan

Answer 15

Subjective, Objective, Assessment, Plan

Question 16

List and explain the tips for coding operative (op) reports?

• Look for key words, Ignore unfamiliar words, Skip the body, Ignore pathology reports, Only code procedures from the header
• Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body
• Highlight familiar words, Look for key words, Read the body, Only code what you have highlighted, Code procedure only
• Read the headers only, Look for key words, Highlight familiar words, Ignore pathology report, Code diagnosis only

Answer 16

Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body

Question 17

What is medical necessity?

• Services to a Medicare beneficiary that are billed for unreasonable and unnecessary treatment.
• The most radical service/procedure that allows for effective treatment of the patient’s complaint or condition.
• Something insurance plans do not care about.
• Relates to whether a procedure or service is considered appropriate in a given circumstance.

Answer 17

Relates to whether a procedure or service is considered appropriate in a given circumstance.

Question 18

What is NOT a common reason Medicare may deny a procedure or service when an ABN is provided to a Medicare beneficiary?

• Patient’s condition
• Frequently proposed
• Covered Services
• Experimental

Answer 18

Covered Services

Question 19

Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?

• Uses or disclosures to drug companies.
• Disclosures to or requests by family members.
• Disclosures to the individual who is the subject of the information.
• Uses or disclosures to insurance companies.

Answer 19

Disclosures to the individual who is the subject of the information.

Question 20

Which is not one of the seven key components of an internal compliance plan?

• Develop open lines of communication.
• Conduct training but not perform education on practice standards and procedures.
• Enforce disciplinary standards through well-publicized guidelines.
• Conduct internal monitoring and auditing through the performance of periodic audits.

Answer 20

Conduct training but not perform education on practice standards and procedures.

Question 21

Which of the following choices is NOT a benefit of an active compliance plan?

• Faster, more accurate payment of claims.
• Eliminates risk of an audit.
• Fewer billing mistakes.
• Increases accuracy of provider documentation.

Answer 21

Eliminates risk of an audit.

Although voluntary, a compliance plan may offer several benefits, among them:

• Faster, more accurate payment of claims.
• Fewer billing mistakes.
• Diminished chances of a payer audit.
• Less chance of violating self-referral and anti-kickback statutes.

Additionally, the increased accuracy of provider documentation that may result from a compliance program actually may assist in enhancing patient care.

Question 22

When reviewing operative reports, which one of the following is a TRUE statement?

• The procedure can be reported from reading the procedure performed header alone.
• Additional details about the procedure can be found in the body of the report.
• Approximately 50% of the operative report contains words that not important to the final procedure coding.
• When encountering unfamiliar words, ask the performing provider to explain what the terminology.

Answer 22

Additional details about the procedure can be found in the body of the report.

The procedure reported can be used as a starting point, but the entire operative report must be read to confirm the procedure performed. Approximately 20% of the words found in the operative report are not essential for coding purposes. When encountering unfamiliar terms, research for understanding. An important skill for medical coders is learning how to research.

Question 23

Which coding manuals do outpatient coders focus on learning?

• CPT®, HCPCS Level II, ICD-10-CM, ICD-10-PCS
• ICD-10-CM and ICD-10-PCS
• CPT®, HCPCS Level II and ICD-10-CM
• CPT® and ICD-10-CM

Answer 23

CPT®, HCPCS Level II and ICD-10-CM

Outpatient coding focuses on provider services. Outpatient coders will focus on learning CPT®, HCPCS Level II and ICD-10-CM.

Question 24

What type of insurance is Medicare Part D?

• A Medicare Advantage program managed by private insurers.
• Hospital coverage available to all Medicare beneficiaries.
• Prescription drug coverage available to all Medicare beneficiaries.
• Provider coverage requiring monthly premiums.

Answer 24

Prescription drug coverage available to all Medicare beneficiaries.

Medicare Part D is a prescription drug program available to all Medicare beneficiaries for a fee. Private companies approved by Medicare provide the coverage.

Question 25

What does CMS-HCC stand for?

• County Mandated Services – Heightened Control Center
• Country Mandated Services – Hospital Correct Coding Initiative
• Centers for Medicare & Medicaid Services – Hierarchal Condition Category
• Centers for Medicare & Medicaid Services – Hospital Correct Coding Initiative

Answer 25

Centers for Medicare & Medicaid Services – Hierarchal Condition Category

Question 26

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)?

• Part A
• Part B
• Part C
• Part D

Answer 26

Part C

Accurate and thorough diagnosis coding is important for Medicare Advantage (Part C) claims because reimbursement is impacted by the patient’s health status. The Centers for Medicare & Medicaid Services-hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient’s diseases and demographic factors. If a coder does not include all pertinent diagnoses and comorbidities, there may be loss of additional reimbursement to which the provider is entitled.

Question 27

HIPAA stands for

• Health Insurance Provider Assistance Action
• Health Insurance Portability and Accountant Advice
• Health Insurance Portability and Accountability Act
• Health Information Privacy Access Act

Answer 27

Health Insurance Portability and Accountability Act

Health Insurance Portability and Accountability Act (HIPAA) (1996)

Question 28

Which of the following is a BENEFIT of electronic transactions?

• Payment of claims
• Security of claims
• Timely submission of claims
• None of the above

Answer 28

Timely submission of claims

Electronic claims benefit the provider office by allowing timely submissions to the insurance carrier and proof of transmission of the claims.

Question 29

What is the value of a remittance advice?

• It states when to schedule the patient’s next appointment.
• It states what will be paid and why any changes to charges were made.
• It confirms the provider is part of the plan in question.
• It catalogs the patient’s coverage benefits.

Answer 29

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

The determination of the payer is sent to the provider in the form of a remittance advice. The remittance advice explains the outcome of the insurance adjudication on the claim, including the payment amount, contractual adjustments and reason(s) for denial.

Question 30

Which statement is TRUE regarding the Merit-Based Incentive Program (MIPS)? **

• All Medicare providers must participate in MIPS.
• Providers with less than 300 Part-B enrolled patients are exempt from MIPS.
• Providers are excluded from MIPS if they are enrolled in a Qualifying APM program.
• Providers with less than $90,000 in Part C allowed charges for covered professional services are exempted.

Answer 30

Providers are excluded from MIPS if they are enrolled in a Qualifying APM program.

Providers who are participating as part of a Qualifying APM are excluded from MIPS reporting requirements and payment adjustments. Not all providers participate in MIPS; providers who are in their first year of Medicare participation are excluded from participation. Providers with less than 200 (not 300) Part-B enrolled patients are exempt from MIPS. MIPS is a program focused on Part B enrollees, not Part C.

Question 31

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?

• Research
• Treatment
• Payment
• Healthcare operations

Answer 31

Research

A covered entity may obtain consent of the individual to use or disclose protected health information to carry out treatment, payment or healthcare operations.

Question 32

A covered entity does NOT include
* Healthcare providers
* Patients
* Clearinghouses
* Health plans

Answer 32

Patients

Question 33

Which type of information is NOT maintained in a medical record?

• Observations
• Medical or surgical interventions
• Treatment outcomes
• Financial records

Answer 33

Financial records

Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions and treatment outcomes. Administrative data, such as financial records, should not be included in the medical record or provided in response to a subpoena or request for health records, unless financial records are specifically stated on the subpoena request.

Question 34

Which of the following is NOT an example of an Advanced Alternative Payment Model (AAPM)?

• Bundled Payments for Care Improvement Advanced
• Comprehensive End-Stage Renal Disease Care
• Comprehensive Primary Care Plus
• Bundled Payments for Home Care Services

Answer 34

Bundled Payments for Home Care Services

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.

Question 35

How many components are included in an effective compliance plan?

Answer 35

7

The following list of components, as set forth in previous OIG Compliance Program Guidance for Individual and Small Group Physician Practices, can form the basis of a voluntary compliance program for a provider practice:

• Conducting internal monitoring and auditing through the performance of periodic audits;
• Implementing compliance and practice standards through the development of written standards and procedures;
• Designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards;
• Conducting appropriate training and education on practice standards and procedures;
• Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities;
• Developing open lines of communication, such as (1) discussions at staff meetings regarding how to avoid erroneous or fraudulent conduct, and (2) community bulletin boards, to keep practice employees updated regarding compliance activities; and
• Enforcing disciplinary standards through well-publicized guidelines.

These seven components provide a solid basis upon which a provider practice can create a compliance program.

Question 36

Which option below is NOT a covered entity under HIPAA?

• Medicare
• Medicaid
• BCBS
• Workers’ Compensation

Answer 36

Workers’ Compensation

The definition of health plan in the HIPAA regulations excludes any policy, plan or program that provides or pays for the cost of excepted benefits. Excepted benefits include:

• Coverage only for accident or disability income insurance, or any combination thereof;
• Coverage issued as a supplement to liability insurance;
• Liability insurance, including general liability insurance and automobile liability insurance;
• Workers’ compensation or similar insurance;
• Automobile medical payment insurance;
• Credit-only insurance;
• Coverage for on-site medical clinics;
• Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

Question 37

According to the OIG, internal monitoring and auditing should be performed by what means?

• Periodic audits.
• Focused audits on problems brought to the attention of the compliance officer.
• Audits on all denied claims.
• Baseline audits.

Answer 37

Periodic audits.

A key component of an effective compliance program includes internal monitoring and auditing through the performance of periodic audits. This ongoing evaluation includes not only whether the provider practice’s standards and procedures are in fact current and accurate, but also whether the compliance program is working, (for example, whether individuals are properly carrying out their responsibilities and claims are submitted appropriately).

Question 38

What is the purpose of National Coverage Determinations?

• To notify beneficiaries of non-covered services.
• To provide payment options to physicians.
• To explain CMS policies on when Medicare will pay for items or services.
• To set standards for all payers on coverage items.

Answer 38

To explain CMS policies on when Medicare will pay for items or services.

National Coverage Determinations (NCD) explain CMS policies on when Medicare will pay for items or services.

Question 39

Many coding professionals go on to find work as:

• Accountants
• Consultants
• Medical Assistants
• Financial Planners

Answer 39

Consultants

The coding profession has evolved significantly over the past several decades into a career path with unlimited possibilities. Many professionals who have learned coding have also gone on to roles as consultants, educators, or medical auditors. There are endless possibilities in an ever-changing field.

Question 40

In what year did HIPAA become law?

• 1992
• 1995
• 1997
• 1996

Answer 40

1996

HIPAA was adopted into law in 1996.

Question 41

According to the AAPC Code of Ethics, which term is NOT listed as an ethical principle of professional conduct?

• Integrity
• Responsibility
• Efficiency
• Commitment

Answer 41

Efficiency

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

Question 42

What type of health insurance provides coverage for low-income families?

• Medicaid
• Medicare
• Commercial PPO
• Commercial HMO

Answer 42

Medicaid

Medicaid is a health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments.

Question 43

**ABN stands for **

• Advance Beneficiary Notice
• Admitting Beneficiary Notice
• Advisory Beneficial Notice
• Advanced Benefits Notification

Answer 43

Advance Beneficiary Notice

Question 44

Which of the following is NOT a component of the MIPS program?

• Readmission Rates
• Quality
• Promoting Interoperability
• Improvement Activities

Answer 44

Readmission Rates

The four components of the MIPS program are Quality, Promoting Interoperability, Improvement Activities and Cost. While readmission rates can impact cost, the overall cost is a metric considered in the MIPS program.

Question 45

What is the definition of medical coding?

• Deciphering explanation of benefits provided by an insurance carrier.
• Translating documentation into numerical/alphanumerical codes used to obtain reimbursement.
• Translating services a provider performs into documentation.
• Translating documentation into software compatible notes.

Answer 45

Translating documentation into numerical/alphanumerical codes used to obtain reimbursement.

Medical coding is the process of translating a healthcare provider’s documentation of a patient encounter into a series of numeric or alphanumeric codes.