Deck 21: Practice Management

Question 1

To whom does Tricare provide coverage?

A) active and retired military personnel and their families, that do not qualify for Medicare
B) active and retired military personnel only
C) retired military personnel and their families, that do not qualify for Medicare
D) active military personnel and their families

Answer 1

active and retired military personnel and their families, that do not qualify for Medicare

Question 2

According to the AAPC Code of Ethics, members will avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between what?

A) personal and professional interests
B) legal and ethical considerations
C) employer and personal ethical standards
D) criminal and civil law

Answer 2

personal and professional interests

Question 3

What is a covered entity?

A) any patient that purchases health insurance from a third-party payer
B) any provider or organization that transmits health information electronically
C) any provider that has agreed to accept assignment with a third-party payer
D) any patient that chooses to receive medical treatment from a provider that accepts assignment from the patient's health insurance

Answer 3

any provider or organization that transmits health information electronically

Question 4

Which document serves as the basis for processing ethical complaints initiated against AAPC members?

A) AAPC Code of Conduct
B) AAPC Code of Ethics
C) AAPC bylaws
D) AAPC Policies and Procedures Manual

Question 5

In order for a retired member of the military to be eligible for CHAMPVA coverage, he/she may be eligible for Medicare but may not be enrolled in which part of Medicare?

A) Part C
B) Part A
C) Part D
D) Part B

Question 6

One of the elements of the AAPC's Code of Ethics includes a statement that all members should "Strive to achieve the highest _________, effectiveness and dignity in both the process and products of professional work".

A) consistency
B) proficiency
C) accuracy
D) quality

Question 7

_____ are a means of assessing the risk of medically managing each patient based on current conditions and comorbid conditions that are impacting care:

A) concurrent review
B) hierarchical condition categories
C) diagnosis related groups
D) utilization review

Question 8

What does Medicare Part B cover?

A) pays for inpatient facility care
B) pays for provider services, outpatient hospital and lab services, and DME
C) provides managed care and private fee-for-service plan options as an alternative to original Medicare
D) provides prescription drug coverage through various Medicare plans

Question 9

What does Medicare Part A cover?

A) pays for inpatient facility care
B) provides prescription drug coverage through various Medicare plans
C) pays for provider services, outpatient hospital and lab services, and DME
D) provides managed care and private fee-for-service plan options as an alternative to original Medicare

Question 10

Which penalty may an AAPC member face if he/she is determined to have failed to comply with the AAPC Code of Ethics?

A) loss of reputation
B) forced resignation
C) imprisonment
D) loss of credentials

Question 11

Which two provisions do participating providers agree to when contracting with Medicare?

A) hire additional staff and provide high quality care to all patients
B) process claims quickly and sign non-compete contracts
C) accept assignment and accept allowed amount
D) see all Medicare patients and prepare reports when requested

Question 12

The AAPC's Code of Ethics establishes principles that define the ethical behavior of whom?

A) payers
B) AAPC members
C) providers
D) healthcare professionals

Question 13

Which modifier is used to identify circumstances in which it is appropriate to report NCCI-identified code pairs together?

A) 59
B) 78
C) 51
D) 58

Question 14

All of the following are components of developing a voluntary compliance program are included in the OIG's "Compliance Program Guidance for Individual and Small Group Physician Practices" except:

A) develop open lines of communication
B) conduct appropriate training and education on practice standards and procedures
C) immediately terminate an employee suspected of a violation
D) designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards

Question 15

In a non-PAR provider restriction, what are fees restricted to?

A) no more than 150% of the allowable charge
B) the allowable amount
C) the limiting charge
D) the fee for service

Question 16

The Office of Inspector General investigates charges of all of the following except:

A) misconduct
B) fraud
C) abuse
D) misadventure

Question 17

Mary presents for an examination at Dr. Frank's office. The coder assigns an Evaluation and Management code 99213 to the day's service. The provider's charge for a 99213 code is $100. After calculating the allowable amount and determining Medicare allows 100% of the MFPS and it will pay 80% of the Medicare provider fee schedule allowable amount, Mary receives a bill from Dr. Frank's office for $24. Joan Little presents for an examination at Dr. Kappan's office, and she is assigned an Evaluation and Management code of 99213 for the day's service, with a provider charge of $100. After calculating the allowable amount and determining Medicare allows 95% of the MFPS and it will pay 80% of the Medicare provider fee schedule allowable amount, Joan receives a bill from Dr. Frank's office for $45. Why would Joan's Medicare reimbursement be calculated differently from Mary's when the providers' charges for the CPT code 99213 are the same and the same payer was billed?

A) Mary's provider accepts assignment and Joan's does not
B) Mary has more disposable income than Joan
C) Joan and Mary received different diagnosis codes for the day's service
D) Joan and Mary live on opposite sides of the same town

Question 18

Which of the following is not a stated element of the AAPC Code of Ethics?

A) Use only legal and ethical principles that reflect the profession's core values and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee
B) Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests
C) Maintain and enhance the dignity, status, integrity, competence, and standards of our profession
D) Avoid conflicts with superiors or peers when observed unethical behavior occurs

Question 19

According to the AAPC Code of Ethics, coders are to use only legal and ethical principles that reflect what?

A) the profession's core values
B) sound moral judgment
C) the coder's employer's code of ethics
D) state and local laws

Question 20

The specification of a Code of Ethics enables AAPC to clarify to current and future members, and to those served by members, the nature of the ethical responsibilities held in ______ by its members:

A) common
B) close contact
C) high esteem
D) disregard

Question 21

When the AAPC Ethics Committee determines a member has failed to adhere to the standards outlined in the AAPC Code of Ethics, which consequence might that member face?

A) fines payable to the AAPC
B) loss of membership with the AAPC
C) criminal charges
D) must take a written test administered by the AAPC regarding the Code of Ethics prior to resuming employment in the healthcare industry

Question 22

What is a CMS national-level rule that identifies payment coverage for a specific service, procedure, test, or technology based on medical necessity or frequency:

A) national coverage determination
B) advance beneficiary notice
C) surgical release form
D) local coverage determination

Question 23

Which category of individuals does Medicaid cover?

A) individuals who also qualify for state and locally-funded benefits
B) individuals falling below the state poverty line
C) individuals falling below the national poverty line
D) individuals with income below state-prescribed levels, based on a scale compared to how many individuals live in the household

Question 24

Which of the following is not a restriction typically placed on non-PAR providers?

A) only the deductible and/or coinsurance can be collected at the time of service
B) fees are restricted to no more than the limiting charge
C) lab fees are paid as accept assignment only at the allowed fee schedule regardless of the providers status as PAR or non-PAR
D) claims must be filed by the patient

Question 25

The specification of a Code of Ethics enables AAPC to clarify the nature of the ethical responsibilities held in common by its members to all of the following audiences identified in the Code of Ethics listed except:

A) future members
B) those served by members
C) members in competing organizations
D) current members

Question 26

How many components of developing a voluntary compliance program are included in the OIG's "Compliance Program Guidance for Individual and Small Group Physician Practices"?

A) 7
B) 5
C) 4
D) 6

Question 27

What does adherence to the standards found in the AAPC Code of Ethics assure?

A) public confidence
B) member promotions
C) effective coding practices
D) member compliance

Question 28

Provider and outpatient facility services are usually reported on which claim form?

A) UB-04
B) PAR 600
C) CMS-1500
D) ABN 30

Question 29

It is vital that professional coders know the AAPC's ____________:

A) complaint history
B) code of ethics
C) bylaws
D) organizational structure

Question 30

Select from the following a methodology that is not utilized to manage, negotiate, and contract with providers of service:

A) health maintenance organization
B) provider fee organization
C) fee for service
D) preferred provider organization

Question 31

In a payer contract, what is a predetermined amount that is deemed the patient's responsibility before the payer benefits begin?

A) copayment
B) deductible
C) coinsurance
D) allowable amount

Question 32

Which of the following is not considered to be a common type of provider?

A) PA
B) MD
C) DO
D) CNA

Question 33

Per AAPC Code of Ethics standards, coders should "Respect the ___________ and honor confidentiality".

A) wishes of others
B) feedback of others
C) privacy of others
D) religious beliefs of others

Question 34

According to the AAPC Code of Ethics, all members should "Maintain and enhance the dignity, status, integrity, competence, and ______ of our profession".

A) principles
B) traditions
C) standards
D) theories

Question 35

What is a program designed to encourage correct coding methodologies and control inappropriate payments due to improper coding of Part B claims?

A) advance beneficiary notice
B) national correct coding initiative
C) medically unlikely edit
D) hierarchical condition category

Question 36

What does the acronym NPP stand for?

A) nonpracticing providers
B) nonpaid providers
C) nonpermitted providers
D) nonphysician providers

Question 37

All of the following are classifications of AAPC members listed in Chapter 22 except:

A) clinical
B) auditing
C) practice management
D) compliance

Question 38

What must coders acquire and maintain through continued professional development and education in order to advance the coding profession?

A) knowledge, skills, and abilities
B) certification
C) ethical standards
D) professional competence

Question 39

Select the commitment that is expected of every AAPC member:

A) volunteerism at AAPC events
B) establishing a mentorship program in their geographic area
C) timely responses
D) ethical professional conduct

Question 40

What is an agency that investigates allegations of fraud, waste, abuse, or misconduct and assists the executive branch in identifying and correcting operational deficiencies?

A) FDA
B) CMS
C) OIG
D) DEA

Question 41

In a payer contract, what is the patient-responsible portion, which is based on a percentage of the allowed charge?

A) copayment
B) coinsurance
C) deductible
D) allowable amount

Question 42

In order to remind themselves of why they chose to be a coder, coders should refer to:

A) integrity
B) financials
C) excellence
D) the code of ethics

Question 43

By whom is the Medicare program administered?

A) Department of Health and Human Services
B) Centers for Medicare and Medicaid Services
C) Centers for Disease Control and Prevention
D) Hierarchical Condition Categories

Question 44

At what amount of surgical fees must a Surgical Disclosure Notice be signed?

A) $300
B) $400
C) $600
D) $500

Question 45

__________ are edits that identify limits for units of service or procedure completed by a single provider per patient per day.

A) hierarchical condition category
B) national correct coding initiative
C) medically unlikely edit
D) advance beneficiary notice

Question 46

Which of the following is a benefit that is not part of the OIG's recommended compliance plan?

A) preventing an audit by CMS or the OIG
B) minimizing billing mistakes
C) shows good faith effort to submit accurate claims
D) possibly mitigating fines and penalties due to claim errors

Question 47

What is the Medicare Advantage part of Medicare?

A) provides prescription drug coverage through various Medicare plans
B) provides managed care and private fee-for-service plan options as an alternative to original Medicare
C) pays for inpatient facility care
D) pays for provider services, outpatient hospital and lab services, and DME

Question 48

Any medical or financial information held or managed by a covered entity is:

A) protected health information
B) privileged
C) personal information
D) demographic information

Question 49

On June 1, Susan requests a copy of her CT scan from a radiography laboratory to carry with her to her neurologist's appointment. On what date must the laboratory have provided that CT scan to Susan?

A) July 1
B) January 1
C) August 1
D) September 1

Question 50

How will coders advance the coding profession?

A) through high quality networking with other healthcare professionals
B) through advertising and marketing of the AAPC organization
C) through continued professional development and education
D) through lobbying and petitioning of governmental bodies

Question 51

Per the AAPC Code of Ethics, coders are expected to accurately represent two pieces of information about themselves. What are they?

A) credential earned and status of AAPC membership
B) coding specialty and date available to start
C) work experience and certification
D) level of education and work experience

Question 52

What is the unique identifier for providers under HIPAA?

A) Protected Health Information
B) Employer Identification Number
C) National Provider Identifier
D) Advance Beneficiary Notice

Question 53

To whom should coders report activity that is perceived to violate this Code of Ethics, per the AAPC Code of Ethics?

A) his/her supervisor
B) the AAPC ethics committee
C) state and local authorities
D) the AAPC conduct committee

Question 54

What are rules developed at the local level by Medicare Administrative Contractors that identify payment coverage for a specific service, procedure, test, or technology based on medical necessity or frequency?

A) surgical release form
B) advance beneficiary notice
C) national coverage determination
D) local coverage determination

Question 55

Which claim form is inpatient facility services typically reported on?

A) CMS-1500
B) UB-04
C) ABN 30
D) PAR 600

Question 56

What is another name for Administrative Simplification?

A) Title II of HIPAA
B) the use of optimal character recognition when processing providers' claim forms
C) a secure method by which providers can protect patient's protected health information
D) a process recommended by OIG for increased efficiency in providers' offices

Question 57

What does the OIG publish annually to identify new and ongoing reviews and activities that the OIG will track during that year?

A) manual
B) manifesto
C) work plan
D) policies and procedures

Question 58

Who administers Medicaid?

A) Department of Welfare
B) Medicaid Administrative Contractors
C) Centers for Disease Control and Prevention
D) state governments

Question 59

What is the name of a waiver needed for any service that does not meet the coverage criteria established in an NCD or LCD?

A) hierarchical condition category
B) advance beneficiary notice
C) medically unlikely edit
D) national correct coding initiative

Question 60

With whom must the Office of Inspector General work through to hold jurisdiction over healthcare programs regulated and administered at the state and/or federal level?

A) Medicare Administrative Contractors
B) US Securities and Exchange Commission
C) Centers for Medicare and Medicaid Services
D) Department of Health and Human Services

Question 61

One element of the AAPC Code of Ethics mandates all members will know and respect existing laws in which jurisdictions?

A) state only
B) local and national only
C) local and state only
D) local, state, and federal

Question 62

A(n) _____ is a written plan consisting of standards and procedures designed to implement compliance and practice standards.

A) compliance plan
B) work plan
C) policy and procedures manual
D) operating plan

Question 63

All of the following are identified elements of the AAPC Code of Ethics except:

A) Respect the privacy of others and honor confidentiality
B) Accurately represent the credential(s) earned and the status of AAPC membership
C) Know and respect existing federal, state and local laws, regulations, certifications and licensing requirements applicable to professional work
D) Alert appropriate authorities when unethical behavior is performed or observed

Question 64

Which organization does the Centers for Medicare and Medicaid Services use to assist with administering Medicare?

A) U.S. Food and Drug Administration
B) Drug Enforcement Administration
C) Centers for Disease Control and Prevention
D) Medicare Administrative Contractors

Question 65

What does Title I of HIPAA protect?

A) the patient's right to see any provider of his/her choosing, regardless of whether that provider accepts assignment from the patient's health insurance carrier
B) the patient's right to obtain medical records on behalf of dependents
C) the patient's right to privacy of protected health information
D) the patient's right to health insurance coverage when he/she changes jobs

Question 66

The Medicare program covers several groups of individuals. Select the group of individuals that is not covered by Medicare:

A) disabled persons after receiving two years of disability benefits
B) immigrants for the first five years of citizenship
C) individuals with end-stage renal disease
D) individuals age 65 and older

Question 67

What is the name of a waiver needed for any service that does not meet the coverage criteria established in an NCD or LCD?

A) national correct coding initiative
B) advance beneficiary notice
C) medically unlikely edit
D) hierarchical condition category

Question 68

What is the unique identifier for providers under HIPAA?

A) Employer Identification Number
B) Advance Beneficiary Notice
C) National Provider Identifier
D) Protected Health Information

Question 69

When the AAPC Ethics Committee determines a member has failed to adhere to the standards outlined in the AAPC Code of Ethics, which consequence might that member face?

A) loss of membership with the AAPC
B) fines payable to the AAPC
C) criminal charges
D) must take a written test administered by the AAPC regarding the Code of Ethics prior to resuming employment in the healthcare industry

Question 70

In a payer contract, what is the patient-responsible portion, which is based on a percentage of the allowed charge?

A) copayment
B) coinsurance
C) allowable amount
D) deductible

Question 71

In a non-PAR provider restriction, what are fees restricted to?

A) the limiting charge
B) no more than 150% of the allowable charge
C) the allowable amount
D) the fee for service

Question 72

What does Title I of HIPAA protect?

A) the patient's right to see any provider of his/her choosing, regardless of whether that provider accepts assignment from the patient's health insurance carrier
B) the patient's right to obtain medical records on behalf of dependents
C) the patient's right to privacy of protected health information
D) the patient's right to health insurance coverage when he/she changes jobs

Question 73

Who administers Medicaid?

A) state governments
B) Centers for Disease Control and Prevention
C) Department of Welfare
D) Medicaid Administrative Contractors

Question 74

Which modifier is used to identify circumstances in which it is appropriate to report NCCI-identified code pairs together?

A) 78
B) 58
C) 59
D) 51

Question 75

What is a CMS national-level rule that identifies payment coverage for a specific service, procedure, test, or technology based on medical necessity or frequency:

A) advance beneficiary notice
B) local coverage determination
C) surgical release form
D) national coverage determination

Question 76

How will coders advance the coding profession?

A) through advertising and marketing of the AAPC organization
B) through lobbying and petitioning of governmental bodies
C) through high quality networking with other healthcare professionals
D) through continued professional development and education

Question 77

What must coders acquire and maintain through continued professional development and education in order to advance the coding profession?

A) knowledge, skills, and abilities
B) professional competence
C) ethical standards
D) certification

Question 78

In order for a retired member of the military to be eligible for CHAMPVA coverage, he/she may be eligible for Medicare but may not be enrolled in which part of Medicare?

A) Part C
B) Part B
C) Part A
D) Part D

Question 79

With whom must the Office of Inspector General work through to hold jurisdiction over healthcare programs regulated and administered at the state and/or federal level?

A) Department of Health and Human Services
B) Medicare Administrative Contractors
C) US Securities and Exchange Commission
D) Centers for Medicare and Medicaid Services

Question 80

In order to remind themselves of why they chose to be a coder, coders should refer to:

A) integrity
B) the code of ethics
C) excellence
D) financials