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AAPC CPB FINAL EXAM NEWEST EXAM 2025 |
ALL QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) | LATEST EXAM |
GRADED A+
The Medicaid NCCI program consists of six methodologies. Each methodology is composed of ___ components ---------CORRECT ANSWER----------------- 4 Medicare states that reporting bundled codes in addition to the major procedural code is considered to be unbundling, and if repeated with frequency it is considered to be: ---------CORRECT ANSWER----------------- fraud When looking at the NCCI Edit tables, Column 1 codes are indicated as payable. Column 2 codes contain the codes that are: ---------CORRECT ANSWER-----------------not payable without mod What modifier is required when a procedure is performed on the same day as an E/M service and both should be paid and not considered bundled? --- ------CORRECT ANSWER----------------- 25 What modifier is used to indicate two procedures are performed on the same day and should not be bundled? ---------CORRECT ANSWER---------- ------- 59
NCDs are released by which of the following entities: ---------CORRECT ANSWER-----------------CMS Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include: ---------CORRECT ANSWER-----------------experimental procedures Which of the following modifiers are not used to bypass NCCI edits? --------- CORRECT ANSWER-----------------76, 77 When applying an LCD to services, which of the following statements is TRUE regarding the CPT® and ICD- 10 - CM codes reported on a claim form? ---------CORRECT ANSWER-----------------Documentation should provide medical necessity and support the CPT and ICD- 10 - CM codes reported Codes that are considered to be bundled are based on Centers for Medicare & Medicaid (CMS) standards called: ---------CORRECT ANSWER-----------------NCCI An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier? ---------CORRECT ANSWER----------------- 24 Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found? ---------CORRECT ANSWER-----------------MSP Manual
Most medical debt is discharged, the provider will write-off amounts owed. - --------CORRECT ANSWER-----------------chapter 7 bankruptcy codes What does a high number of days in A/R indicate for a medical practice? --- ------CORRECT ANSWER-----------------problem in revenue cycle TRICARE is the healthcare program for which department of the US government? ---------CORRECT ANSWER-----------------dept of defense Which of the three TRICARE options are not available to active duty service members? ---------CORRECT ANSWER-----------------reserve select, select Medicaid agencies are required to report EPSDT performance information - --------CORRECT ANSWER-----------------annually The conversion factor is updated by CMS ---------CORRECT ANSWER------ -----------annually TRICARE Prime as his health plan. Who will be responsible for coordinating his health care, maintaining his medical records and referrals to specialists when needed ---------CORRECT ANSWER----------------- primary care manager
Medicare's payment amount for services are determined by which of the following formulas? ---------CORRECT ANSWER-----------------RVU x conversion factor Barbara's late husband, Joe, was a lieutenant in the Navy. He served for 30 years, retiring 10 years prior to his death that was related to service connected disability. Barbara will still have healthcare coverage as Joe's widow under which of the following healthcare programs? --------- CORRECT ANSWER-----------------CHAMPVA To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service is payable, noncovered, or bundled into another service? ---------CORRECT ANSWER-----------------status codes The term for a supplemental policy for Medicare is: ---------CORRECT ANSWER-----------------Medigap The Clinical Prior Authorization (PA) Program assists in the monitoring of: - --------CORRECT ANSWER-----------------drugs not on Medicaid formulary Which TRICARE option allows enrollees the most choices utilizing the fee- for-service model? ---------CORRECT ANSWER-----------------select Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the
Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the Blue Cross/Blue Shield network or outside of the network. What type of plan best describes Carl's insurance coverage? ---------CORRECT ANSWER-----------------pt of service Not allowed under a participating provider's contract. ---------CORRECT ANSWER-----------------balance billing A savings account that allows individuals to save pre-tax dollars to reimburse for healthcare expenses is known as a(n): ---------CORRECT ANSWER-----------------FSA, HSA Obtaining approval from the insurance payer before a procedure is performed is known as: ---------CORRECT ANSWER-----------------prior auth Timely filing restrictions are determined by: ---------CORRECT ANSWER---- -------------payer Blue Cross/Blue Shield identifies the individual or employer who pays for healthcare insurance coverage as the: ---------CORRECT ANSWER---------- -------subscriber If a claim is denied, investigated, and found to be denied in error, what should a biller do? ---------CORRECT ANSWER-----------------appeal
An initial denial is received in the office from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna's policy, what must the biller do? --------- CORRECT ANSWER-----------------submit a reconsideration Under what Federal Act must insurance companies implement effective to appeals processes? ---------CORRECT ANSWER-----------------pt protection and affordable care act Which of the following can be appealed regarding a claim? --------- CORRECT ANSWER-----------------coordination of benefits According to Cigna's appeals process, how many level of internal appeals are offered? ---------CORRECT ANSWER----------------- 11 According to Aetna's published guidelines, what is the timeframe for filing an appeal? ---------CORRECT ANSWER-----------------60 days A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received? ---------CORRECT ANSWER- ----------------liability issue When the Cigna appeals process has been exhausted, what happens if the provider still disagrees with the decision? ---------CORRECT ANSWER------- ----------arbitration
subject to that makes the practice a creditor? ---------CORRECT ANSWER- ----------------Truth in Lending Act Which of the following situations allows release of PHI without authorization from the patient? ---------CORRECT ANSWER-----------------workers comp misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients. --------- CORRECT ANSWER-----------------abuse A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? --------- CORRECT ANSWER-----------------abuse According to the Privacy Rule, what health information may not be de- identified? ---------CORRECT ANSWER-----------------phys provider number making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program ---------CORRECT ANSWER-----------------fraud All the following are considered Fraud, EXCEPT: ---------CORRECT ANSWER-----------------inadequate med recd
A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on to the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? ---------CORRECT ANSWER-----------------breach impermissible release or disclosure of information is discovered --------- CORRECT ANSWER-----------------breach What standard transactions is NOT included in EDI and adopted under HIPAA? ---------CORRECT ANSWER-----------------waiver of liability The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident? ---------CORRECT ANSWER----------------- 7 A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate? ---------CORRECT ANSWER-----------------anti kickback laws A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? --------
- CORRECT ANSWER-----------------biz associate Medicare overpayments should be returned within ___ days after the overpayment has been identified ---------CORRECT ANSWER----------------- 60
A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients' claims. The manager of the office brought the civil suit. What type of case is this? ---------CORRECT ANSWER-----------------qui tam OIG, CMS, and Department of Justice are the government agencies enforcing ________. ---------CORRECT ANSWER-----------------fed abuse and fraud laws A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? -- -------CORRECT ANSWER-----------------TILA An insurance plan that provides a gatekeeper to manage the patient's health care is known as a/an ---------CORRECT ANSWER----------------- HMO a corporate umbrella for management of diversified healthcare delivery systems ---------CORRECT ANSWER-----------------IPO An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of- pocket healthcare expenses. She may contribute up to $2650 (2018) per year. If she does not use all of the money during the current year, she forfeits it. What is this? ---------CORRECT ANSWER-----------------FSA
Which option is not considered an MCO? ---------CORRECT ANSWER------- ----------HSA A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim. How should the visit be billed? ---------CORRECT ANSWER----------------- Homeowners, then Medicare Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance? --------- CORRECT ANSWER-----------------association group office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician? --------- CORRECT ANSWER-----------------non par A new physician comes into the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans? ---------CORRECT ANSWER----------------- Credentialing Medicare part without a monthly charge if worked for 10+ years --------- CORRECT ANSWER-----------------A
a unique 10-digit identification number required by HIPAA --------- CORRECT ANSWER-----------------NPI Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct? ---------CORRECT ANSWER-----------------All plans offer HMOs A new physician comes in to the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans? ---------CORRECT ANSWER----------------- credentialling NPI numbers have two types of entities - identify the two types: --------- CORRECT ANSWER-----------------group and sole proprietor NPI ---------CORRECT ANSWER-----------------National Provider Identifier Which of the following services is NOT covered under Medicare Part B? ----
- ----CORRECT ANSWER-----------------Home Health ACOs are formed with ___ lives ---------CORRECT ANSWER----------------- 5000 HMOs are formed with ___ lives ---------CORRECT ANSWER----------------- 100,000 +
When insurance coverage is being verified, which of the following is NOT a method on which to rely? ---------CORRECT ANSWER-----------------patient When a fee ticket (encounter form) is not completed, what procedure would NOT be acceptable? ---------CORRECT ANSWER-----------------no charge Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step? ---------CORRECT ANSWER----------------- verify benefits determine primary and secondary coverage ---------CORRECT ANSWER--- --------------birthday rule Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment? ---------CORRECT ANSWER-----------------auth for treatment Patient types help to classify the patients based on ---------CORRECT ANSWER-----------------payer, ins type Life Cycle of a Claim ---------CORRECT ANSWER-----------------submission processing adjudication payment/denial
If a procedure is performed on a 72-year-old Medicare patient which code category is preferred for reporting? ---------CORRECT ANSWER--------------- --G code HCPCS The NCCI policy manual is updated: ---------CORRECT ANSWER------------- ----annually The part of National Correct Coding Initiative (NCCI) that places frequency limitations on codes that can be billed on a single date of service by a single provider is called: ---------CORRECT ANSWER-----------------MUE provide limitations of frequency on codes that can be billed in a single day by a single provider for a beneficiary. ---------CORRECT ANSWER------------ -----MUE NCCI edits are updated by CMS and released ---------CORRECT ANSWER-----------------quarterly When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user: ---------CORRECT ANSWER----------------- mod not allowed Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider. - --------CORRECT ANSWER---- -------------NCCI file
What is the purpose of the standard CMS-1500 claim form? --------- CORRECT ANSWER-----------------pro services for phys FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span code and dates. When is this section completed? ---------CORRECT ANSWER-----------------inpt services When entering the patient's name on the CMS-1500 claim form, what punctuation should be used? ---------CORRECT ANSWER----------------- comma A ___ is used to indicate an inpatient service is reported on an outpatient claim. ---------CORRECT ANSWER-----------------condition code The UB-04 claim form is also called: ---------CORRECT ANSWER------------- ----CMS 1450 Determination of the insurer's payment amount after the member's insurance benefits have been applied. ---------CORRECT ANSWER----------- ------adjudication ___ provider with overall responsibility for the patient's medical care during hospitalization. ---------CORRECT ANSWER-----------------attending
