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AAPC Official CPC Certification Study Guide Notes

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AAPC Official CPC Certification Study Guide Notes "hold harmless clause" - * found in some non-Medicare health plan contracts * prohibits billing to patient for anything beyond deductibles and co-pays. A compliance plan may offer several benefits, including: - * more accurate payment of claims...

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  • July 7, 2023
  • 11
  • 2022/2023
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AAPC Official CPC Certification Study
Guide Notes
"hold harmless clause" - * found in some non-Medicare health plan contracts
* prohibits billing to patient for anything beyond deductibles and co-pays.

A compliance plan may offer several benefits, including: - * more accurate payment of
claims
* fewer billing mistakes
* improved documentation and more accurate coding
* less chance of violating self-referral and anti-kickback status

A healthcare clearing house is a - entity that processes nonstandard health information
they receive from another entity into a standard format

A key provision in HIPAA is the Minimum Necessary requirement. this means - only the
minimum necessary protected health information should be shared to satisfy a particular
purpose.

A medically necessary service is the - least radical service/procedure that allows for
effective treatment of the patients' complaint or condition

A patient sustaining an injury to her great saphenous vein would have sustained injury to
which of anatomical site? - Leg

APC - Ambulatory Payment Classification

ARRA - American Recovery and Reinvestment Act (of 2009)

ASC - Ambulatory Surgical Centers

Abuse consists of - payment for items or services that are billed by providers in error that
should not be paid for by Medicare.

An ABN protects the provider's financial interest by - creating a paper trail that CMS
requires before a provider can bill the patient for payment if Medicare denies coverage for
the stated service or procedure.

An entity that processes nonstandard health information they receive from another entity
into a standard format is considered what? - Clearinghouse

As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of
fraud to remove the __________ requirement - intent

, By statute, all work RVUs, must be examined no less often than - every 5 years

CF - Coversion Factor - fixed dollar amount used to translate the RVUs into fees

CMS - Centers for Medicare and Medicaid

CMS developed polices regarding medical necessity are based on regulations found in title
XVIII, $1862(a) of the - Social Security Act

CMS will accept the ____________ for either a "potentially non=covered" service or for a
statutorily excluded service - CMS-R-131

CMS-R-131 - ABN form

or

Advance Beneficiary Notice which explains to the patient why Medicare may deny the
particular service or procedure.

CPT - Current Procedural Terminology

CY 2013 Conversion Factor - $25.0008

Commercial (non-Medicare) may develop their own medical policies which do not follow
Medicare guidelines and are specified in - private contracts between the payer and practice
or provider

DRG - Diagnosis Related Group

Does Medicare Part B generally require a yearly deductable and copayment? - yes

E/M OR E&M - Evaluation and Management

EHR - Electronic Health Record

Formula for Calculating Facility Payment amounts - [(Work RVU * Work GPCI) +
(Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF

Formula for Non-Facility Pricing Amount - [(Work RVU * Work GPCI) + (Transitioned Non-
Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * (CF)

GPCI - Geographic Practice Cost Index

GPCI is used to - realize the varying cost based on geographic location

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