AAPC CPC Compliance and Regulatory Test Questions And Answers

We thoroughly check each answer to a question to provide you with the most correct answers. Found a mistake? Tell us about it through the REPORT button at the bottom of the page. Ctrl+F (Cmd+F) will help you a lot when searching through such a large set of questions.

Outpatient CodingFocuses on physician professional services and outpatient facility coding. Coders should learn CPT, HCPCS Level 2 and ICD-10-CM.
Hospital Inpatient CodingFocuses on a different subset of skills, where coders will work with ICD-10-CM and ICD-10-PCS. Coders assign medical severity diagnosis related groups (MS-DRGs).
Types of Providers1. Primary Care Provider (PCP) 2. Physician Extenders 3. Participating Providers 4. Non Participating Providers.
PCPPrimary Care Provider (Gate Keeper).
Physician ExtendersMid-level provider, Advanced Practice Registered Nurse (ARPN), Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS).
Participating Providers – Par Provider or In Network Provider (INN)Is one contracted with the health insurance company to provide service to plan members for specific pre-negotiated rates.
Non Participating Providers – Non Par Provider or Out of Network Provider (OON)Is one not contracted with the health insurance plan.
2 Primary Types of InsurersPrivate Insurance Plans, Government Insurance Plans.
Commercial Insurance or Non Federal InsuranceAre private payers that may offer both group and individual plans. Contracts they provide may include hospitalization, basic and major medical coverage.
Government Insurance or Federal InsuranceThe most significant insurance is Medicare.
MedicareIs a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS).
Centers for Medicare and Medicaid Services (CMS)Provides coverage for people over the age 65, blind or disabled individuals, and people with permanent kidney failure or ESRD.
CMS RegulationsDetermine the coding requirements for Medicare and non-Medicare payers alike.
Medicare Program is Made Up of Several PartsMedicare Part A, Medicare Part B, Medicare Part C, Medicare Part D.
Medicare Part ACover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare.
Medicare Part BCovers medically necessary physicians’ services, outpatient care and other medical services (including some preventive services). Medicare Part B is an optional benefit for which the patient must pay a premium and which generally require a yearly deductible and co-insurance.
Medicare Part C (Medicare Advantage)Combines benefits of Part A and Part B and sometimes Part D. Plans are managed by private insurers approved by Medicare. The plans may charge different co-payments, co-insurance, or deductibles for services.
Medicare Part D (Prescription Drug Coverage Program)Available to all Medicare beneficiaries. Private company approved by Medicare provide coverage.
MedicaidIs a health insurance assistance program for some low income people, children and pregnant women sponsored by federal state and state government.
State-Funded Insurance ProgramsProviding coverage for children up to 21 years of age may include crippled children’s services, children’s medical services, children’s indigent disability services and children with special health care needs.
CHAMPUS or TRICARE– Civilian Health and Medical Program of the Uniformed Services – Insurance linked to military services also known as TriCare – Benefits program for active duty and retired members of the military.
CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs)Is a health care benefits program for permanently disabled veterans and their dependents.
MEDIGAP InsurancePrivately purchased individual or group health insurance policies designed to supplement medicare coverage. Benefits may include payment of Medicare deductibles co-insurance and balance bills, as well as payment for service not covered by Medicare.
Workers CompensationInsurance provided by employers to cover employees injured on the job.
Managed Care Organization (MCO)Includes HMO, PPO, and POS plans.
HMOHealth Maintenance Organization.
PPOPreferred Provider Organization.
POSPoint of Service Plan.
Medical Physician Fee Schedule (MPFS)Look up tool, provides information on each procedure code including the global surgery indicator.
Resource Based Relative Value Scale (RBRVS)To determine how much money medical provider should be paid. Assigns procedures performed by a physician and other medical provider a relative value which is adjusted by geographic region.
Resource Costs are Divided Into 3 Components1. Physician Work 2. Practice Expense 3. Professional Liability Insurance (PLI).
Physician WorkAccounts for just over half (52%) of a procedure/service total relative value. Is measured by the time it takes to perform the service.
Practice ExpenseAccounts 44% of the total relative value for each service. Its relative values are resource based and differ by site of service.
Professional Liability Insurance (PLI)Accounts for 4% of the total relative value for each service.
Physician Fee Schedule (PFS)CMS annually publishes PFS information on its website.
PEPhysician Expense.
GPCI (Geographic Cost Index)Used to realized the varying cost based on geographic location.
CF (Conversion Factor)This is a fixed dollar amount used to translate the RVU’s into fees.
Medical NecessityRefers to whether a procedure or service is considered appropriate in a given circumstance.
National Coverage Determination, (NCD)Explain when Medicare will pay for items or service.
Medicare Administrative Contractor (MAC)Is responsible for interpreting national policies into regional policies, called Local Coverage Determination (LCD).
Local Coverage Determination (LCD)Explain when a given service is indicated or necessary, give guidance on coverage limitations, describe the specific CPT codes to which the policy applies, and list ICD-10-CM codes that support medical necessity for the given service or procedure.
Advance Beneficiary Notice (ABN)Is a written beneficiary notification to the beneficiary indicating that the insurer may not reimburse the cost of the procedure and therefore the patient may be liable to pay.
Types of Claims1. Paper Claims 2. Electronic Claims.
Types of Paper ClaimsHCFA, UB04.
Health Care Financing Administration (HCFA)Also called CMS-1500. Standard medical claim form used for submitting Medicare Part B (outpatient billing).
Uniformed Bill (UB 04)Also called as CMS 150. Paper claim for Medicare Part A (inpatient billing).
Types of Electronic Claims1. NSF 2. ANSI.
NSFNational Standard Format – Limited byte carrying capacity.
ANSIAmerican National Standard Institute – Flexible format.
Medical RecordsChronologically documents patients care between providers, facilitate claims receive and payments and can serve as legal documents. All services provided to the patient must be supported and documented.
EOB (Explanation of Benefits)Documents are protected health information. A report with details the results of processing a claim.
EOMBExplanation of Medicare Benefits, Remittance Advice.
EOB or EOMBA statement sent by a health insurance company to cover individuals, explaining what medical treatments and/or services were paid for on their behalf. Commonly attached to a check or statement of electronic payment.
EOB Typically DescribesThe payee, the payer, and the patient. The services performed. Doctor’s fee and what the insurer allows. The amount the patient is responsible for. Adjustment reasons, adjustment codes.
Co-PayIs a set amount.
CoinsuranceIs a percentage of the service costs that patients pay.
UCRAmounts commonly charged for a service within a particular geographic region.
EDIElectronic Data Interchange.
CapitationPre-established payments to providers for enrollees over a period of time, whether the patient is seen or not by the provider.
DeductibleThe amount the patient is financially responsible before an insurance policy provides payment.
CMS 1500Standard claim form used to submit physician office services to Medicare and other insurance payors.
TPAA company that provides health benefits claims administration, processes claims and other outsourcing services for self-insured companies.
COB (coordination of benefits)Prevents multiple insurance plans from paying benefits covered by other plans when the patient has more than one policy.
Timely FilingYou must file the claim within a set amount of time your insurance contract indicates to be paid.
MCOA health care provider or a group or organization of medical service providers who offers managed care health plans.
Participating ProviderPhysician will accept the amount paid by the insurance company and will be responsible to write-off the non-allowed amount.
Denied ClaimInvestigate to see why it was denied and re-bill with information to support payment.
Claim AdjudicationClaim is reviewed by the insurance company to make sure it correct for demographics, codes, payer rules have been followed and are covered benefits under the patients insurance contract.
Utilization Review OrganizationThe insurance companies will hire companies to review the appropriateness and medical necessity of procedures, surgeries and other services. This takes the burden off the insurance company off not authorizing a service due to cost.
Medigap PoliciesHealth insurance sold by private insurance to help pay for some costs the medicare plan doesn’t cover.
EPSDTEarly and Periodic Screening, Diagnosis, and Treatment – Medicaid’s comprehensive preventative child health care program for individuals 0-21 years of age.
Medicaid BenefitsFederally funded program, and administered by each state.
Service DescriptionIs a description of the health care services you received, like a medical visit, lab tests or screenings.
Provider ChargesIs the amount your provider bills for your visit.
Allowed ChargesIs the amount your provider will be reimbursed; this may not be the same as the provider charges.
Remark CodeIs a note from the insurance plan that explains more about the costs, charges and paid amounts for your visit.
HIPAA Standards Code Sets1. Codes for Dental Procedures and Nomenclature (CDT) 2. Healthcare Common Procedure Coding System (HCPCS).
National ProviderName for the identifier physicians and other healthcare providers must use when claiming Medicare reimbursement.
Medicare Part BPays for physician service.
Prospective AuditRefers to auditing patient records against proposed billing information.
Qui TamA lawsuit initiated by a private citizen on the government’s behalf.
Hospital Authorization for Emergency PatientsHospitals can request insurance prior authorization for patients with emergency medical conditions once the patient is admitted to the hospital as an inpatient.
Patient (under HIPAA)Would not be considered a covered entity under HIPAA.
HIPAA “Minimum Necessary” PolicyOnly individuals whose job requires it may have access to protected health information.
ARRAAmerican Recovery and Reinvestment Act.
HITECHHealth Information Technology Economic and Clinical Health Act.
OIG Compliance Plan GuidanceA document that is created to assist physician offices with the development of compliance manuals.
OIG Work PlanA document to be referred to when looking for potential problem areas identified by the government indicating scrutiny of the services within the coming year.
CoinsuranceAn arrangement where the patient and the insurance company share payment of a health care service.
AMACPT is published by the American Medical Association.
ICD 10-CMThe manual used to code diagnosis.
ICD 9-CMIs revised every year on October 1st.
HCPCSIs published by CMS.
COBCoordination of Benefits.
COBRAConsolidated Omnibus Budget Reconsideration Act.
DRGDiagnosis Related Group.
SSNSocial Security Number. It has 9 digits.
DSM IVDiagnostic and Statistical Manual of Mental Disorders, fourth edition.
Advanced Billing Contract CodesCodes are alphanumeric representatives of alternative medicine, nursing and other integrative health care interventions.
MACs or FIsCMS delegates the daily operation of the Medicare program to these entities.
Medicare Part ACovers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part BCovers most medically necessary doctor, preventative care, medical equipment, hospital outpatient services, lab tests, mental health care, home and ambulance. Always requires monthly premium.
Physician EditsThese code pairs apply to physicians, non-physician practitioners, and ambulatory surgery centers.
Outpatient EditsThese edits apply to the following types of bills: hospitals, skilled nursing facilities, home health agencies, outpatient physical therapy and speech language pathology providers, and comprehensive outpatient rehabilitation facilities.
National Coverage Determination (NCD)Is a US nationwide determination of whether Medicare will pay for an item or service.

Was this helpful?

Quizzma Team
+ posts

The Quizzma Team is a collective of experienced educators, subject matter experts, and content developers dedicated to providing accurate and high-quality educational resources. With a diverse range of expertise across various subjects, the team collaboratively reviews, creates, and publishes content to aid in learning and self-assessment.
Each piece of content undergoes a rigorous review process to ensure accuracy, relevance, and clarity. The Quizzma Team is committed to fostering a conducive learning environment for individuals and continually strives to provide reliable and valuable educational resources on a wide array of topics. Through collaborative effort and a shared passion for education, the Quizzma Team aims to contribute positively to the broader learning community.