AAPC-CIC Certified Inpatient Coder - Set 5 - Part 1

Correct Answer: Certifying that providers meet conditions of participation

State agencies certify to DHHS whether providers satisfy, and continue to satisfy, the conditions of participation. The A/B MAC (A) and (HHH) enrolls providers, processes claims and makes payments, but does not perform certification. Option b is incorrect because the A/B MAC pays providers, with the payment amount restricted to the lower of billed charge, reasonable cost or fee schedule amount. Option c is incorrect because the guidance names enrollment of legitimate providers as a core duty of the A/B MAC under its agreement with CMS. Option d is incorrect because claims processing under both Part A and Part B is stated as part of what the A/B MAC does for institutional providers.

Correct Answer: I, II, and IV

CMS determines entitlement in consultation with the SSA, manages the Medicare Premium Collection Operation, and establishes operational policy for contractors. Advising State agencies on provider standards belongs to the Public Health Service. Option a is incorrect because statement III describes a duty of the Public Health Service, which advises State agencies on provider standards, rather than a CMS duty. Option b is incorrect because statement III is assigned to the Public Health Service, so this pairing leaves out two CMS duties and includes a non-CMS one. Option d is incorrect because this choice counts all four statements, yet one of them is a Public Health Service function, not a CMS responsibility under the manual.

Correct Answer: Step therapy

Step therapy is a utilization management policy for coverage of drugs. It begins medication for a condition with the most preferred or cost effective therapy and moves to other therapies if medically necessary. Option b is incorrect because it identifies a person, either a full subsidy eligible or other subsidy eligible individual, rather than a utilization management policy for drugs. Option c is incorrect because it is a process of grouping Part D drugs into different cost sharing levels within a sponsor's formulary, not a sequence of therapies. Option d is incorrect because it names the geographic area, defined differently for each plan type, within which access standards are met, and says nothing about drug therapy order.

Correct Answer: Terminally ill

To elect hospice care under Medicare, an individual must be entitled to Part A and be certified as terminally ill, meaning a medical prognosis of a life expectancy of 6 months or less if the illness runs its normal course. Option a is incorrect because Medicare ties hospice election to Part A entitlement; Part B is the supplementary medical insurance program with its own enrollment period and premiums. Option b is incorrect because posthospital extended care in a SNF is a separate Part A benefit with its own day limit, not a hospice election condition. Option d is incorrect because confinement to the home is a requirement for home health benefits, which Medicare treats as a separate eligibility rule from hospice election.

Correct Answer: Part B cannot pay for visits that Part A may pay.

Part B is designed to supplement hospital insurance, so payment may not be made under Part B for any service that may be paid under Part A. Part B pays only where Part A payment is not possible. Option a is incorrect because the order is reversed: the first 100 visits are paid under Part A for a beneficiary entitled under Part A, and the remainder of the visits may be paid under Part B. Option b is incorrect because to obtain SMI, an eligible individual must enroll during an enrollment period and pay the required premiums, even when entitled to HI. Option c is incorrect because the deductible applies to covered services under Part B, yet payment is barred under Part B whenever a service may be paid under Part A.

Correct Answer: Oxygen

The Medicare Benefit Policy Manual states that oxygen furnished to hospital inpatients is covered under Part A as an inpatient supply. The other choices are excluded or covered only under narrow stated conditions. Option a is incorrect because Medicare does not pay for deluxe accommodations in any case, so they are excluded and are not treated as a covered supply. Option b is incorrect because these are not covered as inpatient hospital services in general, except for a limited supply medically necessary to permit or facilitate departure. Option d is incorrect because such packs are not covered; the hospital may charge the beneficiary only if the request is made knowing the item and its charge.

Correct Answer: Services reasonably attributable to preparation for the transplant

Medicare treats services as "related to" a non-covered transplant when the nature of the services and their timing against the date the beneficiary was identified as a transplant candidate show they prepared for the transplant. Such services are also non-covered. Option a is incorrect because Medicare guidance gives a broken leg in a hospitalized beneficiary as a clear example of a "not related to" service, which remains covered. Option c is incorrect because when the original admission was entirely unrelated to the diagnosis leading to the transplant recommendation, Medicare guidance says the services for the admitting condition would be covered. Option d is incorrect because services needed after discharge to treat complications of earlier non-covered services may be covered under the guidance if reasonable and necessary in all other respects.

Correct Answer: Medical social services

Under 42 CFR 409.10, inpatient hospital or inpatient CAH services include medical social services, listed with bed and board, nursing, facility use, supplies, and transportation. The other three options appear in the list of services not included. Option a is incorrect because the regulation carves this out of the definition when furnished by a hospital or CAH with swing-bed approval, so it is not an inpatient hospital service. Option b is incorrect because the regulation lists these among the types of services that inpatient hospital services do not include, so they fall outside the definition. Option c is incorrect because these appear on the regulation's list of excluded service types, alongside nurse practitioner and clinical nurse specialist services, and are not part of the covered definition.

Correct Answer: Nonphysician services furnished outside hospital arrangements

Medicare excludes nonphysician services furnished to hospital inpatients by anyone other than the hospital or a provider or supplier under arrangements made by the hospital. An outside supplier without an arrangement falls within this exclusion. Option b is incorrect because custodial care is excluded because of the kind of care provided and is furnished by the hospital itself, which does not match an outside supplier. Option c is incorrect because it depends on whether the patient is entitled to Part A benefits at all, which the scenario never questions; the problem here is the supplier. Option d is incorrect because this exclusion turns on the patient's used-up Part A benefit days, not on who furnished the service or whether the hospital arranged it.

Correct Answer: Federal Supplementary Medical Trust Fund

Part B is financed by monthly premiums of voluntary enrollees and Government contributions from general revenues. All of this money is deposited in the Federal Supplementary Medical Trust Fund, which pays only Part B benefits and administrative expenses. Option a is incorrect because it receives the payroll contributions that finance Part A and pays only for hospital insurance benefits and related administrative expenses, not Part B. Option c is incorrect because Medicare names no such fund for Part B; premiums and general revenue contributions go to the Federal Supplementary Medical Trust Fund instead. Option d is incorrect because Medicare Premium Collection is an operation that CMS manages, not a trust fund that holds Part B premiums and Government contributions.

Correct Answer: Tiered cost-sharing

Under 42 CFR 423.4, tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. Option a is incorrect because this refers to the geographic area where a plan meets access standards, so it describes location rather than drug grouping within a formulary. Option b is incorrect because this names a product licensed under a biologics license application and marketed without a brand name, which is a drug product type, not a cost sharing process. Option d is incorrect because this term identifies a person who qualifies as a full or other subsidy eligible individual, not a method of grouping drugs by cost level.

Correct Answer: Consultation, proposed LCD publication, open meeting, written public comment, final LCD with response to comments, 45-day notice

The Medicare manual requires proposed LCDs to move through consultation, publication of the proposed LCD, an open meeting, written public comment, a final LCD with response to comments, and public notice 45 days before the effective date. Option b is incorrect because an open meeting concerns the proposed policy, so it cannot precede consultation or publication, and the 45-day notice announces the new policy after the final LCD. Option c is incorrect because consultation is the first step in the process, and the open meeting concerns the published proposed policy, so this order places both out of position. Option d is incorrect because the final LCD must follow public comment because it includes a response to comments received, and the proposed LCD is published before any meeting.

Correct Answer: Compliance toolkit on measuring effectiveness

OIG created compliance toolkits to give the health care community a structured approach to measure compliance program effectiveness. The toolkit lists measurement options applicable to organizations of diverse size, complexity, and resources. Option a is incorrect because it accepts tips and complaints about potential fraud, waste, abuse, and mismanagement in HHS programs, so it gives an entity no measurement options. Option b is incorrect because its educational materials and case examples teach physicians about Federal laws protecting Federal health care programs from fraud, waste, and abuse, which is a different purpose. Option c is incorrect because it is the primary statistical tool of OIG's Office of Audit Services, used to select random samples and estimate improper payments, not to measure program effectiveness.

Correct Answer: Voluntary, nonbinding guidance

OIG uses the word "should" in the General Compliance Program Guidance to present voluntary, nonbinding guidance. The document is not binding on any individual or entity and creates no new legal obligations. Option b is incorrect because the guidance states it is not binding on any individual or entity, and it does not establish or interpret program rules or regulations. Option c is incorrect because OIG states the guidance does not create any new law or legal obligations; it only summarizes existing Federal authorities. Option d is incorrect because the guidance and its legal overviews do not address State fraud and abuse laws, and they are summaries only.

Correct Answer: Completion of the medical screening examination

Where EMTALA applies, a written notice should not be given until the hospital has met its EMTALA obligations, which include completing the medical screening examination or stabilizing any emergency medical condition. Option a is incorrect because a routine notice given to all beneficiaries is itself an unacceptable form of evidence of knowledge and cannot serve as a timing point. Option b is incorrect because claim submission comes after services are furnished; the guidance ties the timing of notice to the hospital meeting its EMTALA obligations instead. Option d is incorrect because an authorized representative is also not expected to make a rational decision in an emergency, so arrival does not make the beneficiary a capable recipient.

Correct Answer: Generic written notice

A generic written notice is a routine document that does no more than say Medicare denial is possible, or is little more than a signed agreement to pay if Medicare denies anything. It is not acceptable evidence of written notice. Option b is incorrect because such a notice is acceptable for current items only if it cites similar items with denial expected on the same basis, which this form does not. Option c is incorrect because that problem arises when a beneficiary signs a notice left blank and the notifier completes it later, which is not what this form describes. Option d is incorrect because a blanket notice means giving written notices for all claims, items or services, whereas this form is defined by its vague promise to pay, not by its scope.

Correct Answer: Refund the beneficiary the proper amount

Under the Collection of Funds and Refunds provision, when Medicare or a secondary insurer pays all or part of a claim the beneficiary already paid, the notifier must refund the beneficiary the proper amount in a timely manner. Option a is incorrect because retention applies when Medicare ultimately denies the claim and does not find the provider liable, which is the opposite of a later payment. Option b is incorrect because a new notice does not resolve funds already collected; the guidance calls for a timely refund of the proper amount. Option c is incorrect because the guidance directs the money back to the beneficiary who paid it, not to a contractor.

Correct Answer: Service furnished under the Medicare Advantage Program

The Medicare manual lists ordering/rendering, technical/professional and signature/billing splits as situations where either party may be notifier. The ABN is not used for items or services under the Medicare Advantage Program, so it is not such a circumstance. Option a is incorrect because a physician ordering a lab test while an independent laboratory performs it is the CMS manual's own example of when either party may be notifier. Option b is incorrect because when the entity collecting the signature differs from the one billing Medicare, such as a referring laboratory, the manual permits either party to act as notifier. Option d is incorrect because the manual lists this split, such as a facility rendering a radiological test and a physician interpreting it, as allowing either party to give the notice.

Correct Answer: a one-size-fits-all approach

OIG states that the general and industry-specific guidance documents are a resource and are not intended to be one-size-fits-all, completely comprehensive, or all-inclusive of compliance considerations for every organization. Option b is incorrect because helping organizations consider risk areas is a stated goal of the guidance, so this phrase describes what the documents do. Option c is incorrect because OIG itself calls the guidance voluntary compliance guidelines and tips, so describing it that way matches its stated purpose rather than contrasting with it. Option d is incorrect because the guidance is meant to be considered when developing a new compliance program or evaluating and updating an existing one, so this is an intended use.

Correct Answer: Greater harm or liability than having no program

OIG hospital guidance warns that programs hastily constructed and implemented without appropriate ongoing monitoring will likely be ineffective and could cause greater harm or liability to the hospital than no program at all. Option a is incorrect because the guidance describes programs as an internal control but never promises protection from sanctions, and a poorly monitored program may increase exposure rather than shield the hospital. Option b is incorrect because claims and billing operations are described as often being a source of fraud and abuse, and a rushed, unmonitored program cannot be expected to remove that risk. Option d is incorrect because OIG states that an effective program demands a substantial commitment of time, energy and resources from senior management and the governing body, so rushing does not lessen that demand.