AAPC-CPB Certified Professional Biller - Set 3 - Part 1

Correct Answer: Institutional Review Board or Privacy Board waiver documentation

The Privacy Rule permits disclosure for research without authorization when the covered entity obtains documentation that an Institutional Review Board or Privacy Board approved an alteration or waiver of the individuals' authorization for the research use. Option b is incorrect because it is another distinct permitted category, built on giving the individual a chance to agree or object, and it is not the research basis. Option c is incorrect because required disclosures are limited to two situations, access or accounting requests from individuals and HHS compliance reviews, so a university research request is outside both. Option d is incorrect because it is a separate permitted category covering care, billing and internal functions, and a request for a generalizable-knowledge study does not fall within it.

Correct Answer: originator

Under the Privacy Rule, a covered entity must obtain an authorization for psychotherapy notes, except that the originator of the notes may use them for treatment without one. Option a is incorrect because payment is not the use the exception allows here; the rule permits only the originator's own treatment use without authorization. Option c is incorrect because business associates are not named in the exception, which gives the treatment use to the covered entity that created the notes. Option d is incorrect because an oversight agency may receive the notes for lawful oversight of the originator, which is a disclosure exception and not a treatment use.

Correct Answer: A statement reserving the right to make such changes

A covered entity may apply a changed privacy practice to protected health information created or received before the notice revision only if its notice included a statement reserving its right to make such a change. Option b is incorrect because documentation governs other policy changes made at any time; it does not settle whether a notice practice change reaches earlier information. Option c is incorrect because the rule makes retroactive effect depend on a statement in the notice, and it does not mention any individual authorization. Option d is incorrect because change-in-law provisions require prompt policy updates and notice revision, but they do not set the condition for applying a practice change to earlier information.

Correct Answer: Proof of intent to violate the law

The PSL is a strict-liability statute, so proof of intent to violate the law is not required. The six elements are a physician, a referral, DHS, Medicare payment, an entity, and a financial relationship. Option a is incorrect because a financial relationship, either an ownership or investment interest or a compensation arrangement, is the sixth element linking the physician and the entity. Option b is incorrect because a physician making the referral is the first listed element, so it must be present for the PSL to be implicated. Option d is incorrect because payability by Medicare is the fourth element; the designated health services referred must be payable by Medicare for the law to apply.

Correct Answer: No longer than 30 days from the oral statement

Under the law enforcement delay provision, an oral statement must be documented, including the official's identity, and the delay is temporary, no longer than 30 days from the oral statement, unless a written statement arrives during that time. Option a is incorrect because the covered entity has no discretion here; an oral statement permits only a temporary delay, and it must be documented. Option b is incorrect because 60 calendar days is the outer limit for a business associate's notice to the covered entity after discovery, not the oral-statement delay period. Option c is incorrect because the regulation sets a fixed outer limit for oral statements instead of tying delay to the end of an investigation.

Correct Answer: Claim tainted by illegal remuneration

A claim that includes items or services resulting from an anti-kickback statute violation is tainted by illegal remuneration. Such a claim is false or fraudulent, creating liability under the civil False Claims Act. Option b is incorrect because this is a separate example of a false claim, where the service was never actually provided to the patient, and the excerpt does not concern that situation. Option c is incorrect because upcoding means billing a higher level of service than was provided, which is a distinct example and not tied to anti-kickback statute violations. Option d is incorrect because the problem here is missing documentation in the patient's record, whereas the excerpt turns on a violation of the anti-kickback statute.

Correct Answer: Assessment under the PSL

OIG guidance says it is usually best to start with an assessment under the PSL because it is a strict liability statute. An arrangement permissible under the PSL still needs separate analysis under the Federal anti-kickback statute. Option a is incorrect because this statute must still be analyzed separately, but the guidance places it second, after the arrangement is found permissible under the PSL. Option b is incorrect because the advisory opinion process is a distinct mechanism, and the guidance does not make it the first step in evaluating an arrangement. Option c is incorrect because the False Claims Act is a separate civil law on false claims; the guidance links it to PSL violations afterward, not as the starting review.

Correct Answer: services

OIG guidance states that a properly documented medical record verifies and documents precisely what services were actually provided. This is why documentation supports the accuracy of billing as well as patient care. Option b is incorrect because referrals belong to the kickback and self-referral risk area, and the documentation discussion does not describe the record as verifying them. Option c is incorrect because a fee schedule sets payment amounts and is no part of clinical documentation, so a medical record cannot verify what was provided through it. Option d is incorrect because diagnoses are part of encounter content, such as assessment or clinical impression, but the record verifies the services actually delivered to the patient.

Correct Answer: Facility rate

Under the site of service payment differential, a service to a hospital inpatient is paid at the facility rate regardless of where the face-to-face encounter occurred. The place of service code governs the rate. Option a is incorrect because nonfacility rates apply when the place of service code identifies a nonfacility setting, which is not the case for a hospital inpatient. Option c is incorrect because contractor pricing is reserved for services lacking fee schedule RVUs, such as By Report services, and does not apply to this situation. Option d is incorrect because participation status drives the five percent nonparticipating reduction, a separate differential that does not decide between facility and nonfacility settings.

Correct Answer: Services requiring By Report payment

Medicare guidance says CMS provides fee schedule RVUs for all services except four groups: local codes, national codes without established relative values, By Report or A/B MAC (B) priced services, and non-physicians' services. Option a is incorrect because the exclusion list reaches national codes only when national relative values have not been established, so codes with established values are not in the excluded group. Option b is incorrect because Medicare guidance treats unusual circumstances as a basis for A/B MACs (B) to raise or lower payment after record review; it is not listed among the exclusions. Option d is incorrect because these prepayment edits exist to detect separate billing of services already included in the global package, and the list of services without CMS RVUs does not name them.

Correct Answer: Participating versus nonparticipating differential

Medicare's manual places the 95 percent ceiling on payments to nonparticipants under the participating versus nonparticipating differential, one of the listed adjustments made to reach the final fee schedule amount. Option b is incorrect because a re-operation reduction is tied to repeat surgery, while the excerpt turns on whether the payee is a participant, with no reference to surgical procedures. Option c is incorrect because the excerpt sets its limit by the provider's participation status, not by the place where the service is furnished, so this listed adjustment does not fit. Option d is incorrect because the excerpt caps payment at a percentage of the fee schedule amount for nonparticipants and says nothing about a markup, which this adjustment's name concerns.

Correct Answer: Included in the payment for the procedure

Visits by the same physician on the same day as a minor surgery are included in the procedure payment unless a significant, separately identifiable service is also performed. Identifying the need for sutures and confirming allergy and immunization status does not qualify. Option a is incorrect because separate payment requires a significant, separately identifiable service, such as a full neurological examination for head trauma, and this visit did not go beyond identifying sutures and checking status. Option b is incorrect because the day of the procedure does not by itself justify separate payment; same-day visits by the same physician are included unless a separately identifiable service is performed. Option d is incorrect because a postoperative visit relates to recovery from the procedure, and A/B MACs (B) do not allow separate payment for those within the 10 days either.

Correct Answer: Services for complications requiring a return to the operating room

The global surgical package covers complications only when they do not require additional trips to the operating room. Care for a complication that does require a return trip is therefore outside the package. Option b is incorrect because these are the postoperative visits component, which covers follow-up care during the postoperative period that relates to recovery. Option c is incorrect because it falls under the miscellaneous services the Medicare manual lists as part of the package, alongside dressing changes and removal of drains, casts and splints. Option d is incorrect because the Medicare manual names it as its own component of the package, so the surgeon cannot bill it separately.

Correct Answer: The 10 days immediately following the day of surgery

For major surgeries, A/B MACs count 1 day before surgery, the day of surgery, and the 90 days after. A 10-day postoperative period applies to some minor surgeries, not to the major surgery count. Option a is incorrect because the preoperative day is part of the count, since the major surgery period begins with 1 day immediately before the surgery date. Option c is incorrect because the date of the procedure is counted for both major and minor procedures, so it belongs inside the global period. Option d is incorrect because these days make up the postoperative portion of a major surgery's global period, ending on the last postoperative day.

Correct Answer: Descending order by Medicare fee schedule amount

Under the standard multiple surgery rules, the claims system ranks the surgeries in descending order by Medicare fee schedule amount. The highest valued procedure receives full payment, and later ranked procedures are paid at reduced percentages. Option a is incorrect because line position carries no weight in the standard rules; surgeries are ranked by their Medicare fee schedule values instead of submission sequence. Option b is incorrect because the billed amount only serves as a cap, since payment is based on the lower of billed amount or fee schedule amount; it does not set rank. Option d is incorrect because the ranking runs from highest to lowest value, so the highest valued procedure is paid in full and lower ones are reduced.

Correct Answer: Complications rules

When a patient returns to the operating room on the same day because of complications from the original surgery, the complications rules apply to each procedure needed to treat the complications. The multiple surgery rules do not apply. Option a is incorrect because these cover procedures performed on both sides of the body in one operative session or on one day, which is unrelated to treating complications. Option b is incorrect because the manual states these rules would not apply to procedures treating complications, whether the return occurs on the same day or later in the postoperative period. Option c is incorrect because these address more than one surgeon participating in a single procedure, not payment for a return to the operating room because of complications.

Correct Answer: Anesthesia practitioner begins preparing the patient for anesthesia

Medicare defines anesthesia time as the period the anesthesia practitioner is present with the patient. It starts when the practitioner begins preparing the patient for anesthesia services in the operating room or an equivalent area. Option b is incorrect because this documentation can support one additional time unit under the medically supervised rate, but it does not define when anesthesia time begins. Option c is incorrect because the manual ties the start to the practitioner's preparation of the patient in the operating room or equivalent area, not to the surgical procedure. Option d is incorrect because that event relates to the end of anesthesia time, when the practitioner is no longer furnishing anesthesia services to the patient.

Correct Answer: The procedure with the highest base unit value

Medicare instructs physicians to bill anesthesia for multiple bilateral surgeries by reporting the procedure with the highest base unit value with the multiple procedure modifier, and to report total time for all procedures on that line item. Option a is incorrect because the guidance directs the physician to report the total time for all procedures in a single line item, not to split time among lines. Option b is incorrect because actual time of all procedures is combined and reported on one line, which is chosen by base unit value rather than by duration. Option c is incorrect because the guidance ties total time to base unit value, not to the order in which the surgeries were performed.

Correct Answer: Personally performing every procedure in the anesthesia plan

The physician must personally participate only in the most demanding procedures and must ensure that any other procedures in the plan are performed by a qualified individual. Personally performing every procedure is not required. Option b is incorrect because the Medicare manual lists prescribing the anesthesia plan as one of the required physician activities for medically directed payment. Option c is incorrect because the manual requires the physician to provide indicated post-anesthesia care, and the medical record must document that it was done. Option d is incorrect because frequent monitoring of anesthesia administration appears among the required activities, so it belongs to the set the stem names.

Correct Answer: benchmark

The statute requires estimated average per capita Medicare expenditures for parts A and B to be at least a set percent below the applicable benchmark, which the Secretary estimates for each agreement period for each ACO. Option a is incorrect because quality performance standards are a separate eligibility condition the ACO must meet, and they are not the expenditure level that spending is measured against. Option c is incorrect because this is the span of the ACO's agreement, in each year of which savings are determined; it does not serve as a spending comparison figure. Option d is incorrect because this describes how a beneficiary is attached to an ACO, and a beneficiary's voluntary identification can supersede it; it sets no expenditure threshold.