AAPC-CPB Certified Professional Biller - Set 2 - Part 3

Correct Answer: Billing Provider National Provider ID

The Billing Provider National Provider ID is reported in FL 56, which falls outside the payer identification range of FLs 50 to 55. Health Plan ID, release of information and prior payments all belong to that range. Option b is incorrect because FLs 54A, B, and C carry this item, which is situational and required when the indicated payer has paid an amount toward the bill. Option c is incorrect because FL 51 reports the national health plan identifier when one exists, otherwise the number Medicare assigned, so it sits within this range. Option d is incorrect because this indicator is described for FLs 52A, B, and C and is required, showing that the provider holds a signed statement permitting release of data.

Correct Answer: A grand jury subpoena

The law enforcement standard permits disclosure in compliance with, and as limited by, the relevant requirements of a court order, court-ordered warrant, subpoena or summons issued by a judicial officer, or a grand jury subpoena. Option a is incorrect because an employer may receive information on work-related illness or injury or workplace medical surveillance under public health activities, which is a different public interest purpose. Option b is incorrect because public health authorities are recipients under the separate public health activities purpose, which concerns preventing or controlling disease, injury, or disability rather than law enforcement. Option d is incorrect because a stipulation by the parties is mentioned in the judicial and administrative proceedings provisions as part of a qualified protective order, not as a law enforcement instrument.

Correct Answer: A parent

In most cases, parents are the personal representatives for their minor children, so they can exercise individual rights such as access to the medical record. Exceptions apply only in certain cases defined by the Rule and State law. Option b is incorrect because this person is an administrative role inside the covered entity and is not someone legally authorized to make health care decisions for the minor. Option c is incorrect because a provider is the covered entity that holds the information, and the Rule does not make the provider the minor's personal representative. Option d is incorrect because a plan sponsor receives protected health information only for plan administration and has no role as a minor's personal representative.

Correct Answer: I, II, and III

The breach definition presumes a breach unless a risk assessment shows low probability of compromise. The minimum factors include the nature and extent of the PHI, the unauthorized person, whether PHI was acquired or viewed, and mitigation. Option a is incorrect because it leaves out the factor on whether the PHI was actually acquired or viewed, which the regulation also lists among the minimum factors. Option c is incorrect because it adds covered entity size, a consideration the regulation does not list, while dropping the identifiers and re-identification factor that it does require. Option d is incorrect because entity size is not a listed factor, and this combination also omits the unauthorized person who used or received the PHI, which is a required factor.

Correct Answer: Format requirements of the standard

Under the exception for direct data entry transactions, the provider must use the standard's data content and data condition requirements but is not required to use its format requirements, which cover enveloping and hierarchical structure. Option a is incorrect because data conditions describe when a data element or segment must be used, and the provider remains bound by them under the exception. Option b is incorrect because data content is expressly named in the exception as a requirement the provider must still follow when using direct data entry. Option d is incorrect because code sets are part of data content, defined as all data elements and code sets inherent to a transaction, so they still apply.

Correct Answer: I and II

The False Claims Act whistleblower provision lets a private individual sue on behalf of the United States and, if appropriate, share in recoveries. Whistleblowers are not limited to current employees, and specific intent is not required. Option a is incorrect because leaves out statement II, which is also accurate because the provision entitles a whistleblower to a percentage of recoveries, if appropriate. Option c is incorrect because adds statement III, but anyone with knowledge of potential fraud can be a whistleblower, including ex-business partners, patients and competitors. Option d is incorrect because relies on two inaccurate statements; the Act defines knowing conduct so that no proof of specific intent to defraud is required, and whistleblowers are not limited to staff.

Correct Answer: It loses safe harbor protection

OIG guidance says safe harbor protection is afforded only to arrangements that squarely meet all conditions. If even one condition is not met, the protection no longer applies, though the arrangement is then judged on its facts. Option a is incorrect because protection goes only to arrangements that squarely meet all conditions, so a missed condition leaves no partial coverage, and the guidance describes no proportional shield. Option b is incorrect because compliance with a safe harbor is voluntary under OIG guidance, so a missed condition creates no duty to conform to it. Option d is incorrect because OIG guidance states that failing to meet a safe harbor does not make an arrangement automatically illegal; the totality of facts and circumstances is reviewed instead.

Correct Answer: Requesting the item or service

The statute states that, for an item or service payable under Part B, the request by a physician for the item or service constitutes a "referral" by a "referring physician." This includes a request for a consultation with another physician. Option b is incorrect because the statute defines a referral by the physician's request, so performing the service personally is not what creates a referral under the definition. Option c is incorrect because a share of overall profits is a payment rule for physicians in a group practice, allowed if not tied to referral volume or value. Option d is incorrect because a faculty practice plan is a special group practice arrangement with its own rule, and membership in it is not a request that forms a referral.

Correct Answer: Office and equipment leases with entities receiving referrals

OIG guidance lists office and equipment leases with entities to which the physician refers as a risk factor under improper inducements, kickbacks and self-referrals. A practice renting equipment from a referral recipient fits that factor directly. Option a is incorrect because this factor covers items given or received without a business exchange, while the practice here is paying for equipment under a rental arrangement. Option c is incorrect because a joint venture involves shared ownership or investment with a supplier, but the facts describe a rental between the practice and the company, not a venture. Option d is incorrect because these arrangements pay a physician for professional or administrative services, which is not what happens when a practice rents equipment from a company.

Correct Answer: Code of conduct

Under Element 1, written policies and procedures, OIG guidance describes the code of conduct as an important tool for communicating mission, goals, and ethical requirements, and it sets the ethical standards governing those who work for the organization. Option b is incorrect because it is a communicated and documented stopgap used when policy revision and approval would delay a needed process change. Option c is incorrect because it is where compliance with the code and applicable policies is assessed for employees and contractors, not the document that states ethical requirements. Option d is incorrect because it lists the training topics and target audience for each topic, which belongs to Element 3 rather than stating ethical requirements.