Mixed Deck — All AAPC Topics Flashcards
100 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Mixed Deck — All AAPC Topics flashcards as text
What is the Resource-Based Relative Value Scale (RBRVS)?
Answer: A system that values physician services based on resources required, including work, practice expense, and malpractice
The RBRVS was developed to standardize Medicare physician payments based on the actual resources required to provide each service.
The combining form 'hepat/o' refers to which organ?
Answer: Liver
Hepat/o is the combining form for liver, as in hepatitis (inflammation of the liver).
What is 'phantom billing' in healthcare fraud?
Answer: Submitting claims for services, procedures, or supplies that were never provided to the patient
Phantom billing is a fraudulent scheme where claims are submitted for services that were never rendered, representing one of the most egregious forms of healthcare fraud.
In patient billing, who is the 'guarantor'?
Answer: The person legally responsible for paying the patient's bill
The guarantor is the individual responsible for the account balance, which may be the patient, a parent, or a legal guardian.
What does 'assignment of benefits' mean in insurance?
Answer: The provider receives payments directly from the insurer
'Assignment of benefits' is an agreement where the patient authorizes their insurance company to pay their healthcare provider directly for covered services. Instead of the patient paying the provider and then seeking reimbursement from the insurer, the payment is sent straight to the provider. This simplifies the billing process for patients and ensures providers receive payment more efficiently.
What is a compliance plan in medical billing?
Answer: A plan to ensure adherence to laws and ethics
A compliance plan in medical billing is a formal program designed to ensure that a healthcare organization adheres to all applicable federal and state laws, regulations, and ethical standards. It typically includes policies and procedures for preventing fraud and abuse, conducting internal audits, and providing staff training. Implementing a robust compliance plan helps mitigate risks, promotes ethical practices, and protects the organization from legal and financial penalties.
The medical term 'dyspnea' means:
Answer: Difficulty breathing
Dyspnea is derived from dys- (difficult) and -pnea (breathing), meaning labored or difficult breathing.
Why is accurate coding important for claims adjudication?
Answer: It speeds up the claim payment and prevents denials
Accurate coding is paramount for claims adjudication because it directly impacts the speed and success of claim processing. Correctly applying CPT, HCPCS, and ICD-10 codes ensures that the services rendered are clearly and precisely communicated to the payer, aligning with medical necessity and policy guidelines. This reduces the likelihood of denials, accelerates reimbursement, and maintains compliance with healthcare regulations.
Which provision in a commercial insurance contract specifies how long after a service date the provider has to submit a claim?
Answer: Timely filing provision
The timely filing provision in a provider contract establishes the deadline by which claims must be submitted, after which they may be denied.
What is a premium in insurance terms?
Answer: The regular payment to keep insurance coverage active
In insurance terms, a premium is the regular payment, typically made monthly or annually, that an individual or employer pays to an insurance company to maintain active insurance coverage. This payment is the cost of the insurance policy itself. Failure to pay premiums can result in the cancellation of the policy and loss of coverage.
What is balance billing?
Answer: Billing the patient for the difference between the provider's charge and the payer's allowed amount
Balance billing occurs when a provider bills a patient for the difference between their charge and the amount the insurer allows, which is often prohibited for in-network providers.
Which suffix means 'surgical fixation' or 'stabilization'?
Answer: -pexy
-Pexy means surgical fixation, as in nephropexy (fixation of a floating kidney).
What is the first step in the healthcare revenue cycle?
Answer: Patient registration and scheduling
The revenue cycle begins with patient registration and scheduling, where demographic and insurance information is collected.
The prefix 'poly-' means:
Answer: Many or much
Poly- means many or much, as in polyneuropathy (disease affecting many nerves).
What is 'charge capture' in the revenue cycle?
Answer: The process of recording all billable services provided to a patient
Charge capture is the process of documenting all services rendered so they can be billed accurately to the payer.
What is 'credentialing' in healthcare practice management?
Answer: The process of verifying a provider's qualifications, licenses, and experience to grant privileges or payer enrollment
Credentialing verifies that providers meet the required standards of education, training, and licensure before they can treat patients or be enrolled with payers.
What is a 'corrected claim'?
Answer: A resubmission of a previously processed claim with corrections to specific data elements
A corrected claim is submitted when information on a previously processed claim was incorrect or incomplete, requiring specific bill type and frequency code changes.
What is risk adjustment in managed care?
Answer: A process of modifying payments to plans or providers based on the health status of the enrolled population
Risk adjustment modifies capitation payments based on the health risk of enrolled members, ensuring plans and providers receive appropriate compensation for treating sicker patients.
Which type of appeal is submitted directly to an independent external reviewer when internal payer appeals are exhausted?
Answer: External appeal
An external appeal is reviewed by an independent organization outside the insurance company and is typically the last step when internal appeals are denied.
What does the acronym HIPAA stand for?
Answer: Health Insurance Portability and Accountability Act
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, which established national standards for protecting health information.