Medical Coding Certification Exam Prep: Your Running Start to the Practice Management Questions

Confused by Medicare mumbo-jumbo? This simple quick-start guide puts you ahead of the pack on 3 key terms.

In a previous post, we got some good advice from Manas Maity, who recently passed the CPC-H exam. He told us he wishes he had known a little more about Medicare before he took the test.

So today, let’s brush up on Medicare terms that Maity suggests we know in order to pass the CPC-H exam— acronyms and rules like ABN, OPPS, and the Stark law. Understanding these terms will also come in handy for the practice management questions on the CPC exam. We’ll give you the basic facts about each one, plus some links to help you learn more.

Advance Beneficiary Notice (ABN): Medicare covers only a limited number of certain procedures per patient per time period. So an ABN is a written notice that informs the beneficiary (that is, the patient) that Medicare might not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he or she may have to pay for the procedure or service if Medicare does not. To learn about CMS instructions for ABNs, go here.

Outpatient Prospective Payment System (OPPS): Medicare pays a certain amount for certain outpatient services beneficiaries receive at hospitals, like x-rays or outpatient surgeries. Each year, CMS updates the OPPS rule, which determines the Medicare payment rate for groups of outpatient services — ‘APCs‘ or ‘Ambulatory Payment Classifications.’ To learn more about APCs, go to this APC FAQ sheet at the American College of Emergency Physicians’ site.

Besides the APC payment rates, every year’s new OPPS rule always contains lots of other rules providers must follow if they are billing Medicare. The CMS OPPS page is here.

Stark Law: Physicians have a lot of power when it comes to how Medicare dollars get spent. That’s because physicians are the people who ‘refer’ or send patients to services Medicare pays for — services like lab tests, radiological exams, and home care. There is a law (named after Rep. Fortney ‘Pete’ Stark) that restricts ‘self-referral‘ — that is, physicians referring their patients to services in which they have a financial interest.

One thing that makes the law complicated is that many health care arenas, such as hospitals, must pay doctors to do things like be medical directors. For that reason, the Stark Law has many ‘exceptions‘ that allow health care entities to pay doctors for services. Some exceptions even allow physicians to invest in businesses like labs if they follow certain rules.

Stark regulations are very complicated and change all the time. To learn more about them, go to ‘Stark Law Made Simple (Maybe)‘, a resource on the American Gastroenterological Association site.

Want to learn more about Medicare mumbo jumbo? Check out CMS’s cool new reference chart of resouces. Our personal favorite is the CMS acronym listing: We just learned what an ‘HBP’ is.


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