CPC Certification Review - Study Notes - The Business of Medicine

Sep 25, 2026

Uploaded by Connor

CPC certification review study notes focused on medical billing and coding concepts used in healthcare reimbursement and compliance. Covers payers and Medicare program parts (A through D), RBRVS pricing formulas and facility versus non-facility amounts, and medical necessity standards. Includes key regulatory topics such as national coverage determinations, Advance Beneficiary Notice requirements, HIPAA and HITECH, OIG compliance plan elements, and ICD-9-CM coding principles including NEC vs NOS, punctuation guidance, and use of additional and combination codes. Also outlines steps to look up diagnosis codes and references official guidelines.

LanguageEnglish

CategoryExam

FormatPDF

Pages125

Reading Time5 h 15 min

AccessFree to download

Payers

Self-pay and insurance types

Medicare overview

Parts A–D and Medicare Advantage

RBRVS pricing

Non-facility vs facility pricing amounts

Medical necessity

Coverage and notices

National Coverage Determinations

Advance Beneficiary Notice (ABN)

HIPAA and HITECH

OIG compliance plan

ICD-9-CM coding foundations

NEC vs NOS

Punctuation and bracket/parenthesis usage

Additional codes

Combination codes

Steps to look up a diagnosis code

1/26/2012 | CPC® Certification Review | | | --- | --- | | |
1 | CPT® CPT® copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT® , and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 2 | The Business of Medicine | | | --- | --- | | | | 1/26/2012 Payers • Self-pay • Insurance – Private (commercial) insurance • BCBS • Aetna • Cigna • Etc – Government insurance • Medicare • Medicaid • TriCare 4 | Medicare
• Part A – Inpatient hospital care
• Part B – Outpatient medical care
• Part C – Medicare Advantage
Part D – Prescription drug coverage | | | --- | --- | | | | | RBRVS
– Non-Facility Pricing Amount [(Work RVU * Work GPCI) +
(Transitioned Non-Facility PE RVU * PE GPCI) +(MP RVU * MP GPCI)] * Conversion Factor (CF)
– Facility Pricing Amount [(Work RVU * Work GPCI) +
(Transitioned Facility PE RVU * PE GPCI) +(MP RVU * MP GPCI)] * CF | | | --- | --- | | | | 1/26/2012 Medical Necessity Services or supplies that: • are proper and needed for the diagnosis or treatment of your medical condition, • are provided for the diagnosis, direct care, and treatment of your medical condition, • meet the standards of good medical practice in the local area, and • aren’t mainly for the convenience of you or your doctor. [www.cms.gov/apps/glossary](www.cms.gov/apps/glossary) 7 | National Coverage Determinations
• National Coverage Determinations (NCD) help to spell out CMS policies on when Medicare will pay for items or services
– Each Medicare Administrative Carrier (MAC) is then responsible for interpreting national policies into regional policies
– LCD’s only have jurisdiction within their regional area | | | --- | --- | | | | | Advance Beneficiary Notice
• Providers are responsible for obtaining an ABN prior to providing the service or item to a beneficiary.
– The form must be filled out in its entirety as well asthe cost to the patient and the reason why Medicare may deny the service
– Only the approved Form CMS-R-131 is valid and the forms may not be altered | | | --- | --- | | | | 1/26/2012 | HIPAA
• National standards for electronic health care transactions and code sets;
• National unique identifiers for providers, health plans, and employers;
• Privacy and Security of health data. | | | --- | --- | | | | | HITECH
• The Health Information Technology for Economic and Clinical Health Act
– Promote the adoption and meaningful use of health information technology
– Strengthened HIPAA
– Patient audit trail | | | --- | --- | | |
11 | | OIG Compliance Plan
1. Conduct internal monitoring and auditing.
2. Implement compliance and practice standards.
3. Designate a compliance officer or contact.
4. Conduct appropriate training and education.
5. Respond appropriately to detected offenses and develop corrective action.
6. Develop open lines of communication with employees.
7. Enforce disciplinary standards through well-publicized guidelines. | | | --- | --- | | [http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp](http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp) |
12 | 1/26/2012 | ICD-9-CM Coding | | | --- | --- | | | | | NEC vs. NOS
• NEC Not elsewhere classifiable
“We know what’s wrong, but there isn’t a specific code for it.”
• NOS Not otherwise specified“We aren’t sure what’s wrong.” | | | --- | --- | | |
14 | Punctuation [ ] Brackets: in tabular enclose synonyms or alternate wording Example: 008.0 Escherichia coli [E. coli] [] Slanted brackets: in index id

FAQs

What payer types are listed in the review notes?

The notes list self-pay and insurance, including private (commercial) insurance and government insurance such as Medicare, Medicaid, and TriCare.

How do the notes describe non-facility versus facility RBRVS pricing?

They provide formulas for non-facility pricing amount and facility pricing amount, differing by which PE RVU and GPCI components apply, multiplied by the conversion factor.

What information must be included for an Advance Beneficiary Notice (ABN)?

Providers must obtain an ABN before services or items, complete the form in its entirety, include the cost to the patient and the reason Medicare may deny the service, and use only the approved Form CMS-R-131 without alteration.

Sep 25, 2026

Uploaded by Connor