CPC Exam: Things You Should Know

In the CPC examination, the questions are not just about codes and understanding guidelines. There is a section in the exam that is about compliance and regulatory and the questions are based on correlation with the standards of USA.

The following are things that you should know before taking the CPC exam:

1. What are the different types of payers?

  • Private insurance plans
  • Government insurance plan/Federal insurance plan

2. What is the meaning of CMS?

  • Centers for Medicare and Medicaid Services

3. What is Medicare?

  • It is the federal health insurance administered by CMS

4. What are the criteria of the Medicare program?

  • People who are 65 or older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

5. What are the different parts of Medicare?

  • Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
  • Part C (Medicare Advantage Plans): A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:
    • Health Maintenance Organizations
    • Preferred Provider Organizations
    • Private Fee-for-Service Plans
    • Special Needs Plans
    • Medicare Medical Savings Account Plans

    If you’re enrolled in a Medicare Advantage Plan:

    • Most Medicare services are covered through the plan
    • Medicare services aren’t paid for by Original Medicare

    Most Medicare Advantage Plans offer prescription drug coverage.

  • Part D (Prescription Drug Coverage): Adds prescription drug coverage to:
    • Original Medicare
    • Some Medicare Cost Plans
    • Some Medicare Private-Fee-for-Service Plans
    • Medicare Medical Savings Account Plans

6. What is Medicaid?

  • Health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by the federal state governments. Administered on a state by state basis following federal guidelines.

7. What is a Medical Necessity?

  • Refers to whether a procedure or service is considered appropriate in a given circumstance. Generally, a medically necessary service or procedure is the least radical service or procedure that allows for effective treatment of patient’s complaint or condition.

8. What is the Advanced Beneficiary Notice (ABN)?

  • A standardized form that explains to the patient why Medicare may deny the particular service or procedure. also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service. You may receive an ABN if you have Original Medicare, but not if you have a Medicare Advantage Plan. The ABN may look different, depending on the type of provider who gives it to you.

The above mentioned are just some of the things that you should know before you take the CPC examination. Stay tuned for more!