AAPC CPB Course Notes

Payer identification, benefits, coordination of benefits, and patient responsibility.

• Referral is not the same as prior authorization.

• For scenario questions, identify the plan type, network status, referral/authorization requirement, and patient cost-sharing before choosing an action.

Coverage/payment rules, NCCI, incident-to, global surgery, forms, and payer policies.

• ACO participation ≠ HMO network lock-in.

• When a question mentions an ACO, identify the payment model, quality/risk terms, and whether the issue is ordinary claim billing or later performance reconciliation.

Privacy/security, retention, compliance programs, financial policies, and fraud/abuse.

• Minimum necessary ≠ “disclose nothing.”

• Identify the purpose of the disclosure, who is requesting it, and whether authorization or a HIPAA permission applies.

PFS/RBRVS, refunds, enrollment, A/R, collections, medical necessity, remittance, and debt.

• Charge amount ≠ RVU-based allowed payment.

• When a scenario gives RVUs/GPCIs/conversion factor, follow the formula in order.

Claim lifecycle from registration through denial, correction, appeal, follow-up, and patient liability.

• Correction ≠ appeal.

• Identify the denial reason and deadline first.

ICD-10-CM, CPT/modifiers, HCPCS Level II, and place of service.

• Outpatient uncertain-diagnosis rule differs from inpatient facility rules.

• Start with the documented diagnosis/condition, verify in the Tabular List, and apply all instructional notes.

Apply supplied source documents exactly to billing cases; do not import assumptions.

• Professional vs institutional form selection is the first gate.

• Read the source excerpt first, circle/identify the controlling field rule, then compare it to the exact claim line.