Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Practice Exam

CPC Practice Exam and Study Guide Package

Practice Exam

What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

CPC Exam Review Video

Laureen shows you her proprietary “Bubbling and Highlighting Technique”

Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page

Practice Exam

2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

How To Flip To the Codes Faster in the Medical Coding CPC exam

Featured Well for the ICD Manual, I’ll start with that. One of the frustrating things for me is I don’t think there’s any version of a manual out there that has the true Table of Contents. And most versions are volumes 1 and 2 and one spiral bound book. And if you’re into Inpatient Hospital Coding, you have 3 volumes in it and it’s very hard when you’re brand new at using it to figure out you know, where to even start. So what I recommend to my students is that at the top of the manual, not on the sides, that they get those hard tabs and put them where all the main sections of their manual are. So obviously, where each volume starts when you have volumes 1 through 3.

More here:

Watch Laureen Jandroep show you her proprietary “Bubble and Highlighting Technique”


For more CPC Exam study techniques, visit Laureen’s official site here at

You can also get access to Practice CPC Exam Questions which comes with full rationale answers at


How To Prepare For Your CPC Exam and How To Pass It On Your First Try


Medical Coding Certification CPC Exam Review

Watch Laureen Jandreop show you her special “Bubbling and Highlighting Technique” and how you can practice it in your coding manual too (The CPC exam is an open book exam so you can bring in your coding manual with you to your exam)

Feeling stressed studying for your CPC exam? Maybe overwhelmed by the amount of studying involved?

Maybe you are not sure whether you are well prepared for the CPC exam questions, or maybe you have a hard time planning and managing your study time, maybe you’re worried that you can’t finish the CPC exam paper in the five and a half hours time.

Fear not, I’ve been there too and this was exactly how I felt. I was especially worried about the 5 and a half hours alloted time frame which always seems too short.

Maybe this is your first time studying for the CPC exam. Or maybe you are re-sitting the CPC exam. Either way, as the date draws nearer you might be getting desperate for a method to help you study for and pass the CPC exam.

Good news! Laureen Jandroep (CPC) has put together the highly result driven Medical Coding Certification Review Blitz Videos that you cna watch online from the comfort of your own home. It shows 12 hours of CPC exam review and CPC exam tips that you wouldn’t wanna miss! And as a bonus, a full set of 7 DVD’s of these video course will be delivered to your home or office!

This Medical Coding Review Program prepares you for the Certified Professional Coder (CPC) exam by the American Academy of Professional Coders (AAPC) and also the Certified Coding Specialist-Physician Based (CCS-P) exam by the American Health Information Association (AHIMA).

This is a two in one program where the program will guide you in the review of the subject matter, as well as guide you in doing well on the CPC exam. The video course will guide you through an exhaustive review of all the diagnostic and therapeutic procedures covered in the exam, and also teaches you how to make the best use of the time alloted in the CPC exam, which is only five anda half hours! And since the CPC exam is an open-book exam, Laureen Jandroep’s proprietary bubbling and highlighting technique will greatly save time and enable you to locate the important points quickly and efficiently during the CPC exam. This Bubbling and Highlighting Technique actually teaches you how to mark and highlight your coding manual, making it easier to choose the correct answer for any question in the CPC exam. It will also teach you how to manage more difficult questions.

The online video program and the DVD program is identical. This is what they will cover:

01 Introduction to the program

02 Medical Terminology CPC Exam Prep

03 HCPCS CPC Exam Prep

04 Modifiers CPC Exam Prep

05 ICD-9 CPC Exam Prep

06 E&M Section CPC Exam Prep

07 Anesthesia Section CPC Exam Prep

08 Radiology Section CPC Exam Prep

09 Path & Lab Section CPC Exam Prep

10 Medicine Section CPC Exam Prep

11 Integumentary System CPC Exam Prep

12 Musculoskeletal System CPC Exam Prep

13 Respiratory System CPC Exam Prep

14 Cardiovascular System CPC Exam Prep

15 Digestive System CPC Exam Prep

16 Urinary System CPC Exam Prep

17 Genital System CPC Exam Prep

18 Endocrine/Nervous System CPC Exam Prep

19 Eye/Ear System CPC Exam Prep

Laureen Jandroep has been teaching medical coding 12 years ago since 1999. She has personally taken all the certification exams so she could understand the format of the exams and thus prepare her students for what was gonna be covered in the exams. The video course was created when her students begged her to help them prepare for the following weeks exam and therefore she reviewed the whole CPC training program in two days. Since then, Laureen has been teaching this CPC review program and has helped many students successfully pass the CPC exam.

Click here to visit the official site now!

You can also download Laureen’s CPC Exam Study Guide at

Practice CPC Exam Package Review – 150 Question CPC Practice Exam, Answer Key, With Full Rationale, Medical Coding Certification Study Guide


What I like most about this CPC Practice Exam Package is that the full answers and rationales are given for all 150 questions. It also refers you to the relevant part of your textbook. They also provide the answer keys to each CPC exam question, so you can go through each one and see if your rationale is correct when testing yourself. I also found the CPC Exam Study Guide very helpful as it summarizes the whole textbook for you. As the CPC exam is an open book exam, you can actually mark your book or highlight the important texts or codes to help you search for the codes faster during the test. Do practice answering all 150 questions of the practice test within 5 and a half hours, make it to 5 hours if you can so you will have time to go back and check your answers.

The CPC Medical Coding Practice Exam is delivered as an electronic download (in the PDF format), which means it’s instantly accessible after purchase. The good news is that ut’s priced at only $37.

This Price Includes:

What is included in this package?

  • The Full 150 Question CPC Practice Exam
  • Answer Key, With Full Rationale
  • Scan Tron Bubble Sheets
  • The Exam Study Guide, including:
    Common Anatomy Terminology Handouts
    Common Medical Terminology Prefix, Root Word, and Suffix Handouts
  • The Official AAPC Proctor-to-Examinee Instructions (read out loud on the day of the CPC exam)

Download the full CPC Practice Exam Package here and receive your bonus at

You can also get the latest CPC Exam updates at

Best Compilation Of Sample CPC Exam Questions – Followed With Full Answer And Rationale


Sample CPC Exam Question 3: ICD-9-CM

Jim was at a bonfire when he tripped and fell into the flames. Jim sustained multiple burns. He came to the emergency room via an ambulance and was treated for second and third degree burns of his face, second degree burn on his shoulders and forearms, and third degree burns on the fronts of his thighs.

a. 941.20, 841.30, 943.25, 943.21, 945.36, 948.42, E897
b. 941.30, 943.29, 945.36, 948.42, E897
c. 941.09, 943.09, 945.09, 948.64, E897
d. 941.30, 943.29, 945.36, 948.64, E897


Answer: B

Burn codes always have no less than three codes: A burn code, a total body surface area code (948.XX), and an E code. You can have more than three codes but never less. Burn codes have the following rules (which can be found at the beginning of the ICD-9 book under general guidelines), always code one location to the highest degree (Ex. 1st and 2nd degree burns on the arm, only code 2nd degree). When sequencing burn codes always list the highest degree first (Ex. 1st degree burns to the face and 3rd degree burns to the arm. List the arm burn first and then the face burn). Answer B is the answer because its codes describe the highest degree burn to each anatomical location, it sequences the burn codes in order of highest to lowest degree burns, the 948 (TBSA code) has the correct calculation, and the E code correctly describes the bonfire incident.

Sample CPC Test Questions 4: Anesthesia

When does anesthesia time begin?

a. After the induction of anesthesia is complete
b. During the pre-operative exam prior to entering the OR
c. When the anesthesiologist begins preparing the patient for the induction of anesthesia
d. Once the supervising physician signs over the patient’s care to the anesthesiologist


Answer: C

The answer to this question can be located in the anesthesia coding guidelines under the title “Time Reporting”

Go Through more of these Sample CPC Test Questions with full answers and explanation at

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More CPC Sample Exam Questions – Comes With Correct Answer And Full Rationale For Each Question


Sample CPC Exam Question 2: Musculoskeletal


PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.

POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.

1. Anterior discectomy, C5-C6
2. Arthrodesis, C5-C6
3. Partial corpectomy, C5
4. Machine bone allograft, C5-C6
5. Placement of anterior plate with a Zephyr C6


INDICATIONS: This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.

The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. I then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C6. The disc was then completely removed at C5-C6. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Part of the body of C5 was taken down to assure that all fragments were removed and that there was no additional constriction. The nerve root was then widely decompressed. Machine bone allograft was placed into C5-C6 and then a Zephyr plate was placed in the body C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.

a. 22554, 63081, 63082, 20931, 22845
b. 22551, 63081, 20931, 22840
c. 22551, 63081, 63082, 20931, 22845
d. 22554, 63081, 20931, 22840


Answer: A

Per. Paul Cadorette and the American Medical Association article titles, “Coding Guidance for Anterior Cervical Arthrodesis”, “When a spinal fusion (arthrodesis) is performed, the first thing a coder needs to recognize is the approach or technique that was utilized. With an anterior (front body approach)to cervical fusion the incision will be made in the patient’s neck, so the key terms to look for are platysma, esophagus, carotid, and sternocleidomastoid. These structures will be divided and/or protected during dissection down the vertebral body. After dissection, the procedure can proceed on one of three ways:

1) When the interspace is prepared (minimal discectomy, perforation of endplates) then 22554 would be reported.

2) When a discectomy is performed to decompress the spinal cord and/or nerve root(s) report 22554 for the arthrodesis along with 63075 for the discectomy procedure.

3) When a partial corpectomy (vertebral body resection) is performed at C5 and C6 report CPT code 22554 for the arthrodesis with 63081 and 63082. Two codes are reported because the corpectomy procedure is performed on two vertebral segments (C5 and C6). CPT codes 63081-63091 include a discectomy above and/or below the vertebral segment, so code 63075 (discectomy) would not be reported if performed at the C5-C6 interspace.

Once the decompression procedure has been completed, a PEEK cage can be placed within the interspace or a structural bone graft can be fashioned to fit the vertebral defect created by the previous corpectomy. Insertion of the PEEK cage would be reported with a biomechanical device code 22851. This code is only reported one time per level even if two cages are placed at C5-C6. When a structural bone graft is used, determine whether it is an allograft (20931)) or an autograft (20938). The bone graft codes are only reported one time per procedure and not once for each level. Finally, the physician will place an anterior plate with screws (22845) across the C5-C6 interspace to stabilize the area fusion”.

Some guidance on coding such procedures can also be located in the Spine (vertebral column) coding guidelines (above code 22010).

Learn more of these CPC exam questions with full answers and explanation at

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CPC Sample Exam Questions – Comes With Correct Answer And Full Rationale For Each Question


Example Of Sample CPC Exam Question 1: Medical Terminology

The term “Salping-Oophorectomy” refers to

a. The removal of the fallopian tubes and ovaries
b. The surgical sampling or removal of a fertilized egg
c. Cutting into the fallopian tubes and ovaries for surgical purposes
d. Cutting into a fertilized egg for surgical purposes


Answer: A

The term “salp” means tube, the term “ooph” refers to the ovary, and the suffix “ectomy” means to surgically remove. Some CPT books (like the professional edition put out by the AMA) contains pages with common medical terms like these in the beginning of the book (prior to the coding guidelines)

Learn more of these CPC exam questions with full answers and explanation at

Get the latest Medical Coding Certification and CPC Exam Updates at

Practice CPC Exam Questions And Answers And Time Yourself To Finish It In 5 Hours


AAPC’s CPC exam is 150 questions long. Questions range from true and false, to 1-2 sentences, to full page operative notes.

Questions on the CPC exam do not cover just specific medical codes. Questions can be very diverse, testing the examinees knowledge on:

  • Coding Guidelines
  • Understanding of Conventions
  • Correct Modifier Use
  • Bundling and Global Packages
  • Medical Terminology and Gross Anatomy

We have taken into account the wide spectrum of diversity the CPC exam offers and have constructed the questions on our CPC Practice Exam to reflect those on the actual exam as closely as possible.

In addition to our well constructed questions we are also providing a full rationale for each question.

These rationales provide the correct answer for each question as well as a full explanation as of why this option is correct, why the other three options are incorrect, and where in the medical coding books the answer can be located.

Studying the rationale of an answer may very well be the easiest and most efficient way to learn how to pass the CPC exam.

Download and practice the CPC Exam Questions with Answers at

Get the latest Medical Coding Certification and CPC Exam Updates at

What Medical Coding And Billing Questions Are Good For The CPC Practice Exam?


A good practice exam should fully prepare its examinee for the real exam. Knowing what to expect and not being surprised on exam day are important.

AAPC’s CPC exam is 150 questions and must be completed in 5 hours and 40 minutes or less.

There are three main sections to the CPC exam:

1. Medical Concepts
2. Surgery and Modifiers
3. Remaining CPT codes
Each of these three sections are then further divided into the following smaller headings.

1. Medical Concepts:
**The following sub-divisions are each assigned 5-10 category specific questions**
Payment management
Medical terminology
ICD-9-CM codes
HCPCS codes

2. Surgery And Modifiers:
**This section is mainly sub-divided to reflect the surgery section of the CPT book and assigns 5-10 category specific questions to each of the following sub-divisions**
Hemic/Lymphatic systems
Male and Female reproductive organs
Maternity/ Endocrine system
Nervous system

3. Remaining CPT Codes:
**This portion of the exam focuses on the remaining CPT codes and assigns 5-10 category specific questions to each of the following sub-division**
Evaluation and Management

Our 150 question CPC practice exam was created using the structure listed above in order to emulate the actual CPC exam as closely as possible. We felt that by doing this examinees would know exactly what to expect on examination day. By utilizing this structure examinees can better prepare for the exam by focusing on category specific questions and identifying areas of weakness. Knowing what to expect in detail also tend to help calm pre-test anxiety.

Get the latest Medical Coding Certification and CPC Exam Updates at

Practice CPC Exam Questions And Answers For Your Exam Preparation – This Is The Best Way To Learn Medical Coding And Pass Your CPC Exam


Are you about to take the AAPC exam for Certified Professional Coder for the first time?

Or are you one of the many people who FAILED the exam the first time, and are now looking to retake the test, perhaps for the third or fourth time?

It’s Time To STOP Doing What’s Not Working, And Get The CPC Practice Exam!


CPC Practice Exam Questions

CPC Practice Exam Questions

  • 150 Question CPC Practice Test
  • Answer Key, With Full Rationale
  • Scan Tron Bubble Sheets
  • The Exam Study Guide, including:
    Common Anatomy Terminology Handouts
    Common Medical Terminology Prefix, Root Word, and Suffix Handouts
  • The Official AAPC Proctor-to-Examinee Instructions (read out loud on the day of the exam)

Download your copy of the CPC Exam Practice Questions And Answers at

Get the latest Medical Coding Certification and CPC Exam Updates at

Medical Billing And Coding At Home Jobs – How to pass the CPC Exam and become a Certified Professional Medical Coder


Download your CPC Practice Exam Questions at

A good practice exam should fully prepare its examinee for the real exam. Knowing what to expect and not being surprised on exam day are important.

AAPC’s CPC exam is 150 questions and must be completed in 5 hours and 40 minutes or less.

Contents of the CPC practice exam:

* 150 Question CPC Practice Exam

* Answer Key, With Full Rationale * Scan Tron Bubble Sheets

* The Exam Study Guide, including: Common Anatomy Terminology Handouts Common Medical Terminology Prefix, Root Word, and Suffix Handouts

* The Official AAPC Proctor-to-Examinee Instructions (read out loud on the day of the CPC exam) AAPC’s CPC exam is 150 questions long. Questions range from true and false, to 1-2 sentences, to full page operative notes.

* Coding Guidelines

* Understanding of Conventions

* Correct Modifier Use

* Bundling and Global Packages

* Medical Terminology and Gross Anatom In addition to our well constructed questions we are also providing a full rationale for each question.

These rationales provide the correct answer for each question as well as a full explanation as of why this option is correct, why the other three options are incorrect, and where in the medical coding books the answer can be located.

Studying the rationale of an answer may very well be the easiest and most efficient way to learn how to pass the CPC exam. Download your FREE “Medical Coding From Home eBook” at

How These Videos Will Help You Pass the CPC Exam – CPC Exam Video Review


 Download your FREE “Medical Coding From Home eBook” at

CPC Practice Exam Questions at

Elimination of AAPC Apprentice Credential – Medical Coding Certification


For the latest updates, visit

( Enclosed is the article)

Letter from the Chairman and CEO (Jan 2012)

Elimination of “A” Designation

The Apprentice designation is not needed anymore.

The National Advisory Board (NAB) has recommended, and the AAPC leadership team has discussed and agreed, that the Certified Professional Coder-Apprentice (CPC-A®) credential has outlived its usefulness. The objective of the apprentice (A) designation was to show others—primarily prospective employers—an individual had passed the CPC® exam, but did not yet have one or two years of on-the-job experience. Instead, it was too often preventing most CPC-As® from getting interviews for potential jobs and hurting their prospects.

We believe the résumé indicating the experience level of an individual should speak for itself. Whether the individual has great aptitude, a terrific work ethic, good people skills, or any other desirable attribute is often never discovered because an interview was unable to be obtained. While we still believe experience is needed to become a good coder, we think it should be the employer’s decision who to hire.

Accordingly, AAPC is accepting comments through Jan. 31, 2012 on the following proposal:

Effective July 1, 2012, the CPC-A® credential will no longer be granted. All current CPC-As® would have their “A” removed by doing one of the following:

Getting at least one year of on-the-job experience no later than Dec. 31, 2013 (helpful to those with a job and currently working towards that end), or

Successfully passing a clinical exam consisting of coding 20 operative/office notes

Thus, no current CPC-A® would be “grandfathered” into the CPC® credential.

Those taking the CPC® exam after July 1, 2012 will have two ways to get their CPC® credential.

They can have one year of coding experience prior to taking the CPC® exam (proof given at time of exam application), and then pass the CPC® exam, or

They can pass both the current CPC® exam and clinical exam by successfully coding 20 operative/office notes. On-the-job experience after taking the CPC® exam will not be required.

It does not matter in which order the two exams are taken; if lacking prior experience, both are required to become a CPC®.

The pass rate for the CPC® exam will stay the same and a 90 percent pass rate on the clinical exam will be required. The 90 percent will be determined by correctly coding 18 of the 20 notes (and most will require multiple codes). The clinical exam will not be multiple choice; it will be free form and hand graded.

The clinical exam will include a sampling of office visits, surgical notes, evaluation and management (E/M) coding, ancillary services, modifier usage, and diagnosis coding.

The clinical exam would be taken at any AAPC proctored exam site. The same five hours and 40 minutes time restriction and code books will be allowed into this exam. If additional resources beyond code books are needed to properly code the notes, that information will be provided as part of the exam.

Both exams will be paid for at the same time and the cost for both exams will increase by $35. Applicants may still take each exam twice to pass it. If the examinee has one year experience, then he or she would pay only the CPC® exam price. If one exam is passed after two attempts, but not the other, then the fee for the exam not passed would be paid to re-take it.

Of course, current CPCs® are not affected by this change. As stated above, we would appreciate comments to this important change to our credentialing program through Jan. 31, 2012. You may go to to submit your comment. From those comments we will either proceed ahead, make modifications that strengthen the change, or slow down the change due to legitimate concerns that AAPC has not properly considered.

For the latest updates, visit

How to study for the CPC exam paper? More important tips to help …


A strategy that has been adopted by many, it might work out better for you to start answering the questions from back to front. Start the CPC exam paper from the end to the front may work for you because the questions are generally more advanced at the end, while the front questions are somewhat simpler. Therefore you may not need to spend as much time on the front questions.

Also, do not worry if you’re unsure of the answers to some questions. Just skip those questions and mark them. You can come back to them later. Work on those that you are sure of, as there is a higher chance of you getting more questions correct this way, and you can be sure that you’ve got time to cover every question. After you have gone through the whole paper, return to those marked questions to work on them. If you are really running out of time, just pick an answer randomly, this way you will at least have a chance of choosing the correct answer as opposed to leaving the question blank.

Confirm and check out the CPC examination venue beforehand if possible. This will help you feel prepared and less stressed out on the actual CPC exam date. Confirm the examination venue on the website, and always arrive early just in case. This is very important as you may be forbidden from taking the CPC exam if you are late.

On the day of the CPC exam, take a breakfast rich in protein and low in greasy fat. Take some carbohydrates too. Two half-boiled or poached eggs taken with some toast would be perfect. Taking a glass of milk would be good too as it is full of protein and natural sugars and vitamins that will nourish you, your brain and your body. Refrain from eating fried or oily food for breakfast as you may feel sluggish later. Never ever sit for your CPC exam with an empty stomach. That is the biggest mistake anyone can make as you are not operating with your full potential with low blood sugar and an empty stomach. Remember, this CPC exam is 5 and a half hours long. It’s a long time to fast.

Things to bring along to the CPC exam:

Bring along a bottle of water with you into the CPC exam venue. You will need water for optimal function of your body and brain. Also, bring a watch with you to keep track of the time. Plan your time accordingly. For example, 2 and a half hours into the test, you should be halfway through the questions. Lastly, bring along a jacket or sweater to keep you warm and comfortable if needed during the test.

Click here for CPC practice exam questions and the CPC exam study guide

You can also download the CPC Exam Practice Questions which come with the answer keys and full rationale at

Or if you’d like to learn more about Laureen Jandroep’s CPC exam study guide and her special Bubbling and Highlighting technique, you can visit

Message From Your Region 1 Representatives: Stephanie Sjogren and Stephanie Thebarge

HealthCon and Regional Conferences are a great way to connect & network with other AAPC members, National Advisory Board members and AAPCCA BOD members.  But did you know that is not the only way to connect with members?  AAPC has plenty of social networking opportunities, online Forums, and Mentoring programs.  You are not alone in […]

The post Message From Your Region 1 Representatives: Stephanie Sjogren and Stephanie Thebarge appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Healthcare News: CMS invites comments on 2-midnight rule payment calculation

A recent court ruling determined that CMS had to explain its calculation for a negative 0.2% reduction in inpatient payment rates as a result of implementing the 2-midnight rule. The court also said that providers should have an opportunity to comment on the calculation. 
In early December, CMS released a notice with comment period to meet the court’s requirement, but providers might not be pleased with forcing the agency’s hand. CMS notes that when originally estimating the number of outpatient cases that should shift to inpatient as a result of the rule, it looked at 2011 claims containing HCPCS codes G0378 (hospital observation service, per hour) and G0379 (direct admission of patient for hospital observation care). 
Using this data, CMS identified approximately 350,000 observation stays that lasted two or more midnights. The agency combined that with approximately 50,000 claims that contained major procedures based on APCs that resulted in stays lasting more than two midnights. CMS also analyzed data from the inpatient side by looking at inpatient claims containing surgical MS-DRGs with stays that lasted less than two midnights and found approximately 360,000. 
The agency used this data to determine a net increase of 40,000 inpatient discharges as a result of the rule to calculate $ 220 million in increased expenditures on the inpatient side, leading to the reduction.
However, CMS now says that in light of new regulations and by using different metrics to estimate the shift, as many as 570,000 cases could move to the inpatient side, resulting in an even larger payment shift. 
Providers can comment on the notice at and all submissions must be received by February 2, 2016. – JustCoding News: Inpatient

CMS sets sights on future quality, payment initiatives in 2016 SNF PPS proposed rule

CMS sets sights on future quality, payment initiatives in 2016 SNF PPS proposed rule

In mid-April, CMS released its proposed SNF PPS rule for fiscal year (FY) 2016. Though the rulemaking document is an annual ritual, this year’s iteration, which experts who spoke with HCPro predict will pass largely unaltered, departed from its recent predecessors in one distinct aspect: its preoccupation with long-term projects.

"It was not a … rule like we’ve had in recent years," says Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE, principal at Judy Wilhide MDS Consulting, Inc., in Virginia Beach, Virginia.

In lieu of remedying small-scale, immediate concerns (like FY 2015’s COT OMRA fix), the FY 2016 proposed rule lays the framework for SNF-specific value-based purchasing (VBP) and quality reporting programs (QRP)?two more distant initiatives that, through their ongoing integrations in different settings, promise to reshape long-standing paradigms, business models, and care practices across the care continuum in the coming years.

But despite the unusual foresight of the latest SNF rule, experts say its provisions hold few surprises, as the two far-off programs they detail are products of high-profile legislation passed last year:

  • The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 calls for the phasing in of various quality improvement and reporting initiatives throughout postacute care (PAC), including a SNF QRP. The legislation also requires the creation of standardized reporting metrics that allow for more equitable comparisons of care delivery strategies, patient outcomes, and overall performance across the various PAC settings (i.e., SNFs, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals).
  • The Protecting Access to Medicare Act (PAMA) of 2014 added new subsections to the Social Security Act that authorize the establishment of a SNF VBP program beginning in FY 2019, under which value-based incentive payments will be distributed to SNFs based on their performance on designated quality metrics.

Payment update

In addition to these long-term projects, experts say the one major constant of annual CMS rulemaking?the payment update?was also familiar territory this year.

CMS projects that aggregate reimbursement to SNFs will increase by 1.4% ($ 500 million) in FY 2016. The proposed bump would be the result of a 2.6% market basket increase combined with two 0.6% reductions, one stemming from the forecast error adjustment, and the other from the multi-factor productivity adjustment.

But although the anticipated increase is within normal bounds?Brandt says the industry is accustomed to an annual boost between 1% and 2%?Maureen McCarthy, RN, BS, RAC-CT, president and CEO of Celtic Consulting, LLC, in Torrington, Connecticut, had hoped that SNFs would see a higher market basket raise next fiscal year. Although McCarthy says the multi-factor productivity adjustment and the forecast error affect reimbursement rates each year, she says this year’s adjustments may also be intended to fund some of the proposal’s other initiatives that center on improving quality of care and patient satisfaction. Still, McCarthy prefers this strategy over ones that would divest providers after payment was awarded or that would only target certain SNFs.

"It’s the least punitive," she explains. "It’s money we haven’t gotten yet, so it’s easier to lose."


Payroll-based staffing reporting

The other major change addressed in the proposed rule that will actually hit providers next fiscal year is an electronic system for submitting staffing data pulled directly from payrolls, which CMS plans to debut this October for volunteer SNF testing. The so-called payroll-based journal (PBJ) is a response to the Affordable Care Act (ACA)’s call for the introduction of more accountability into the SNF staff reporting sphere by creating a method to electronically submit data on direct care staff (including agency and contract workers). The ACA requires that such a system fulfill the following criteria:

  • Culls data that is verifiable and auditable, such as that from payrolls
  • Specifies the job classification of each employee (e.g., RN, LPN, licensed vocational nurse, CNA, therapist, or other medical personnel) and the number of care hours each employee category provides per resident day
  • Distinguishes data on agency and contract staff from that on SNF employees
  • Tracks employee turnover and tenure
  • Includes data on resident census and case mix
  • Facilitates public reporting on a regular schedule


Although CMS has long been developing a qualifying system and periodically updating the industry about its progress, the FY 2016 proposed rule offers a more comprehensive discussion of how the agency plans to implement these ACA stipulations. Most strikingly, the rule reiterates CMS’ recent announcement that all SNFs will be required to submit data through the PBJ beginning July 1, 2016.

Although this wholesale shift in staff reporting is coming up fast, McCarthy says the details of its execution aren’t yet set in stone. She therefore urges SNFs to parse CMS’ proposals in this domain to bring to light any potential snares, including:

  • How the PBJ will consider corporate nurses who aren’t on a facility’s payroll but may perform direct care.
  • What documentation will be required to support the new collection system. For example, will the CMS-671 and CMS-672 forms feed the PBJ until CMS develops a more tailored alternative?
  • How the PBJ will account for time worked by salaried employees. Although full-time staff are typically thought to spend 40 hours per week on the job, McCarthy says many salaried direct care staff work 50- to 60-hour weeks, meaning a facility could have higher staffing levels at any given time than the size of its workforce would suggest.


Despite these lingering uncertainties, Brandt believes that CMS recognizes the gravity of the industry’s upcoming transition to a much more robust?and complex?reporting mechanism. In turn, she’s optimistic that the agency will implement the new system methodically, accounting for industry feedback and not jeopardizing honest performers.

"I trust that their goal is that it be fair and reliable, so I trust that people who are staffing to acuity are going to be just fine," she says.

Despite Brandt’s confidence in the ability of worthy providers to acclimate to the upcoming shift, Bonnie G. Foster, RN, BSN, MEd, long-term care consultant in Columbia, South Carolina, doesn’t think they should have to. Foster sees the PBJ as a symbol of the government’s misplaced distrust in an industry largely composed of scrupulous providers that are trying their best to field unforeseeable staffing challenges (e.g., last-minute callouts and heavy turnover) as they arise.

But others don’t have such a high view of the SNF provider community. In addition to fulfilling legislative mandates, the government hopes that the PBJ will quell worries expressed by industry stakeholders about the validity of today’s self-reported staffing data?worries that were stoked by an August 2014 New York Times exposé that charged some in the long-term care setting with artificially inflating reported staffing levels to fare better on Nursing Home Compare’s star ratings.

Of course, many providers have denounced these charges. Some, like Brandt, believe that they represent only a small proportion of providers?providers that may soon be exposed through the verifiable PBJ data.

"The people who have been spending their time trying to manipulate the data and … figure out ways to beef up staffing before a survey … all of those tricks are going away if these measures get implemented," Brandt says.

But Foster fears the PBJ could have the reverse effect, driving providers to enlist staff whose titles look the best on paper (or screens) rather than those who are the most qualified. For example, with increasing pressure from CMS and consumer advocates to bump up levels of RN staffing and supervision at SNFs (which will be more easily identifiable in an electronic reporting system), LPNs with years of nursing and management experience may fall by the wayside, Foster explains.

"I don’t want people to put staffing down there to satisfy the system," she says. "That part scares me a lot."

Regardless of her qualms about the forthcoming reporting system, Foster says providers have some work to do to brace for the additional staffing scrutiny ahead.

For example, while SNFs have adopted flexible intake practices to stay competitive in an evolving industry (e.g., admitting new residents late at night and on weekends), Foster says many haven’t synced their staffing schedules with these new patterns, potentially leaving a workforce that is undermanned or underqualified to cope with peak admission periods.

"If you’re going to continue to admit at those strange hours, then you better be sure that all of your staff understand everything," she says.

In addition to improving general staffing strategies, Brandt says providers should focus on understanding the specifics of the forthcoming PBJ.

"People need to read the draft manual on submitting staffing data, and it’s not too early to start preliminary talks about how they’re going to comply," she explains, encouraging providers to begin priming staffing data for the new collection process by identifying the employees who will be responsible for reporting through the system, kick-starting training initiatives, and setting away necessary budget today.



To satisfy provisions of the IMPACT Act that task CMS with collecting quality data, the agency is proposing to build a SNF QRP that considers the three quality measures outlined in the table below.

Under the QRP, SNFs would be required to submit certain data on these measures beginning in FY 2018, as well as on any other focuses CMS finalizes in future rulemaking. In addition, the IMPACT Act dictates that providers failing to comply with these reporting requirements will be penalized with a 2% reduction in their annual payment update.

These prospective QRP requirements will carry significant changes in SNFs’ approaches to quality improvement. The proposed fall and functional status measures have not yet been approved by the National Quality Forum for SNFs, and the latter measure could see in an additional MDS component: Section GG. This new section, which would prompt SNFs to evaluate the functional abilities and goals of residents at the start and end of care, would also foretell a new required assessment for facilities to complete when a beneficiary is discharged from a Medicare Part A stay but does not leave the facility?a status shift that CMS says affects 30% of SNF residents.

Brandt has encountered some providers that are wary about the prospect of an additional assessment on top of their already heavy documentation load?not to mention the associated data capture, training, and resource distribution changes it could carry. However, she thinks these fears are overstated because much of Section GG is pulled straight from the Continuity Assessment Record and Evaluation (CARE) item set, a tool that’s been in development since the 2005 enactment of the Deficit Reduction Act compelled CMS to examine the consistency of payment incentives across the various Medicare providers. CMS states that the CARE tool, which is an output of this directive, is "designed to standardize assessment of patients’ medical, functional, cognitive, and social support status across acute and post-acute settings." And Brandt says it has long been on the radars of central SNF departments.

"The CARE tool has been around for a long time now, and if you read through [Section GG], it’s what therapy has been doing, maybe in different formats, every time they do an evaluation in the discharge summary," she says, explaining that, consequently, many rehab providers already have the tool in their software and have been collecting data through it for some time.

"The MDS community needs to realize that adding a section to the MDS doesn’t mean that it’s going to add more to the job of the MDS coordinator," she says.

Beyond the new quality considerations CMS has posed, the agency also seeks to redefine the current bounds of the industry’s skin integrity measure. Although SNFs are presently required to submit data on changes in their residents’ skin integrity, this measurement is restricted to the development of stage 1?4 pressure ulcers that occur or worsen during facility stays. CMS is proposing to broaden this reporting criteria for SNFs (and other PAC providers) to include:

  • Unstageable pressure ulcers
  • Suspected deep tissue injuries
  • Stage 1 or 2 pressure ulcers that become unstageable due to slough or eschar (indicating progression to a stage 3 or 4 pressure ulcer) after admission


CMS points out that since SNFs are already required to complete items related to unstageable pressure ulcers in the MDS, the revision would require a change in the way the agency calculates the measure but would not increase the data collection burden for SNFs.

In addition, by capturing more incidences of decline, CMS says these proposed updates?which are backed by a number of experts and the agency’s own data analyses?could potentially reveal a wider range of SNF performance, improving "the ability of the quality measure to discriminate between poor- and high-performing facilities."

Brandt thinks this attempt to better discern the success of pressure ulcer prevention throughout the provider community demonstrates CMS’ overarching proposal strategy: to elevate hard workers and undercut bad actors.

"Facilities that have been sincerely and tirelessly working on achieving the highest quality of care are going to rise to the surface," she says. "There are nursing facilities all over this country that have been … doing what they can to prevent injuries from falls, preventing pressure ulcers, and I think they’re going to shine."

In addition to putting the necessary frameworks in place to highlight today’s top-performing facilities, ­McCarthy says the QRP proposals can serve as a road map for providers on shakier ground to launch targeted quality improvement initiatives.

"I think providers should take a look at what’s going to be reported for 2018 … and then look at those quality metrics within their own organizations," she says, adding that facilities should pay particular attention to the proposed methods of collecting and scoring quality data.

"They have the opportunity to correct some issues before [there’s] mandatory reporting if CMS will allow it," she continues, explaining that the agency is soliciting public comments through the proposed rule on whether to give providers this head start.

However, Brandt cautions facilities to avoid putting too much stock in the formulas for calculating these quality measures until they are finalized.



In addition to putting the finishing touches on the QRP’s initial aims, CMS is considering another quality-related focus intended to shape future payments dispensed through the setting’s forthcoming VBP program: the SNF 30-day all-cause readmission measure (SNFRM), which CMS specifies would assess the rate of unplanned readmissions among SNF residents that occur within 30 days of discharge from an inpatient hospital. However, McCarthy says CMS has failed to disclose whether the measure would also penalize providers for hospital readmissions that occur within 30 days after discharge from the SNF itself.

To gather preliminary data for the potential introduction of this metric?whose development was first kindled by PAMA?in October 2016, CMS plans to require facilities to report certain rehospitalization rates starting this October.

Beyond the prospect of an imminent reporting start date tied to its contents, Brandt thinks the SNFRM is significant for another reason: It would be calculated using data from claims rather than MDS documentation, an unprecedented move in the SNF quality domain and one that wouldn’t require any additional data collection or submission by providers.

"It’s kind of historic that we’ve finally got our first measure that is not MDS-based," says Brandt, who believes that the financial tie-ins carried by both the VBP and QRP will further undermine bad actors by stripping them of their primary motivation: monetary reward.

"I think the people who are in long-term care for the goal of providing the service of quality care and who are interested in quality outcomes are going to rise to the surface," she says. "I think people who are in long-term care for any other reason are going to be leaving."

Foster is more ambivalent about the financial incentives (and disincentives) that will soon underlie key performance metrics in the sector. She says that although the forthcoming measures?and their monetary drivers?target long-standing industry shortcomings, she thinks they paint with too broad a brush.

"It’s your entire building is doing a good job, or your entire building is not doing a good job," she says.

Foster worries that this stance could penalize facilities that take on the most compromised residents or reward those whose emphasis on producing favorable bodily outcomes jeopardizes the psychosocial health of the individuals they serve.


Today’s strategies for future success

Despite the far-off focuses of CMS’ latest SNF rulemaking, experts warn providers against lapsing into complacency in the absence of more urgent proposals. They stress that the changes, although distant, are likely to become finalized without major revision. Further, the sweeping scope of QRP and VBP demands preparation from providers today to facilitate compliance and operational stability down the road.

To address the spirit of these changes?the facilitation of effective and efficient care?Foster urges SNFs to implement new restorative nursing programs (or modernize existing ones) with an eye to addressing CMS’ focuses, such as functional status and rehospitalization. Foster says this latter quality indicator, in particular, has been an historic pain point in the industry.

"We’re just worried about the people that keep going back and forth to the hospital as [if through] a revolving door," she explains. To combat this issue, Foster says restorative programs should target services that have traditionally landed residents back in the hospital even though SNFs are equipped to render them, such as providing extra hydration through IVs.

Currently, Foster?who has extensive experience helping facilities implement restorative strategies?says many providers are failing to capitalize on the benefits of a formal restorative program, instead opting for one-off interventions (e.g., designating nursing staff to take residents for a walk once or twice a week) and dedicating the bulk of their resources to enriching therapy offerings. Although some experts say that therapy has been gaining priority throughout the industry as an adaptation to today’s influx of patients seeking short-term intensive SNF rehab services, Foster argues that restorative nursing is a more sustainable practice in some respects. For example, she says that Medicare-covered SNF therapy services have federal cost caps, while restorative programs oftentimes have no mandated expiration date.

Thus, Foster urges providers to shift some of their focus to modeling restorative programs after their often more robust therapy counterparts (e.g., by framing the program with concrete, measurable goals). Not only does Foster believe a restorative mindset will align a facility’s practices with large-scale regulatory shifts, but she says it can breed better connectivity between therapy and nursing departments, thereby fostering a unified vision of care.

In order to build a restorative program that can achieve these manifold benefits in time for the implementation of QRP and VBP measures, Foster says providers need to get started soon.

"It’s going to take you a year to get it right," she explains, citing chronic industry shortfalls as barriers to speedy implementation.

In particular, Foster says providers need to strengthen communication with physicians and the families of residents. She believes many rehospitalizations can be attributed to insistence by families that a SNF readmit a resident to the hospital for any change in condition?even one a facility is capable of remedying.

"When nurses call the families to let them know … "Something’s changed in your loved one," families are notorious for saying, ‘We’ll just send them to the hospital,’ and that’s what [SNFs] do," she says.

To combat families’ reflexive panic and facilities’ equally knee-jerk acquiescence, Foster urges SNFs to sit down with partnering physicians to write a concrete strategy for addressing condition changes. The document should list the specific events a facility can handle on its own and detail the procedures it will use to do so. This will arm SNFs and physicians with an official document to assure families that the SNF is well-equipped to stabilize their loved one’s condition after certain adverse events.

But SNFs’ current communication shortfalls aren’t restricted to external stakeholders, according to Foster, who also charges the industry with insufficient education, particularly among frontline staff. In turn, these lapses can trigger subpar care, inaccurate documentation, and high turnover among mismanaged and frustrated employees. For example, Foster says that documentation among a facility’s CNAs can be erratic and inconsistent, especially regarding a given resident’s functional status, which must be captured multiple times each day and can be evaluated very differently by varying frontline staff members.

To begin clearing up disparate clinical understandings, Foster recommends focusing training efforts around the component of the MDS that corresponds to functional status. "If nothing else, just teach Section G," she says?a directive that seems particularly fitting, given the potential implementation of Section GG, which would build on the functional data already captured today.

Beyond ramping up education, Foster proposes an unconventional solution for warding off critical quality lapses: establishing a mentor program that assigns a qualified staff member to remain by each newly admitted resident’s side for the first two days of his or her stay, a period during which Foster believes the lion’s share of adverse incidents occurs.

"Everything bad happens within the first 48 hours of admission," she says, explaining that she’s seen mentor programs targeted to this time frame reduce fall rates.

But before getting too caught up in planning any full-fledged program refurbishments, McCarthy urges providers to take advantage of the public reporting period on the proposed rule?in effect through June 15?to point out to CMS any perceived issues, discrepancies, or oversights (e.g., surrounding the PBJ and SNFRM) that could jeopardize the future success of their facility.

"Providers really should use that opportunity to voice their concerns to CMS on what issues they think may negatively impact them," she explains. "Because once they become public, they become public, and there’s no opportunity to correct the information that’s out there."

In many respects, the proposed rule provides a first glimpse into CMS’ big-picture plans for the industry in the years ahead. Although it glazes over some key nuances of the agency’s potential execution strategy, Brandt is optimistic the proposal will ultimately introduce new, more reliable methods of upholding virtuous SNFs that have been overshadowed in recent years by the industry’s small, yet potent faction of abusers.

"I think that all the good, decent, honest nursing home operators have ever asked for was a fair chance and to be measured realistically on a level playing field, and I think this is a great step in that direction," she says. "I’m excited to see what’s going to happen in our industry in the coming years." – Billing Alert for Long-Term Care

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