CHAPTER 1 CPMA PREP EXAM
QUESTIONS WITH CORRECTLY
SOLVED ANSWERS.
12.1% --Answer-- # of improper Medicare Fee-For-Service claim payments,
according to Federal Government.
FFS --Answer-- Fee-For-Service
Prepayment Review --Answer-- Review of claims prior to payment.
Prepayment reviews result in an initial determination.
Post payment Review --Answer-- Review of claims after payment. May result
in either no change to the initial determination or a revised determination,
indicating an underpayment or overpayment.
Underpayment --Answer-- A payment a provider receives under the amount
due for services furnished under the Medicare statute and regulations.
Overpayment --Answer-- A payment a provider receives over the amount due
for services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: --Answer-- *Billing for excessive
and subsequent payment of the same service or claim.
*Duplicate submission and payment for same service or claim
*Payment for excluded or Medically unnecessary services.
*Payment for services in setting not appropriate to pt's needs or condition
*Payment to an incorrect payee.
MACs --Answer-- Medicare Administrative Contractors
MAC Responsibilities --Answer-- Process claims from physicians, hospitals,
and other health care professionals, and submit payment to those providers
according to Medicare rules and regulations (including identifying under- and
overpayments).
ZPICs --Answer-- Zone Program Integrity Contractors
PSCs --Answer-- Program Safeguard Contractor
,ZPICs/PSCs --Answer-- Perform investigations that are unique and tailored to
specific circumstances and occur only in situations where there is potential
fraud, and take appropriate corrective actions
SMRC --Answer-- Supplemental Medical Review Contractor
SMRC Responsibilities --Answer-- Conduct nationwide medical review as
directed by CMS (includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors --Answer-- Review claims to identify
potential underpayments and overpayments in Medicare FFS, as part of the
Recovery Audit Program
Zone 6 --Answer-- All PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, --Answer-- Each contractor
conducting a claim review must apply all Medicare policies to the claim
under review. Additionally, once a claim is reviewed, a different contractor
should not reopen it. Therefore, it is important when conducting claim
reviews, contractors review each claim in its entirety.
Claim Review Programs --Answer-- There are 5 claim review programs
NCCI Edits --Answer-- National Correct Coding Initiative Editor
NCCI Edits are performed by --Answer-- Macs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to --Answer-- Promote national correct coding
methods and to control improper coding that leads to inappropriate payment
in Medicare Part B claims. NCCI Edits prevent improper payments when
incorrect code combinations are reported. The NCCI Edits are updated
quarterly.
The coding policies are based on the following coding conventions... --
Answer-- *American Medical Association (AMA) Current Procedure
Terminology (CPT) Manual
*National and local Medicare policies and edits
*Coding guidelines developed by the National societies, standard medical
and surgical practice, and current coding practice.
PTP --Answer-- Procedure-to-Procedure edits
, Column One/Column Two edit pair --Answer-- If a claim contains the two
codes of an edit pair, the Column One code is eligible for payment, but CMS
will deny the Column Two code
NCCI edit pairs that are both appropriate --Answer-- If both codes are
clinically appropriate, you must append with an appropriate NCCI-associated
modifier to be eligible for payment.
Medicare beneficiaries and NCCI edits --Answer-- You cannot bill Medicare
beneficiaries for services denied based on NCCI Edits.
ABN --Answer-- Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits --Answer-- When the denials are based on incorrect
coding rather than medical necessity, you cannot use an ABNS (Form CMS-R-
131) to seek payment from a Medicare beneficiary.
NCCI edits and Notice of Exclusions from Medicare Benefits --Answer-- If
denials are based on incorrect coding rather than a legislated Medicare
benefit exclusion, you cannot use a "Notice of Exclusions from Medicare
Benefits" form to seek payment from a Medicare beneficiary.
OCE --Answer-- Outpatient Code Editor edits
Refer to the OCE edits for claims --Answer-- For all Outpatient institutional
providers
Refer to NCCI Edits for --Answer-- Physician services under the Medicare
Physician Fee Schedule (PFS)
PFS --Answer-- Physician Fee Schedule
While a number of the NCCI Edits are included in the OCE edits --Answer--
The OCE edits are not used within the Medicare PFS (Physician Fee
Schedule).
MUEs --Answer-- Medically Unlikely Edits
Message are performed by --Answer-- Macs (noncomplex)
CMS developed MUEs to --Answer-- Reduce the paid claim error rate for
Medicare Part B claims.
Unlike NCCI Edits, the MUEs --Answer-- Are automated prepayment edits
QUESTIONS WITH CORRECTLY
SOLVED ANSWERS.
12.1% --Answer-- # of improper Medicare Fee-For-Service claim payments,
according to Federal Government.
FFS --Answer-- Fee-For-Service
Prepayment Review --Answer-- Review of claims prior to payment.
Prepayment reviews result in an initial determination.
Post payment Review --Answer-- Review of claims after payment. May result
in either no change to the initial determination or a revised determination,
indicating an underpayment or overpayment.
Underpayment --Answer-- A payment a provider receives under the amount
due for services furnished under the Medicare statute and regulations.
Overpayment --Answer-- A payment a provider receives over the amount due
for services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: --Answer-- *Billing for excessive
and subsequent payment of the same service or claim.
*Duplicate submission and payment for same service or claim
*Payment for excluded or Medically unnecessary services.
*Payment for services in setting not appropriate to pt's needs or condition
*Payment to an incorrect payee.
MACs --Answer-- Medicare Administrative Contractors
MAC Responsibilities --Answer-- Process claims from physicians, hospitals,
and other health care professionals, and submit payment to those providers
according to Medicare rules and regulations (including identifying under- and
overpayments).
ZPICs --Answer-- Zone Program Integrity Contractors
PSCs --Answer-- Program Safeguard Contractor
,ZPICs/PSCs --Answer-- Perform investigations that are unique and tailored to
specific circumstances and occur only in situations where there is potential
fraud, and take appropriate corrective actions
SMRC --Answer-- Supplemental Medical Review Contractor
SMRC Responsibilities --Answer-- Conduct nationwide medical review as
directed by CMS (includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors --Answer-- Review claims to identify
potential underpayments and overpayments in Medicare FFS, as part of the
Recovery Audit Program
Zone 6 --Answer-- All PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, --Answer-- Each contractor
conducting a claim review must apply all Medicare policies to the claim
under review. Additionally, once a claim is reviewed, a different contractor
should not reopen it. Therefore, it is important when conducting claim
reviews, contractors review each claim in its entirety.
Claim Review Programs --Answer-- There are 5 claim review programs
NCCI Edits --Answer-- National Correct Coding Initiative Editor
NCCI Edits are performed by --Answer-- Macs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to --Answer-- Promote national correct coding
methods and to control improper coding that leads to inappropriate payment
in Medicare Part B claims. NCCI Edits prevent improper payments when
incorrect code combinations are reported. The NCCI Edits are updated
quarterly.
The coding policies are based on the following coding conventions... --
Answer-- *American Medical Association (AMA) Current Procedure
Terminology (CPT) Manual
*National and local Medicare policies and edits
*Coding guidelines developed by the National societies, standard medical
and surgical practice, and current coding practice.
PTP --Answer-- Procedure-to-Procedure edits
, Column One/Column Two edit pair --Answer-- If a claim contains the two
codes of an edit pair, the Column One code is eligible for payment, but CMS
will deny the Column Two code
NCCI edit pairs that are both appropriate --Answer-- If both codes are
clinically appropriate, you must append with an appropriate NCCI-associated
modifier to be eligible for payment.
Medicare beneficiaries and NCCI edits --Answer-- You cannot bill Medicare
beneficiaries for services denied based on NCCI Edits.
ABN --Answer-- Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits --Answer-- When the denials are based on incorrect
coding rather than medical necessity, you cannot use an ABNS (Form CMS-R-
131) to seek payment from a Medicare beneficiary.
NCCI edits and Notice of Exclusions from Medicare Benefits --Answer-- If
denials are based on incorrect coding rather than a legislated Medicare
benefit exclusion, you cannot use a "Notice of Exclusions from Medicare
Benefits" form to seek payment from a Medicare beneficiary.
OCE --Answer-- Outpatient Code Editor edits
Refer to the OCE edits for claims --Answer-- For all Outpatient institutional
providers
Refer to NCCI Edits for --Answer-- Physician services under the Medicare
Physician Fee Schedule (PFS)
PFS --Answer-- Physician Fee Schedule
While a number of the NCCI Edits are included in the OCE edits --Answer--
The OCE edits are not used within the Medicare PFS (Physician Fee
Schedule).
MUEs --Answer-- Medically Unlikely Edits
Message are performed by --Answer-- Macs (noncomplex)
CMS developed MUEs to --Answer-- Reduce the paid claim error rate for
Medicare Part B claims.
Unlike NCCI Edits, the MUEs --Answer-- Are automated prepayment edits
