Certified Professional Medical Auditor (CPMA) Exam Prep – Chapter 1 Questions and 100% Correct Answers (2025)

CPMA EXAM CHAPTER 1 PREP QUESTIONS AND
100% CORRECT ANSWERS (2025)

12.1% - CORRECT ANSWERV - # of improper Medicare Fee-For-Service claim
payments, according to Federal Government.

FFS - CORRECT ANSWERV - Fee-For-Service

Prepayment Review - CORRECT ANSWERV - Review of claims prior to
payment. Prepayment reviews result in an initial determination.

Postpayment Review - CORRECT ANSWERV - 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 - CORRECT ANSWERV - A payment a provider receives under
the amount due for services furnished under the Medicare statute and regulations.

Overpayment - CORRECT ANSWERV - A payment a provider receives over the
amount due for services furnished under Medicare statutes and regulations

5 Common reasons for overpayment are: - CORRECT ANSWERV - *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 - CORRECT ANSWERV - Medicare Administrative Contractors

MAC Responsibilities - CORRECT ANSWERV - 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 - CORRECT ANSWERV - Zone Program Integrity Contractors

,PSCs - CORRECT ANSWERV - Program Safeguard Contractor

ZPICs/PSCs - CORRECT ANSWERV - 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 - CORRECT ANSWERV - Supplemental Medical Review Contractor

SMRC Responsibilities - CORRECT ANSWERV - Conduct nationwide medical
review as directed by CMS (includes identifying underpayments and overpayments

Medicare FFS Recovery Auditors - CORRECT ANSWERV - Review claims to
identify potential underpayments and overpayments in Medicare FFS, as part of
the Recovery Audit Program

Zone 6 - CORRECT ANSWERV - All PSCs transitioned to ZPICs with the
exception of Zone 6

While all contractors focus on a specific area, - CORRECT ANSWERV - 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 - CORRECT ANSWERV - There are 5 claim review
programs

NCCI Edits - CORRECT ANSWERV - National Correct Coding Initiative Editor

NCCI Edits are performed by - CORRECT ANSWERV - Macs, ZPICs, CERT,
and Medicare FFS

Complexity: Non-complex

CMS developed the NCCI to - CORRECT ANSWERV - 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... - CORRECT
ANSWERV - *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 - CORRECT ANSWERV - Procedure-to-Procedure edits

Column One/Column Two edit pair - CORRECT ANSWERV - 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 - CORRECT ANSWERV - 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 - CORRECT ANSWERV - You cannot bill
Medicare beneficiaries for services denied based on NCCI Edits.

ABN - CORRECT ANSWERV - Advance Beneficiary Notice of Noncoverage

ABNs and NCCI edits - CORRECT ANSWERV - 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 - CORRECT
ANSWERV - 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 - CORRECT ANSWERV - Outpatient Code Editor edits

Refer to the OCE edits for claims - CORRECT ANSWERV - For all Outpatient
institutional providers

Refer to NCCI Edits for - CORRECT ANSWERV - Physician services under the
Medicare Physician Fee Schedule (PFS)

PFS - CORRECT ANSWERV - Physician Fee Schedule