CPB PRACTICE EXAM C, Questions and answers, 100% Accurate. Approved.

CPB PRACTICE EXAM C, Questions and answers, 100% Accurate. Approved. A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. - -The birthday rule states the parent whose birthday falls first in the year is primary. The year of birth is not relevant. In this case, the mother's birthday falls before the father's birthday so the mother's insurance is primary. Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided? A. Health Maintenance Organization (HMO) B. Point-of-Service Plan (POS) C. Exclusive Provider Organization (EPO) D. Integrated Delivery System (IDS) - -EPO is a managed care plan in which enrollees must receive their care from doctors and hospitals within the EPO network, but cannot go outside of the network for care. If an enrollee goes to a provider or hospital outside of the network the enrollee will have to pay the medical bills out of pocket. A network provider for EPO plans is reimbursed on fee-for-service basis. Which TRICARE plan is similar to an HMO plan? A. TRICARE Extra B. TRICARE Standard C. TRICARE Prime D. TRICARE Premium - -TRICARE Prime is one of the three healthcare options that is similar to an HMO plan as the patient is assigned a PCP and the treatment goes through the PCP. Which of the services are covered by Medicare Part A? I. Skilled Nursing Facility Care II. Ambulatory Surgery III. Durable Medical Equipment IV. Hospice Care V. Home Health Services VI. Long Term Care VII. Outpatient prescription drugs A. I-VII B. II, III, VI C. I, II, IV, VII D. I, IV, V - -Medicare Part A covers hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Which is a TRUE statement regarding Workers' Compensation? A. There is no copayment for the injured worker in workers' compensation cases. B. The filing deadline for a first report of injury form is one week from the date of the accident. C. Providers can balance bill a patient when compensation payment is not paid in full. D. There is a deductible for the injured worker in workers' compensation claims. - -There is no co-payment for workers' compensation cases. A worker (employee) cannot be given a bill for co-pay or anything else because it is the insurance policy of the employer, and not the workers' personal policy, that pays the bill. The filing deadline for a first report of injury form is determined by state law. All providers must accept the compensation payment as payment in full. There is no deductible in workers' compensation. Bob sees his family physician for seasonal allergies.Before leaving, Bob pays the charge for the office visit. As a courtesy, the physician's staff submits a claim to Bob's insurance company. If the service is covered by the insurance company, Bob can expect to be reimbursed for the office visit. This is which type of insurance model? A. Healthcare Anywhere B. Managed Care Plan C. Fee-for-service (traditional coverage) D. Health Maintenance Organization (HMO) - -Blue Cross/Blue Shield fee-for-service (traditional coverage) plan is selected by individuals who do not have the access to a group plan, and for small business employers. The plan has two types of coverage, basic coverage and major medical benefits. Which of the following benefits are NOT covered by all Medigap polices? I. Part A co-insurance and hospital costs II. Skilled nursing facility care co-insurance III. Parts A & B deductible IV. Part B excess charges V. Foreign travel exchange A. I, II, III B. I, III C. I, IV, V D. II, III, IV, V - -Medigap is required to cover Part A coinsurance and hospital costs. The remaining items are only covered by some of the Medigap policies. Medicaid eligibility is primarily determined by? A. Income B. Prior insurance coverage C. Marital status D. Number of living relatives - -Medicaid eligibility is primarily determined by the patient's monthly income. ____________ is incorporated by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to a patient. A. Outpatient Code Editor (OCE) B. Medically Unlikely Edits (MUE) C. Physician Fee Schedule D. National Coverage Determination (NCD) - -Medically unlikely edits (MUE), which are units of service edits, was implemented by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to an individual patient. CMS developed the MUE program to reduce the error rate for Part B coding and to control improper payments. In the CPT® codebook, which of the following codes may be used for reporting synchronous telemedicine services when appended by modifier 95? A. 93000 B. 99441 C. 99225 D. has the star symbol next to it. The star symbol identifies codes that the code can be used for reporting synchronous telemedicine services when appended by modifier 95 (see Appendix P). 11 - -11 Which service is NOT included in the global package for surgical procedures? A. Treatment for postoperative complications that require a return trip to the OR. B. Writing orders C. Evaluating the patient in the Post-Anesthesia Care Unit D. Local infiltration, digital block, topical anesthesia - -Treatment for postoperative complication that requires a return trip to the OR is not included in the global package. An example of this is when someone has a postoperative complication of an infected seroma a couple days after surgery and needs to return to the OR for incision and drainage of the seroma. Modifier 78 is appended to the surgical procedure code to indicate this. A biller notices there is a large amount of Medigap claims where Medicare has paid the claim but Medicaid has not processed or paid the claim. After research, the biller discovers the IDs for the Medigap coverage is not formatted correctly on the CMS 1500 claim form. Which of the following format is correct for the Medigap insurer ID in Item 9a? A. B. AETNA C. MG D. Item 9a is left blank - -When a patient has Medigap in addition to Medicare, item 9a is completed with the Medigap insurer's policy and/or group number preceded by MEDIGAP, MG, or MGAP. When item 18 on a CMS-1500 claim form has dates of service for inpatient care, what is entered in item 32? A. Physician's name and office address who saw the patient in the hospital. B. Patient's name and address. C. Name and address of the facility that provided the service D. You can leave block Item 32 blank because block Item 33 has the required information. - -When a patient has dates of service for inpatient care the name and address of the facility that provided services is entered in Item 32. According to CPT® subsection guidelines for Excision-Malignant Lesions, when there is a removal of a 3 cm malignant lesion on the arm and the defect area is repaired with an intermediate layer closure how is it reported? A. 11603, 12032-51 B. 11603 C. 12032 D. 11603, 12002-51 - -Referring to the CPT® subsection guidelines for Excision-Malignant Lesions (found before code 11600) indicates when an excision of a malignant lesion requires an intermediate closure () or complex closure () you report both the repair code and lesion excision code. A simple closure repair code () is included (or bundled) in the lesion excision code and not reported separately. On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided? A. Digit 1 B. Digit 2 C. Digit 3 D. Digit 4 - -Digit 3 in TOB classifies the type of care provided (example, Inpatient [Medicare Part A], Outpatient). Digit 1 (the leading zero) is ignored by CMS. Digit 2 identifies the type of facility (example, Hospital, Skilled Nursing). Digit 4 is the sequence of this bill for this particular episode of care (example, Late Charge only, Interim-first claim). The CPT® or HCPCS Level II code reported on a UB-04 is translated to what type of code by Medicare to reimburse for outpatient facility services? A. Ambulatory Payment Classification (APC) B. National Drug Code (NDC) C. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) D. Both B and C - -In the case of Medicare reimbursement for outpatient services, CPT® or HCPCS Level II codes assigned to charges will be translated into APC groups. Each APC will generate a predetermined payment amount, which is multiplied by the number of units of the charge Which of the following are common identifiers for protected health information (PHI) which can be used to identify an individual? I. Birth Date II. Past mental health condition III. Driving records IV. Mailing Address V. Medical record number A. I-V B. I, II, IV, V C. III, V D. I, IV - -Protected health information is "individually identifiable health information" that includes many common identifiers, such as demographic data, name, address, birth date, and social security number. It also includes information that relates to an individual's past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or, the past, present, or future payment for the provision of healthcare to the individual, which reasonably may be used to identify an individual Which of the following service type providers is required to accept assignment on Medicare claims? I. Clinical diagnostic laboratory services II. Specialized radiology services III. Services provided to Medicare/Medicaid patients IV. Simplified billing roster for influenza virus vaccine and pneumococcal vaccine V. Physical therapy services A. I, III, and IV B. I, II, and V C. III, IV, and V D. I, III, and V - -Medicare requires the following types of providers to accept assignment on Medicare claims: clinical diagnostic laboratory services, physician services to individuals dually entitled to Medicare and Medicaid, participating physician/supplier services, services of physician assistants, nurse practitioners, clinical nurse specialist, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers, ambulatory surgical center services for covered