Chapter 1 CPMA Exam Prep questions and answers 100% guaranteed success.

Chapter 1 CPMA Exam Prep questions and answers 100% guaranteed success. 12.1% - correct answers.# of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS - correct answers.Fee-For-Service Prepayment Review - correct answers.Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review - correct answers.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 answers.A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment - correct answers.A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: - correct answers.*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 answers.Medicare Administrative Contractors MAC Responsibilities - correct answers.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 answers.Zone Program Integrity Contractors PSCs - correct answers.Program Safeguard Contractor ZPICs/PSCs - correct answers.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 answers.Supplemental Medical Review Contractor SMRC Responsibilities - correct answers.Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments Medicare FFS Recovery Auditors - correct answers.Review claims to identify potential underpayments and overpayments in Medicare FFS, as part of the Recovery Audit Program Zone 6 - correct answers.All PSCs transitioned to ZPICs with the exception of Zone 6 While all contractors focus on a specific area, - correct answers.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 answers.There are 5 claim review programs NCCI Edits - correct answers.National Correct Coding Initiative Editor NCCI Edits are performed by - correct answers.Macs, ZPICs, CERT, and Medicare FFS Complexity: Non-complex CMS developed the NCCI to - correct answers.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 answers.*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 answers.Procedure-to-Procedure edits Column One/Column Two edit pair - correct answers.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 answers.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 answers.You cannot bill Medicare beneficiaries for services denied based on NCCI Edits. ABN - correct answers.Advance Beneficiary Notice of Noncoverage ABNs and NCCI edits - correct answers.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 answers.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 answers.Outpatient Code Editor edits Refer to the OCE edits for claims - correct answers.For all Outpatient institutional providers Refer to NCCI Edits for - correct answers.Physician services under the Medicare Physician Fee Schedule (PFS) PFS - correct answers.Physician Fee Schedule While a number of the NCCI Edits are included in the OCE edits - correct answers.The OCE edits are not used within the Medicare PFS (Physician Fee Schedule). MUEs - correct answers.Medically Unlikely Edits Message are performed by - correct answers.Macs (noncomplex) CMS developed MUEs to - correct answers.Reduce the paid claim error rate for Medicare Part B claims. Unlike NCCI Edits, the MUEs - correct answers.Are automated prepayment edits An MUE for a HCPCS/CPT code - correct answers.Is the maximum units of service that a provider would report, under most circumstances, for a single beneficiary on a single date of service. MUEs do not exist for all HCPCS/CPT codes - correct answers.While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUEs because of fraud and abuse concerns. Providers should NOT interpret MUE values as utilization guidelines. - correct answers.MUE values do not represent units of service that providers may report and avoid further medical review. Providers should continue to report only services that are Medically reasonable and necessary. Medical Review Program is performed by - correct answers.Macs, ZPICs/PSCs, and SMRCs Complexity : Complex Claim Review contractors identify suspected improper billing through - correct answers.Error rates produced by the CERT Program, vulnerabilities identified through the Recovery Audit Program, claim data analysis, and evaluation of other information (for example, complaints). Generally, claim review contractors focus Medical Review (MR) activities on identified - correct em areas and select appropriate action for the severity of the problem. 3 types of corrective actions can result from a Medical Review (MR) - correct answers.*Provider Education/Feedback *Prepayment review *Postpayment review. SMRC reviews are selected by - correct answers.CMS Both Prepayment and Postpayment reviews may require - correct answers.Providers to submit medical records To help prevent improper payments, the MAC's - correct answers.Provider Outreach and Education (POE) department educates providers submitting claims Prepayment review - correct answers.Providers with identified problems may be placed on prepayment review, in which a selection of their claims undergo MR before the MAC authorizes payment. Once providers reestablish the practice of billing correctly, Prepayment review ends Postpayment review - correct answers.Contractors perform postpayment claim reviews most commonly by using statistically valid sampling. Sampling allows estimation of an underpayment or overpayment (if one exists) without requesting all records on all claims from providers. CERT Program - correct answers.Performed by CERT Review Contractor (RC) and CERT Statistical Contractor (SC) COMPLEXITY: Complex CMS must calculate the - correct answers.National Medicare FFS improper payment rate. CERT randomly selects a - correct answers.Statistically valid sample of processed Medicare FFS claims, and requests medical documentation from the provider or supplier that submitted the sampled claim. CERT performs a complex - correct answers.Medical Review of the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, payment, coding, and billing rules. CERT - correct answers.Comprehensive Error Rate Testing CMS calculates a national Medicare FFS improper payment rate and improper payment rates by service type to - correct answers.Accurately measure the performance of the Macs and gain insight into the causes of error. CMS publishes the results of these reviews annually. The FFS Improper Payment Rate is a good indicator of - correct answers.How claim errors in the Medicare FFS Program impact the Medicare Trust Fund. The 5 error categories that CERT contractors identify - correct answers.*No documentation *Insufficient documentation *Medical Necessity *Incorrect coding *Other No documentation - correct answers.Provider or supplier fails to respond to repeated requests for the medical records or they do not have the requested documentation Insufficient documentation - correct answers.Submitted medical documentation is inadequate to say payment for the services billed; the CERT contractor reviewers could not conclude that the billed service was actually provided, was provided at the level billed and/or was medically necessary; or a specific documentation element that is required as a condition of payment is missing Medical necessity - correct answers.There is adequate documentation in the medical records to make the informed decision that the services billed were Medically necessary based upon Medicare coverage and payment policies. Incorrect coding - correct answers.Provider or supplier submit s medical documentation supporting *a different code than was billed *the service was performed by someone other than the billing provider or supplier *the billed service was unbundled *a beneficiary was discharged to a site other than the one coded on a claim Claims selected for CERT Review are subject to potential - correct answers.Postpayment denials, payment adjustments, or other actions depending upon the result of the review. Normal appeal rights and processes apply. CERT reviews have the following corrective actions - correct answers.*Improving system edits *Increasing and focusing medical review on problem areas *Updating coverage policies and manuals *Conducting provider education efforts Recovery Audit Program is performed by - correct answers.Medicare FFS Recovery Auditors Complexity : Complex Recovery Auditors - correct answers.Review past Medicare FFS claim data for potential overpayments or underpayments, reviewing medical records when necessary to make appropriate determinations.