Chapter 1 CPMA Exam Prep rated A
12.1% - # of improper Medicare Fee-For-Service claim payments, according to
Federal Government.
FFS - Fee-For-Service
Prepayment Review - Review of claims prior to payment. Prepayment reviews
result in an initial determination.
Postpayment Review - 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 - A payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
Overpayment - A payment a provider receives over the amount due for services
furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: - *Billing for excessive and subsequent
payment of the same service or claim.
*Duplicate submission and payment for same service or claim
,Chapter 1 CPMA Exam Prep rated A
*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 - Medicare Administrative Contractors
MAC Responsibilities - 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 - Zone Program Integrity Contractors
PSCs - Program Safeguard Contractor
ZPICs/PSCs - 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 - Supplemental Medical Review Contractor
,Chapter 1 CPMA Exam Prep rated A
SMRC Responsibilities - Conduct nationwide medical review as directed by CMS
(includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors - Review claims to identify potential
underpayments and overpayments in Medicare FFS, as part of the Recovery Audit
Program
Zone 6 - All PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, - 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 - There are 5 claim review programs
NCCI Edits - National Correct Coding Initiative Editor
NCCI Edits are performed by - Macs, ZPICs, CERT, and Medicare FFS
, Chapter 1 CPMA Exam Prep rated A
Complexity: Non-complex
CMS developed the NCCI to - 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... - *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 - Procedure-to-Procedure edits
Column One/Column Two edit pair - 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
12.1% - # of improper Medicare Fee-For-Service claim payments, according to
Federal Government.
FFS - Fee-For-Service
Prepayment Review - Review of claims prior to payment. Prepayment reviews
result in an initial determination.
Postpayment Review - 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 - A payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
Overpayment - A payment a provider receives over the amount due for services
furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: - *Billing for excessive and subsequent
payment of the same service or claim.
*Duplicate submission and payment for same service or claim
,Chapter 1 CPMA Exam Prep rated A
*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 - Medicare Administrative Contractors
MAC Responsibilities - 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 - Zone Program Integrity Contractors
PSCs - Program Safeguard Contractor
ZPICs/PSCs - 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 - Supplemental Medical Review Contractor
,Chapter 1 CPMA Exam Prep rated A
SMRC Responsibilities - Conduct nationwide medical review as directed by CMS
(includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors - Review claims to identify potential
underpayments and overpayments in Medicare FFS, as part of the Recovery Audit
Program
Zone 6 - All PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, - 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 - There are 5 claim review programs
NCCI Edits - National Correct Coding Initiative Editor
NCCI Edits are performed by - Macs, ZPICs, CERT, and Medicare FFS
, Chapter 1 CPMA Exam Prep rated A
Complexity: Non-complex
CMS developed the NCCI to - 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... - *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 - Procedure-to-Procedure edits
Column One/Column Two edit pair - 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
