CPMA Exam Study Guide

EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 3/74 C. The location and severity of wounds repaired D. All of the above - Answer-D. All of the above Which of the following is NOT a covered entity under HIPPA? A. Physician B. Health Plan C. Health Care Consultant D. Physician Assistant - Answer-C. Health Care Consultant When referring to the authentication of a medical record entry, what does this entail? A. Legible signature of author and date signed B. A physician's order for ancillary services C. An original document filed in the record D. The patient's personal information - Answer-A. Legible signature of author and date signed What is the time limit mandated by CMS for adding a late entry to the medical record? EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 4/74 A. One Week B. One Month C. One Year D. No time limit - Answer-D. No time limit When should a ABN be signed? A. Prior to performing a statutorily excluded procedure for a Medicare beneficiary. B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. C. Prior to submitting a claim to Medicaid for a non- service. D. After performing a procedure and finding it is denied. - Answer-B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. Under a Corporate Integrity Agreement (CIA), how many claims must be randomly selected to review to determine the financial error rate? EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 5/74 A. 15 B. 50 C. 75 D. 100 - Answer-B. 50 When using LCDs and CMS program Guidance as a resource for an audit, what should the auditor keep in mind? A. QICs are bound by NCDs, LMRPs, and CMS Program guidance, but ALJs and MACs are not. B. Local carriers and QICs are bound by LCDs and LMRPs C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. D. Local Carriers, QICs, ALJs, and MACs are all bound by NCDs and CMS program guidance. - Answer-C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 6/74 When reporting the claims review findings under a CIA audit, the Independent Review Organization (IRO) must provide: A. A detailed analysis listing the patient files reviewed and findings and previous audit disclosures for all services B. A detailed report with a narrative explanation of finding and supporting rationale approved by the providers attorney. C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. D. A list of data reviewed and findings in a narrative form - Answer-C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. Which statement is most accurate regarding NCCI? A. NCCI are national coding guidelines and must be followed regardless of the insurance carrier. EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 7/74 B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. C. Each individual carrier will have its own bundling edits and will not use NCCI. D. NCCI edits are suggested ways to bundle procedure codes, but are not necessary to review during an audit. - Answer-B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. A provider request you to perform an audit of claims that have been denied payment by XYZ insurance. Since the physician contracted with XYZ insurance, all claims submitted that include the E/M service and EKG interpretation on the same day have been denied for the EKG interpretation. You review the medical record and the EOB and determine the services are documented and coded correctly. Which of the following items will you need to complete your audit? A. Provider contract with XYZ insurance. B. Provider internal billing polices. EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 8/74 C. RAC statement of work D. OIG work plan for the current year. - Answer-A. Provider contract with XYZ insurance. According to the "OIG Compliance Program for Individual and Small Group Physician Practices," There are essential elements for a compliance plan. These elements included: A. Mandatory employment of an internal auditor B. Conduct appropriate training and education C. Disciplinary action for employees who file a qui tam suit D. Develop an effective E/M Audit Tool with reproducible results. - Answer-B. Conduct appropriate training and education John presents today for his yearly physical and during the encounter he alerts his physician to some abdominal issues he has been having including sharp pains that come and go and have been increasing in severity especially after eating. After examination the doctor orders an ultrasound which is performed in the office and medications and schedules a follow-up for two weeks. What is the appropriate modifier for this encounter? EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 9/74 A. No modifier necessary B. 25 C. 57 D. 24 - Answer-B. 25 Which of the following accurately describes the financial impact for appending modifier 24 to an E/M service performed during the global period of a major surgery? A. The E/M service will not be paid when performed during the global period. B. The E/M service will be paid at 20% of the physician fee schedule C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. D. The E/M service will not be paid and a ABN should be signed since the service provided is unrelated to the surgery. - Answer-C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 10/74 Select the scenario that would support medical necessity for observation services. A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. B. A patient who is recovering from abdominal surgery who requires observation until awake from anesthesia. C. A patient who is receiving infusion chemotherapy for the first time and is anxious about that procedure D. A patient who is dependent on a ventilator and requires pulse oximetry to monitor 02 staturation - Answer-A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. When may a focused audit be initiated? A. After a prepayment or retrospective audit has identified a specific problem B. When the auditor first decides to conduct an audit