Chapter 1 CPMA Exam Prep Questions And
Answers
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
*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
,Chapter 1 CPMA Exam Prep Questions And
Answers
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
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.
,Chapter 1 CPMA Exam Prep Questions And
Answers
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
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.
, Chapter 1 CPMA Exam Prep Questions And
Answers
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
NCCI edit pairs that are both appropriate 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 You cannot bill Medicare beneficiaries for services
denied based on NCCI Edits.
ABN Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits 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.
Answers
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
*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
,Chapter 1 CPMA Exam Prep Questions And
Answers
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
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.
,Chapter 1 CPMA Exam Prep Questions And
Answers
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
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.
, Chapter 1 CPMA Exam Prep Questions And
Answers
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
NCCI edit pairs that are both appropriate 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 You cannot bill Medicare beneficiaries for services
denied based on NCCI Edits.
ABN Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits 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.
