CHAPTER 1 CPMA EXAM PREP
CORRECT 100%
12.1% - ANSWER# of improper Medicare Fee-For-Service claim payments, according
to Federal Government.
FFS - ANSWERFee-For-Service
Prepayment Review - ANSWERReview of claims prior to payment. Prepayment reviews
result in an initial determination.
Postpayment Review - ANSWERReview of claims after payment. May result in either no
change to the initial determination or a revised determination, indicating an
underpayment or overpayment.
Underpayment - ANSWERA payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
Overpayment - ANSWERA payment a provider receives over the amount due for
services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: - ANSWER*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 - ANSWERMedicare Administrative Contractors
MAC Responsibilities - ANSWERProcess 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 - ANSWERZone Program Integrity Contractors
PSCs - ANSWERProgram Safeguard Contractor
ZPICs/PSCs - ANSWERPerform 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 - ANSWERSupplemental Medical Review Contractor
, SMRC Responsibilities - ANSWERConduct nationwide medical review as directed by
CMS (includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors - ANSWERReview claims to identify potential
underpayments and overpayments in Medicare FFS, as part of the Recovery Audit
Program
Zone 6 - ANSWERAll PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, - ANSWEREach 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 - ANSWERThere are 5 claim review programs
NCCI Edits - ANSWERNational Correct Coding Initiative Editor
NCCI Edits are performed by - ANSWERMacs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to - ANSWERPromote 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... -
ANSWER*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 - ANSWERProcedure-to-Procedure edits
Column One/Column Two edit pair - ANSWERIf 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 - ANSWERIf both codes are clinically
appropriate, you must append with an appropriate NCCI-associated modifier to be
eligible for payment.
Medicare beneficiaries and NCCI edits - ANSWERYou cannot bill Medicare
beneficiaries for services denied based on NCCI Edits.
CORRECT 100%
12.1% - ANSWER# of improper Medicare Fee-For-Service claim payments, according
to Federal Government.
FFS - ANSWERFee-For-Service
Prepayment Review - ANSWERReview of claims prior to payment. Prepayment reviews
result in an initial determination.
Postpayment Review - ANSWERReview of claims after payment. May result in either no
change to the initial determination or a revised determination, indicating an
underpayment or overpayment.
Underpayment - ANSWERA payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
Overpayment - ANSWERA payment a provider receives over the amount due for
services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: - ANSWER*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 - ANSWERMedicare Administrative Contractors
MAC Responsibilities - ANSWERProcess 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 - ANSWERZone Program Integrity Contractors
PSCs - ANSWERProgram Safeguard Contractor
ZPICs/PSCs - ANSWERPerform 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 - ANSWERSupplemental Medical Review Contractor
, SMRC Responsibilities - ANSWERConduct nationwide medical review as directed by
CMS (includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors - ANSWERReview claims to identify potential
underpayments and overpayments in Medicare FFS, as part of the Recovery Audit
Program
Zone 6 - ANSWERAll PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, - ANSWEREach 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 - ANSWERThere are 5 claim review programs
NCCI Edits - ANSWERNational Correct Coding Initiative Editor
NCCI Edits are performed by - ANSWERMacs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to - ANSWERPromote 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... -
ANSWER*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 - ANSWERProcedure-to-Procedure edits
Column One/Column Two edit pair - ANSWERIf 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 - ANSWERIf both codes are clinically
appropriate, you must append with an appropriate NCCI-associated modifier to be
eligible for payment.
Medicare beneficiaries and NCCI edits - ANSWERYou cannot bill Medicare
beneficiaries for services denied based on NCCI Edits.
