CPMA STUDY EXAMS GUIDE LATEST QUESTIONS
AND ANSWERS SURE A+
✔✔An infectious disease provider has been notified by the MAC (Medicare
Administrative Contractor) in his region that their data shows he is billing level 99214
more frequent than any other provider in the same specialty and same geographic
region. The provider requests that you audit a sample of his claims that were coded as
99214 to determine if he is coding appropriately. What supporting references will you
need to conduct the audit? - ✔✔1995 and 1997 CMS Documentation Guidelines
✔✔The Stark Statute applies to: - ✔✔Only physicians who refer Medicare and Medicaid
patients to entities for designated health care services with which the provider or
immediate family member has a financial relationship
✔✔When can a RAC extrapolate the overpayment(s) on claims? - ✔✔If a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
✔✔Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 -
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to
splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier
,-59 is: - ✔✔Only appropriate if the two procedures are performed on separate lesions or
at separate patient encounters.
✔✔Dr. Jones performed a femoral-femoral bypass graft in the morning on June 1, 20xx.
Later that day, the graft clotted and the entire procedure was repeated. Dr. Jones was
not available so Dr. Martin who is with a different group repeated the procedure in the
evening. The auditor reviewed the documentation for Dr. Martin. The following was
reported by Dr. Martin: Date of Service Procedure 06/01/20xx 35556-76 What
procedure should Dr. Martin report? - ✔✔35558-77
✔✔A family physician requests that you perform a post payment audit on claims from a
particular commercial payer he is receiving denials from. Whenever the provider
performs a minor procedure with an E/M service, the minor surgery is reimbursed but
the E/M service is denied. You review 10 charts and all cases are documented and
coded correctly. What could be the reason for the denial? - ✔✔The payer contract may
bundle the E/M service when performed on the same day as the minor surgery.
✔✔A provider receives a denial on a Medicare claim due to lack of medical necessity.
What resource is a valuable tool for providers to limit denials for medical necessity? -
✔✔LCDs
✔✔A comprehensive audit is: - ✔✔A large number of claims are selected for review that
might be focused on specific procedure and/or diagnosis codes.
✔✔What is RAT-STATS used for by an auditor? - ✔✔Software used in performing
statistical random samples and evaluating results
✔✔What are the recommended number of charts to audit per provider and the minimum
frequency of the audit? - ✔✔10 records per provider each year
✔✔Evaluation and Management documentation is often captured in SOAP format,
which is the acronym for: - ✔✔Subjective, Objective, Assessment, Plan
✔✔Failure to have which form in the medical record will result in payment being sent to
the beneficiary? - ✔✔Assignment of benefits form
✔✔Prior to undergoing a specific medical intervention, law requires the provider to
obtain an informed consent for treatment signed by the patient. In addition to the nature
or purpose of the treatment and risks and benefits involved, the informed consent must
include what information? - ✔✔Alternative treatment options and the risks and benefits
of alternative treatment options.
✔✔Outpatient physical therapy services cannot be initiated until: - ✔✔an initial plan of
care has been established.
,✔✔When auditing operative reports, the header describing the procedure: - ✔✔may not
fully support the procedure documented in the body of the report.
✔✔During an audit of a paper medical record, the auditor finds a correction was made
using white-out and initialed by the nurse. This method of correction is: -
✔✔unacceptable because the original content is not readable.
✔✔An auditor identifies claims for services provided by a non-physician provider as
Incident-to during the month the physician was on vacation. This would be considered: -
✔✔fraud.
✔✔The penalties for violation of the Stark law include program exclusion for knowing
violations and: - ✔✔potential $15,000CMP for each service.
✔✔You audit a provider who performs and bills for an arthroscopic rotator cuff repair,
29827, and for an arthroscopic debridement, 29822. The payer contract specifies NCCI
edit rules will be applied. There is an NCCI edit against reporting both procedures
during the same operative session; in reviewing the surgeon's documentation, you find
that the debridement was performed in a different site supporting the 59 modifier, which
is allowed under NCCI. This is an example of: - ✔✔proper coding and billing practice.
✔✔The False Claims Act allows for reduction of penalties to two times the amount of
damages (as opposed to three times) under what condition(s)? - ✔✔The person
committing the violation self discloses within 30 days of violation notification and the
person fully cooperates with the investigation of the violation.
✔✔The compliance program guidance (CPG) document identifies four risk areas most
likely to affect a physician's practice. The risk areas include: - ✔✔Coding and billing,
reasonable and necessary services, documentation, improper inducements.
✔✔The manager of a small physician's practice who also is the compliance officer,
contacts you an auditor, stating that a coding and billing violation has been identified by
the billing department manager. What should you advise the compliance officer to
document in the practice's compliance file: - ✔✔date of incident, name of reporting
party, name of person responsible for taking action, follow-up action taken
✔✔According to CPT® coding guidelines for inpatient consultation services, how should
consults be reported? - ✔✔Only one consultation is reported per hospital admission.
✔✔Minor procedures as defined by Medicare have a zero or 10-day postop period. How
should minor and endoscopic procedures be billed if an office visit takes place prior to
, the procedure? - ✔✔There is no preoperative period and an office visit is billable if a
significant and separately identifiable service is performed in addition to the procedure.
✔✔An audit of 20 family practice charts for code 20552-20553 reveals that the provider
used fluoroscopic guidance when performing trigger point injections. In reviewing claims
data for these charts, it is found that 76942 was reported with 20552-20553. What
should be stated on the audit findings report? - ✔✔Coding is incorrect, code 77002
should be reported for these cases.
✔✔A provider performs two procedures that NCCI edits state should not be reported
together. However if the NCCI edit does not allow use of NCCI-associated modifiers to
bypass it and the documentation supports and qualifies as an unusual procedure, the
physician may report the column one HCPCS/CPT® procedure code of the NCCI edit
with what modifier? - ✔✔22
✔✔An auditor identifies a procedure that has a modifier appended. This is an indication
that: - ✔✔the procedure performed was altered, but the definition of the code has not
changed.
✔✔Sarah Smith works for an emergency physician group. She has been given the
responsibility to perform a baseline E/M audit for the physicians in the group. What is
the first step she should take to begin this process? - ✔✔Run a utilization report of E/M
services
✔✔An audit performed on one provider would be considered a: - ✔✔Focused audit
✔✔When performing a retrospective audit, the auditor will need to have what materials?
- ✔✔Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies
and CMS-1500 form.
✔✔A sample is gathered of the CPT®/HCPCS codes that have the highest dollar
charges. This would be considered which type of sampling? - ✔✔Proportional
✔✔Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves
what purpose? - ✔✔Identify the financial error rate of the selected sample
✔✔A provider receives denials from a private payer for E/M services performed on the
same date as a minor procedure. You review documentation for 25 records and the
payer contract which states the provider must follow CMS coding guidelines. You
determine that 20 of the records have appropriate documentation to support both E/M
and the procedure and were coded correctly when the claim was originally submitted.
You submit an appeal for the 20 dates of service that are supported by documentation.
To support you findings, you will include in the appeal a letter reporting your findings,
AND ANSWERS SURE A+
✔✔An infectious disease provider has been notified by the MAC (Medicare
Administrative Contractor) in his region that their data shows he is billing level 99214
more frequent than any other provider in the same specialty and same geographic
region. The provider requests that you audit a sample of his claims that were coded as
99214 to determine if he is coding appropriately. What supporting references will you
need to conduct the audit? - ✔✔1995 and 1997 CMS Documentation Guidelines
✔✔The Stark Statute applies to: - ✔✔Only physicians who refer Medicare and Medicaid
patients to entities for designated health care services with which the provider or
immediate family member has a financial relationship
✔✔When can a RAC extrapolate the overpayment(s) on claims? - ✔✔If a RAC can
demonstrate a high level of error, the RAC can then extrapolate the findings and
request a refund.
✔✔Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 -
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to
splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier
,-59 is: - ✔✔Only appropriate if the two procedures are performed on separate lesions or
at separate patient encounters.
✔✔Dr. Jones performed a femoral-femoral bypass graft in the morning on June 1, 20xx.
Later that day, the graft clotted and the entire procedure was repeated. Dr. Jones was
not available so Dr. Martin who is with a different group repeated the procedure in the
evening. The auditor reviewed the documentation for Dr. Martin. The following was
reported by Dr. Martin: Date of Service Procedure 06/01/20xx 35556-76 What
procedure should Dr. Martin report? - ✔✔35558-77
✔✔A family physician requests that you perform a post payment audit on claims from a
particular commercial payer he is receiving denials from. Whenever the provider
performs a minor procedure with an E/M service, the minor surgery is reimbursed but
the E/M service is denied. You review 10 charts and all cases are documented and
coded correctly. What could be the reason for the denial? - ✔✔The payer contract may
bundle the E/M service when performed on the same day as the minor surgery.
✔✔A provider receives a denial on a Medicare claim due to lack of medical necessity.
What resource is a valuable tool for providers to limit denials for medical necessity? -
✔✔LCDs
✔✔A comprehensive audit is: - ✔✔A large number of claims are selected for review that
might be focused on specific procedure and/or diagnosis codes.
✔✔What is RAT-STATS used for by an auditor? - ✔✔Software used in performing
statistical random samples and evaluating results
✔✔What are the recommended number of charts to audit per provider and the minimum
frequency of the audit? - ✔✔10 records per provider each year
✔✔Evaluation and Management documentation is often captured in SOAP format,
which is the acronym for: - ✔✔Subjective, Objective, Assessment, Plan
✔✔Failure to have which form in the medical record will result in payment being sent to
the beneficiary? - ✔✔Assignment of benefits form
✔✔Prior to undergoing a specific medical intervention, law requires the provider to
obtain an informed consent for treatment signed by the patient. In addition to the nature
or purpose of the treatment and risks and benefits involved, the informed consent must
include what information? - ✔✔Alternative treatment options and the risks and benefits
of alternative treatment options.
✔✔Outpatient physical therapy services cannot be initiated until: - ✔✔an initial plan of
care has been established.
,✔✔When auditing operative reports, the header describing the procedure: - ✔✔may not
fully support the procedure documented in the body of the report.
✔✔During an audit of a paper medical record, the auditor finds a correction was made
using white-out and initialed by the nurse. This method of correction is: -
✔✔unacceptable because the original content is not readable.
✔✔An auditor identifies claims for services provided by a non-physician provider as
Incident-to during the month the physician was on vacation. This would be considered: -
✔✔fraud.
✔✔The penalties for violation of the Stark law include program exclusion for knowing
violations and: - ✔✔potential $15,000CMP for each service.
✔✔You audit a provider who performs and bills for an arthroscopic rotator cuff repair,
29827, and for an arthroscopic debridement, 29822. The payer contract specifies NCCI
edit rules will be applied. There is an NCCI edit against reporting both procedures
during the same operative session; in reviewing the surgeon's documentation, you find
that the debridement was performed in a different site supporting the 59 modifier, which
is allowed under NCCI. This is an example of: - ✔✔proper coding and billing practice.
✔✔The False Claims Act allows for reduction of penalties to two times the amount of
damages (as opposed to three times) under what condition(s)? - ✔✔The person
committing the violation self discloses within 30 days of violation notification and the
person fully cooperates with the investigation of the violation.
✔✔The compliance program guidance (CPG) document identifies four risk areas most
likely to affect a physician's practice. The risk areas include: - ✔✔Coding and billing,
reasonable and necessary services, documentation, improper inducements.
✔✔The manager of a small physician's practice who also is the compliance officer,
contacts you an auditor, stating that a coding and billing violation has been identified by
the billing department manager. What should you advise the compliance officer to
document in the practice's compliance file: - ✔✔date of incident, name of reporting
party, name of person responsible for taking action, follow-up action taken
✔✔According to CPT® coding guidelines for inpatient consultation services, how should
consults be reported? - ✔✔Only one consultation is reported per hospital admission.
✔✔Minor procedures as defined by Medicare have a zero or 10-day postop period. How
should minor and endoscopic procedures be billed if an office visit takes place prior to
, the procedure? - ✔✔There is no preoperative period and an office visit is billable if a
significant and separately identifiable service is performed in addition to the procedure.
✔✔An audit of 20 family practice charts for code 20552-20553 reveals that the provider
used fluoroscopic guidance when performing trigger point injections. In reviewing claims
data for these charts, it is found that 76942 was reported with 20552-20553. What
should be stated on the audit findings report? - ✔✔Coding is incorrect, code 77002
should be reported for these cases.
✔✔A provider performs two procedures that NCCI edits state should not be reported
together. However if the NCCI edit does not allow use of NCCI-associated modifiers to
bypass it and the documentation supports and qualifies as an unusual procedure, the
physician may report the column one HCPCS/CPT® procedure code of the NCCI edit
with what modifier? - ✔✔22
✔✔An auditor identifies a procedure that has a modifier appended. This is an indication
that: - ✔✔the procedure performed was altered, but the definition of the code has not
changed.
✔✔Sarah Smith works for an emergency physician group. She has been given the
responsibility to perform a baseline E/M audit for the physicians in the group. What is
the first step she should take to begin this process? - ✔✔Run a utilization report of E/M
services
✔✔An audit performed on one provider would be considered a: - ✔✔Focused audit
✔✔When performing a retrospective audit, the auditor will need to have what materials?
- ✔✔Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies
and CMS-1500 form.
✔✔A sample is gathered of the CPT®/HCPCS codes that have the highest dollar
charges. This would be considered which type of sampling? - ✔✔Proportional
✔✔Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves
what purpose? - ✔✔Identify the financial error rate of the selected sample
✔✔A provider receives denials from a private payer for E/M services performed on the
same date as a minor procedure. You review documentation for 25 records and the
payer contract which states the provider must follow CMS coding guidelines. You
determine that 20 of the records have appropriate documentation to support both E/M
and the procedure and were coded correctly when the claim was originally submitted.
You submit an appeal for the 20 dates of service that are supported by documentation.
To support you findings, you will include in the appeal a letter reporting your findings,
