CPMA CERTIFICATION EVALUATION
QUESTIONS AND SOLUTIONS STUDY GUIDE
●● FFS
Answer: Fee-For-Service
●● Prepayment Review
Answer: Review of claims prior to payment. Prepayment reviews result
in an initial determination.
●● Postpayment Review
Answer: 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
Answer: A payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
●● Overpayment
Answer: A 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
Answer: Medicare Administrative Contractors
●● MAC Responsibilities
Answer: 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
Answer: Zone Program Integrity Contractors
●● PSCs
Answer: Program Safeguard Contractor
,●● ZPICs/PSCs
Answer: 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
Answer: Supplemental Medical Review Contractor
●● SMRC Responsibilities
Answer: Conduct nationwide medical review as directed by CMS
(includes identifying underpayments and overpayments
●● Medicare FFS Recovery Auditors
Answer: Review claims to identify potential underpayments and
overpayments in Medicare FFS, as part of the Recovery Audit Program
●● Zone 6
Answer: All PSCs transitioned to ZPICs with the exception of Zone 6
●● While all contractors focus on a specific area,
Answer: 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
Answer: There are 5 claim review programs
●● NCCI Edits
Answer: National Correct Coding Initiative Editor
●● NCCI Edits are performed by
Answer: Macs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
●● CMS developed the NCCI to
Answer: 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...
Answer: *American Medical Association (AMA) Current Procedure
Terminology (CPT) Manual
QUESTIONS AND SOLUTIONS STUDY GUIDE
●● FFS
Answer: Fee-For-Service
●● Prepayment Review
Answer: Review of claims prior to payment. Prepayment reviews result
in an initial determination.
●● Postpayment Review
Answer: 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
Answer: A payment a provider receives under the amount due for
services furnished under the Medicare statute and regulations.
●● Overpayment
Answer: A 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
Answer: Medicare Administrative Contractors
●● MAC Responsibilities
Answer: 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
Answer: Zone Program Integrity Contractors
●● PSCs
Answer: Program Safeguard Contractor
,●● ZPICs/PSCs
Answer: 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
Answer: Supplemental Medical Review Contractor
●● SMRC Responsibilities
Answer: Conduct nationwide medical review as directed by CMS
(includes identifying underpayments and overpayments
●● Medicare FFS Recovery Auditors
Answer: Review claims to identify potential underpayments and
overpayments in Medicare FFS, as part of the Recovery Audit Program
●● Zone 6
Answer: All PSCs transitioned to ZPICs with the exception of Zone 6
●● While all contractors focus on a specific area,
Answer: 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
Answer: There are 5 claim review programs
●● NCCI Edits
Answer: National Correct Coding Initiative Editor
●● NCCI Edits are performed by
Answer: Macs, ZPICs, CERT, and Medicare FFS
Complexity: Non-complex
●● CMS developed the NCCI to
Answer: 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...
Answer: *American Medical Association (AMA) Current Procedure
Terminology (CPT) Manual
