CPMA Exam Prep Chapter 1 – Questions And Answers
12.1% Correct Ans - # of improper Medicare Fee-For-Service claim
payments, according to Federal Government.
FFS Correct Ans - Fee-For-Service
Prepayment Review Correct Ans - Review of claims prior to
payment. Prepayment reviews result in an initial determination.
Postpayment Review Correct Ans - 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 Correct Ans - A payment a provider receives under
the amount due for services furnished under the Medicare statute and
regulations.
Overpayment Correct Ans - A payment a provider receives over the
amount due for services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: Correct Ans - *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 Correct Ans - Medicare Administrative Contractors
MAC Responsibilities Correct Ans - 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 Correct Ans - Zone Program Integrity Contractors
PSCs Correct Ans - Program Safeguard Contractor
,ZPICs/PSCs Correct Ans - 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 Correct Ans - Supplemental Medical Review Contractor
SMRC Responsibilities Correct Ans - Conduct nationwide medical
review as directed by CMS (includes identifying underpayments and
overpayments
Medicare FFS Recovery Auditors Correct Ans - Review claims to
identify potential underpayments and overpayments in Medicare FFS, as
part of the Recovery Audit Program
Zone 6 Correct Ans - All PSCs transitioned to ZPICs with the
exception of Zone 6
While all contractors focus on a specific area, Correct Ans - 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 Correct Ans - There are 5 claim review
programs
NCCI Edits Correct Ans - National Correct Coding Initiative Editor
NCCI Edits are performed by Correct Ans - Macs, ZPICs, CERT, and
Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to Correct Ans - 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...
Correct Ans - *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 Correct Ans - Procedure-to-Procedure edits
Column One/Column Two edit pair Correct Ans - 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 Correct Ans - 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 Correct Ans - You cannot bill
Medicare beneficiaries for services denied based on NCCI Edits.
ABN Correct Ans - Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits Correct Ans - 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.
NCCI edits and Notice of Exclusions from Medicare Benefits Correct
Ans - If denials are based on incorrect coding rather than a legislated
Medicare benefit exclusion, you cannot use a "Notice of Exclusions from
Medicare Benefits" form to seek payment from a Medicare beneficiary.
OCE Correct Ans - Outpatient Code Editor edits
Refer to the OCE edits for claims Correct Ans - For all Outpatient
institutional providers
Refer to NCCI Edits for Correct Ans - Physician services under the
Medicare Physician Fee Schedule (PFS)
12.1% Correct Ans - # of improper Medicare Fee-For-Service claim
payments, according to Federal Government.
FFS Correct Ans - Fee-For-Service
Prepayment Review Correct Ans - Review of claims prior to
payment. Prepayment reviews result in an initial determination.
Postpayment Review Correct Ans - 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 Correct Ans - A payment a provider receives under
the amount due for services furnished under the Medicare statute and
regulations.
Overpayment Correct Ans - A payment a provider receives over the
amount due for services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: Correct Ans - *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 Correct Ans - Medicare Administrative Contractors
MAC Responsibilities Correct Ans - 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 Correct Ans - Zone Program Integrity Contractors
PSCs Correct Ans - Program Safeguard Contractor
,ZPICs/PSCs Correct Ans - 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 Correct Ans - Supplemental Medical Review Contractor
SMRC Responsibilities Correct Ans - Conduct nationwide medical
review as directed by CMS (includes identifying underpayments and
overpayments
Medicare FFS Recovery Auditors Correct Ans - Review claims to
identify potential underpayments and overpayments in Medicare FFS, as
part of the Recovery Audit Program
Zone 6 Correct Ans - All PSCs transitioned to ZPICs with the
exception of Zone 6
While all contractors focus on a specific area, Correct Ans - 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 Correct Ans - There are 5 claim review
programs
NCCI Edits Correct Ans - National Correct Coding Initiative Editor
NCCI Edits are performed by Correct Ans - Macs, ZPICs, CERT, and
Medicare FFS
Complexity: Non-complex
CMS developed the NCCI to Correct Ans - 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...
Correct Ans - *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 Correct Ans - Procedure-to-Procedure edits
Column One/Column Two edit pair Correct Ans - 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 Correct Ans - 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 Correct Ans - You cannot bill
Medicare beneficiaries for services denied based on NCCI Edits.
ABN Correct Ans - Advance Beneficiary Notice of Noncoverage
ABNs and NCCI edits Correct Ans - 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.
NCCI edits and Notice of Exclusions from Medicare Benefits Correct
Ans - If denials are based on incorrect coding rather than a legislated
Medicare benefit exclusion, you cannot use a "Notice of Exclusions from
Medicare Benefits" form to seek payment from a Medicare beneficiary.
OCE Correct Ans - Outpatient Code Editor edits
Refer to the OCE edits for claims Correct Ans - For all Outpatient
institutional providers
Refer to NCCI Edits for Correct Ans - Physician services under the
Medicare Physician Fee Schedule (PFS)
