CPB Exam B Questions with 100% correct Answers

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? - ANSWER Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? - ANSWER Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. - ANSWER I, IV, V, VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan.He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? - ANSWER Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? - ANSWER One year from the date of service A provider sees a patient who has TRICARE Standard. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? - ANSWER $60.00 What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? - ANSWER Utilization Review Organization Medicaid providers are forbidden by law to: - ANSWER Balance bill patients Which statement is FALSE about Local Coverage Determinations (LCDs)? - ANSWER CMS develops LCDs when there is no National Coverage Determination When a minor procedure is performed on a Medicare patient, what is the global period and what timeframe is covered? - ANSWER 10-day global period - the day of the procedure and 10 days following the procedure If add-on procedure code 11101 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? - ANSWER Code 11101 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? - ANSWER Either 1995 or 1997 CMS documentation guidelines Select the scenario that meets the incident-to requirements - ANSWER Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? - ANSWER G0121 Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers - ANSWER I, II, IV, V and VI According to CPT® Radiology Guidelines if a patient is given oral contrast for a CT scan of the abdomen which code is reported? - ANSWER 74150 Computed tomography, abdomen; without contrast material Which of the following is NOT in the HIPAA Privacy Rule? - ANSWER Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act? - ANSWER False Claims Act Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? - ANSWER Fraud; the provider intentionally over-coded to gain financially What is a Qui tam relator? - ANSWER A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare patients to be complicated patients and therefore, he should be paid at the highest rate possible. Is Dr. Wilson's actions considered fraud or abuse? - ANSWER Fraud; he is knowingly billing patients incorrectly to obtain higher payment Dr. Jay is a gynecologist and has been reporting two codes for a total abdominal hysterectomy with removal of the ovaries and fallopian tubes (salpingo-oophorectomy), codes 58150 and 58720. - ANSWER 58150 JR had surgery on January 15, 20XX by Dr. Waters (a Medicare participating provider). The Medicare fee schedule for the surgery is $500. Four months later, JR and Dr. Waters each received a check from Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR had previously paid the doctor $100 for the co-insurance. In total Dr. Waters has received $900 for the surgery provided on January 15, an overpayment of $400. What should Dr. Waters do? - ANSWER Contact the MAC of the overpayment and provide a refund. Which one is NOT a Nonphysician Practitioner (aka mid-level provider)? - ANSWER Resident Which Federal Law requires written acknowledgement of consumer billing disputes and investigation of billing errors by creditors? - ANSWER Fair Credit Billing Act Mr. Doyle had seen a non-participating provider for a hernia repair in outpatient surgery. His insurance company Telehealth provided a reimbursement check of $400 for the anesthesia services provided to him for the surgery. Mr. Doyle cashed the check and kept the money. Mr. Doyle receives the bill from the anesthesiologist, but he no longer has the money to pay it. The account becomes delinquent and is outsourced to a collection agency. The collection agency is unable to obtain any monies from Mr. Doyle. This is considered? - ANSWER Bad debt Mr. Jones is 67, retired, and has insurance coverage through Medicare and TRICARE. Mrs. Jones is 62 and still working for an employer that has 10 employees. Mr. and Mrs. Jones have health coverage through Mrs. Jones' employer's group health plan, UnitedPlan. Mr. Jones is seen in a non-military hospital in the ED for a fractured wrist. Who gets billed first? - ANSWER Medicare Relative Value Units (RVUs) are payment components consisting of: - ANSWER Physician work; Practice Expense; Professional liability/malpractice insurance Which of the following falls under the Prompt Payment Act? - ANSWER Clean claims must be paid or denied within 30 days from the date of receipt by MACs 25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit because she was having severe pre-eclampsia and needed to have an emergency cesarean section. Reduced payment was sent to the obstetrician by the payer with a remittance advice stating that preauthorization for the cesarean section was not obtained. What does the biller do? - ANSWER Appeal the claim, explaining the reason for the emergency cesarean section When a provider chooses not to participate in the Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is _______ percent of the approved fee schedule amount for non-participating providers. - ANSWER 115 Mr. Allen is scheduled for an appointment with his physician for follow-up of his rheumatoid arthritis and hypertension. The physician is called away for a personal emergency just after Mr. Allen arrives for his appointment and the patient is seen by the physician assistant, who orders labs and refills the patient's prescriptions. Mr. Allen is scheduled to return in one month.This patient's visit should be: - ANSWER Billed under the PA as the incident-to guidelines have not been met. Jill presents to Dr. Calvert for collagen injections to her upper lip for cosmetic reasons. She is informed by the office staff that cosmetic surgery may not be a benefit of her insurance plan in which case she would be responsible for the charges. Jill requests the claim to be submitted to her insurance. The claim is submitted to her insurance for payment. Dr. Calvert's office receives a remittance advice stating that the injections are considered cosmetic and are not a covered service. What is the appropriate next step for resolution? - ANSWER Move charges to patient responsibility and send the patient a statement. The financial policy for MidTown Physicians Group states that when all means for collecting payments have been exhausted and payment has not been received within 120 days, the account is turned over to a collection agency. When generating an accounts receivable aging report you see an outstanding claim for Mrs. Smith that has not received payment for 150 days. Mrs. Smith's account is considered to be: - ANSWER delinquent Which of the following is considered by CMS to be a source document when a provider and billing service file claims electronically? I. Patient's registration form II. Routing Slip III. Superbill IV. Encounter form V. Charge slip VI. Patient's insurance card - ANSWER II-V A hospital chargemaster does not include __________. - ANSWER Diagnosis codes (ICD-10-CM) Mary is tasked to perform an audit on Dr. Pain's practice to verify charges are documented as reported. What are the key elements Mary needs for the audit process on 25 records to support what Dr. Pain is charging? - ANSWER Medical record, encounter form, CMS-1500 claim form Mr. Peabody is an established patient who was told by Dr. Woods to come back for an injection in his right knee if he was still getting pain due to arthritis. Mr. Peabody is in for just the injection. The physician only examines the knee (problem focused exam) before he gives the injection. Dr. Woods explains the risks associated with the procedure and the patient gives consent. The doctor prepped the knee with betadine and injects the right knee with 10 mg of Depo-Medrol. How is this visit reported? - ANSWER 20610, J1020 A CRNA is performing a case personally without medical direction from an anesthesiologist. Which modifier is appropriately reported for the CRNA services? - ANSWER QZ Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still exhibiting symptoms of chronic ischemic heart disease. The physician reviews the current medications to confirm the patient is compliant and discusses a heart-healthy diet and exercise. What is the correct ICD-10-CM code for this condition? - ANSWER I25.9 10-year-old girl is scheduled for her yearly physical exam with her pediatrician .At the time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician first performs a complete physical. Then he also evaluates and treats the patient for a URI supported with separate documentation of an expanded problem focused exam and low medical decision making. What CPT® code(s) is/are reported for this visit? - ANSWER 99393, 99213-25 The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. What ICD-10-CM codes should be reported? - ANSWER Z51.0, C79.51, C80.1 for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr. Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done face to face for 20 minutes on smoking cessation of the 30 minute visit. Prescriptions for Chantrix and Tetracylcine were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT® code(s) for this visit: - ANSWER 99407 A 14-year-old male patient fell while skateboarding. He went to the emergency department at the local hospital. The diagnosis was a fracture of the upper right arm. The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct? - ANSWER Yes; the ICD-10-CM codes reported are correct Obstetrician A recommends a new type of cancer treatment for patient who has ovarian cancer. Before the patient's private insurance company approves the treatment, the insurer mandates Obstetrician B (in a different practice) to conduct a physical examination of the patient. What modifier should obstetrician B append to the E/M consultation code? - ANSWER Modifier 32 1. After review of the information provided, are there any errors on the claim form? If so, which elements are incorrect? I. Insurance ID number II. Secondary insurance information III. Modifier IV. Accept assignment V. Date of Service VI. Place of service (Carol Alexander) - ANSWER II, III, V Riverside Clinic's practice management policy for claims follow-up places priority on outstanding balances past 60 days. Based on the clinic's A/R report above, and the practice's policy, which payer and aging category should be the focus in order to collect the maximum revenue for the practice? - ANSWER Commercial, 61-90 days A Medicare patient has been diagnosed with K50.90 and K92.0 and the small bowel is known to be involved. The patient's condition is being managed by a GI physician and has been scheduled to undergo capsule endoscopy. Will this be a covered service based on the above LCD guidelines? - ANSWER No, the patient's prior diagnoses and management of the condition prevents the capsule endoscopy from being a covered service. A signed ABN is necessary Members plan provides coverage for charges that are reasonable and appropriate as determined by Illinois Med Insurance. This procedure has been paid at 50% of the reasonable and customary rate due to multiple procedures performed on the same dated of service 1. Review the remittance advice. Should this claim be appealed? - ANSWER Yes, the multiple procedure reduction was applied incorrectly After reviewing the above remittance advice and payer policy, what action should the biller take? - ANSWER Post the denial reason and payment amount. Submit an appeal with copy of payment policy. to overturn the denial for the insertion of arte