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Chapter 1 CPMA Exam Prep Questions And Answers 5 Common reasons for overpayment are: *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 fo...

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  • October 19, 2024
  • 35
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • chapter 1 cpma exam prep questions and answers

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  • Cpma
  • Cpma

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Chapter 1 CPMA Exam Prep Questions And
Answers

5 Common reasons for overpayment are: *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 Medicare Administrative Contractors




MAC Responsibilities 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 Zone Program Integrity Contractors




PSCs Program Safeguard Contractor

,Chapter 1 CPMA Exam Prep Questions And
Answers
ZPICs/PSCs 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 Supplemental Medical Review Contractor




SMRC Responsibilities Conduct nationwide medical review as directed by CMS (includes

identifying underpayments and overpayments




Medicare FFS Recovery Auditors Review claims to identify potential underpayments and

overpayments in Medicare FFS, as part of the Recovery Audit Program




Zone 6 All PSCs transitioned to ZPICs with the exception of Zone 6




While all contractors focus on a specific area, 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.

,Chapter 1 CPMA Exam Prep Questions And
Answers
Claim Review Programs There are 5 claim review programs




NCCI Edits National Correct Coding Initiative Editor




NCCI Edits are performed by Macs, ZPICs, CERT, and Medicare FFS




Complexity: Non-complex




CMS developed the NCCI to 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... *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.

, Chapter 1 CPMA Exam Prep Questions And
Answers

PTP Procedure-to-Procedure edits




Column One/Column Two edit pair 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 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 You cannot bill Medicare beneficiaries for services

denied based on NCCI Edits.




ABN Advance Beneficiary Notice of Noncoverage




ABNs and NCCI edits 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.

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