Exam (elaborations)

Chapter 1 CPMA Exam Prep, Questions and answers, 1005% accurate, Verified.

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Chapter 1 CPMA Exam Prep, Questions and answers, 1005% accurate, Verified. 12.1% - -# of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS - -Fee-For-Service Prepayment Review - -Review of claims prior to payment. Prepayment reviews result in an initi...

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Uploaded on February 16, 2023
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Type Exam (elaborations)
Contains Questions & answers

chapter 1 cpma exam prep
questions and answers
1005 accurate
verified 121 of improper medicare fee for service claim payments
according to federal government ffs fee for service pr

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Chapter 1 CPMA Exam Prep, Questions
and answers, 1005% accurate, Verified.

12.1% - ✔✔-# of improper Medicare Fee-For-Service claim payments, according to Federal Government.

FFS - ✔✔-Fee-For-Service

Prepayment Review - ✔✔-Review of claims prior to payment. Prepayment reviews result in an initial
determination.

Postpayment Review - ✔✔-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 - ✔✔-A payment a provider receives under the amount due for services furnished under
the Medicare statute and regulations.

Overpayment - ✔✔-A payment a provider receives over the amount due for services furnished under
Medicare statutes and regulations

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

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.

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.

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.

NCCI edits and Notice of Exclusions from Medicare Benefits - ✔✔-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.

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Exam (elaborations)

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