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CPB Exam Study Guide 2019
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CPB Exam Study Guide 2019
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CPB EXAM STUDY GUIDE 2019QUESTIONS AND CORRECT DETAILED
ANSWERS
v What is a drawback of an HMO? - - Providers have an incentive to keep treatment costs at a minimum
- The HMP administrators determine what services are reimbursed and what is not.
- The Provider is now a gatekeeper to the patient's medical care
This is an example of a carrier refused to accept MOD-RT and MOD-LT and accepted MOD-50. What does
this mean? - This is an example of a carrier-specific rule. In other words a carriers can require MOD-50
over MOD-RT and MOD-LT even though technically they are the same
What is not in the Medicare PFSRVU database? - Medically Necessity
What are the characteristics of the emergency room visit? - These codes are used only for the
emergency room encouters
Which would likely not be covered under a corporate Family Medical Leave Act (FMLA)? - Most vacations
are paid vacations by the employer but not covered under FMLA. Covered are birth of child, provide care
of spouse, child, or parent, and employees serious health condition. The Family Medical Leave Act
(FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also
requires that their group health benefits be maintained during the leave. FMLA applies to all public
agencies, all public and private elementary and secondary schools, and companies with 50 or more
employees.
A PPO is a: - Preferred Provider Organization, there is no gatekeeper like an HMO.
To report co-management, which below must be true? - The doctors must be in separate offices/clinics.
Co-management refers to another provider provider the post-operative care for a surgical procedure
(e.g., cataract surgery ). Co-management is not for two surgeons. Co-management refers to office visits
and standard aftercare. Two doctors cannot be paid for the same dates for post-op care (different dates,
yes).
How does CPT Professional Edition define a new patient? - A new patient is one who has not received
any professional services from the physician or another physician of the exact same specialty and
subspecialty who belongs to the same group practice, within the past three years. You can find this
answer in the E&M Guidelines and on the Decision Tree for New vs. Established Patients (same
guidelines) in the CPT Professional Edition.
If a doctor or supplier "accepts" (Medicare) assignment then: - "The client is only responsible for paying
20 percent of the amount set by Medicare..." is the best answer. Although possible, no practice should
, charge less than Medicare. Standard office practice is at least charging 30% more than the Medicare
Allowable. The limiting charge refers to a provider who does not accept assignment (Medicare)
Medicare Part-A is: - - Billed on the UB-04
-Submitted for Facility Fees
- A mandatory program
At age 65 everyone must enroll in Medicare Part-A. Part-B is voluntary. The professional fees for the
surgeon are submitted on the CMS-1500 form
Which statement could be found in a medical carrier contract? - - That all their contracted patients must
receive their most favorable pricing (no other carrier can be lower, especially Medicare)
- That if a claim is not filed within the "timely filing period" then they cannot bill the patient (if the
carrier refuses payment).
- For children they must provide specific services such as immunizations, heating or vision tests, or other
required services.
Contracts can have very unique and specific payment and compliance requirements
What is the official Medicare appeals process? - Medicare has five levels of appeals in the Medicare Part
A and Part B appeals Process:
- First Level of Appeal: Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare
Administrative Contractor (MAC).
- Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
- Third Level of Appeal: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings
and Appeals
- Fourth Level of Appeal: Review by the Medicare Appeals Council
- Fifth Level of Appeal: Judicial Review in Federal District Court
A living will, personal directive, advance directive, or advance decision are all examples of what? - An
Advance Health Care Directive, also known as living will, personal directive, advance directive, or
advance decision, are instructions given by individuals specifying what actions should be taken for their
health in the event that they are no longer able to make decisions due to illness or incapacity, and
appoints a person to make such decisions on their behalf.
The global period is: - These are established by Medicare and are zero, ten, or ninety. The information is
not in the CPT manual and found in the PFSRVU database.
What is a Certificate of Authority used for? - Certificate of Authority (COA) is issued by the state. It
licenses the operation of an HMA (Health Maintenance Organization).
What does COBRA mean? - COBRA; See Consolidated Omnibus Budget Reconciliation Act of 1986
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