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...
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 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.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller QuickPass. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
