AAPC CPB - Chapter 11 Review

Dr. Allen who is a non-PAR provider performs an appendectomy on a 67 year-old Medicare patient. The physician's UCR for the surgery is $1500. Medicare's approved fee for this procedure is $1100. What is the limiting charge that this non-PAR provider can charge to this Medicare patient? a. $1265 b. $1100 c. $1500 d. $1201.75

d. $1201.75 Response Feedback: A non-PAR provider's fee schedule is 95% of Medicare approved amounts for PAR providers, which sets the fee at $1045 (1100 X .95). The provider's limiting charge would be 115% of the Medicare approved amount for non-PAR (1045 X 115% = $1201.75)

Review the RVU table: Dr. Gregory performs the pre-op and surgery for code 12034, but not the post-op care. The approved amount for the entire service is $200. Using the table above, what will Dr. Gregory's reimbursement be for his portion of the service? a. $200 b. $160 c. $150 d. $180

d. $180 Response Feedback: Looking at the table the pre-op portion is 10%, the intra-op portion is 80%, and the post-op portion is 10%. Dr. Gregory performed the pre-op and intra-op portions, which would equate to 90% of the approved amount. The approved amount is $200 and 90% is $180.

Which of the following services does Medicare consider preventive? a. Depression screening b. Bone mass measurements c. Glaucoma screening d. All of the above.

d. All of the above. Response Feedback: Screenings for a variety of medical conditions, as well as annual wellness visits, vaccinations for influenza, pneumonia, and Hepatitis B are deemed preventive. A comprehensive listing of preventive services can be accessed on the CMS website.

The conversion factor is updated by CMS: a. Monthly b. Quarterly c. Semi-annually d. Annually

d. Annually Response Feedback: The conversion factor is updated annually and has increased by 0.5% from 2016 to 2019 according to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

When processing Medigap claims, Item 9a of the CMS 1500 claim form must have the policy and/or group number of the Medigap insured preceded by: a. MEDIGAP b. MG c. MGAP d. Any of the above.

d. Any of the above. Response Feedback: MEDIGAP, MG or MGAP must precede the policy or group number in Item 9a of the CMS 1500 claim form to allow for proper processing of Medigap claims.

Medicare statutorily excluded services are: a. Non-covered items and services b. Not reimbursed by Medicare c. Reimbursed on a case-by-case basis. d. Both A & B

d. Both A & B Response Feedback: Non-covered items and services are statutorily excluded and are not reimbursed by Medicare. Examples of statutorily excluded services are routine foot care, cosmetic surgery, and acupuncture.

Which of the three TRICARE options are not available to active duty service members? a. TRICARE Prime b. TRICARE Reserve Select c. TRICARE Select d. Both B & C

d. Both B & C Response Feedback: All active duty service members must choose TRICARE Prime. TRICARE Reserve Select and Select options are not available for active duty members.

Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium for this policy? a. Medicare b. MAC c. Medicaid d. Medigap insurance company

d. Medigap insurance company Response Feedback: Premiums for Medigap policies are paid directly to the Medigap insurance company, not to CMS, MAC's or Medicaid.

A 45-year-old patient is diagnosed with N18.6. Based on this diagnosis, would this patient be eligible for Medicare coverage? a. Yes, because he has acute renal failure which is a condition that qualifies for Medicare benefits. b. No, because he is not 65-years-old. c. No, because Medicare only covers patients with chronic renal failure d. Yes, because he has ESRD which is a condition that qualifies for Medicare benefits.

d. Yes, because he has ESRD which is a condition that qualifies for Medicare benefits. Response Feedback: Medicare is a health insurance program for people age 65 and older, people under 65 with certain disabilities, and people of any age with end stage renal disease.

MAC is the acronym for: a. Medicare Administrative Contractor b. Medicare Advantage Contractor c. Medical Access Center d. Medicare Administrative Contact

a. Medicare Administrative Contractor Response Feedback: Medicare Administrative Contractor (MAC) administers and processes claims for Medicare Part A and Part B services organized in multi-state regions.

Medigap policies must conform to minimum standards identified by federal and state laws and clearly be identified as: a. Medicare Supplement Insurance b. Medicare Subsequent Insurance c. Medicare Selective Insurance d. Medicare Secondary Insurance

a. Medicare Supplement Insurance Response Feedback: The Omnibus Budget Reconciliation Act of 1990 requires all Medigap insurance policies to conform to minimum standards including standardized benefits and consumer protection requirements. Every Medigap policy must follow federal and state laws and be clearly identified as Medicare Supplement Insurance.

Medicaid agencies are required to report EPSDT performance information a. annually b. monthly c. quarterly d. weekly

a. annually

TRICARE and CHAMPVA timely filing is a. 180-days from date of service b. 1-year from the date of service c. 90-days from the date of service d. 120-days from the date of service

b. 1-year from the date of service Response Feedback: TRICARE and CHAMPVA both have a one-year timely filing limit. There are exceptions allowed for retroactive benefit issues, when the time frame for filing goes back to your eligibility date. In those cases, once notified, 180 days are allowed to submit a claim.

Barbara's late husband, Joe, was a lieutenant in the Navy. He served for 30 years, retiring 10 years prior to his death that was related to service connected disability. Barbara will still have healthcare coverage as Joe's widow under which of the following healthcare programs? a. TRICARE b. CHAMPVA c. CHAMPUS d. Medicare

b. CHAMPVA Response Feedback: The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is the healthcare program in which the Department of Veterans Affairs covers spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a program associated with: a. Medicare b. Medicaid c. Commercial insurance carriers d. All insurance carriers

b. Medicaid Response Feedback: EPSDT is a benefit of Medicaid that provides comprehensive and preventive healthcare services for enrolled children under the age of 21.

The total RVU is composed of which of the following components: a. Conversion factor (CF), practice expense (PE), and malpractice insurance (MP) b. Physician work, practice expense (PE), and malpractice insurance (MP) c. Sustainable growth rate (SGR), conversion factor (CF), and malpractice insurance (MP) d. Sustainable growth rate (SGR), practice expense (PE), and physician work.

b. Physician work, practice expense (PE), and malpractice insurance (MP) Response Feedback: Total RVU is based on three components of physician services: physician work, practice expense (PE) and malpractice insurance (MP).

Which TRICARE option allows enrollees the most choices utilizing the fee-for-service model? a. TRICARE for Life b. TRICARE Select c. TRICARE Prime d. Both A and B

b. TRICARE Select

Which TRICARE option allows enrollees the most choices utilizing the fee-for-service model? a. TRICARE for Life b. TRICARE Select c. TRICARE Prime d. Both A and B Response Feedback: TRICARE Select is a fee-for-service option that allows the enrollees the most choices.

b. TRICARE Select Response Feedback: TRICARE Select is a fee-for-service option that allows the enrollees the most choices.

Medicare's payment amount for services are determined by which of the following formulas? a. Sustainable growth rate (SGR) X Geographic Practice Cost Index (GPCI) = Medicare payment b. Total RVU X Conversion factor = Medicare payment c. Total Practice Expense (PE) X Conversion factor = Medicare payment d. Total Malpractice insurance (MP) X Conversion factor (CF) = Medicare payment

b. Total RVU X Conversion factor = Medicare payment

Medicare's payment amount for services are determined by which of the following formulas? a. Sustainable growth rate (SGR) X Geographic Practice Cost Index (GPCI) = Medicare payment b. Total RVU X Conversion factor = Medicare payment c. Total Practice Expense (PE) X Conversion factor = Medicare payment d. Total Malpractice insurance (MP) X Conversion factor (CF) = Medicare payment

b. Total RVU X Conversion factor = Medicare payment Response Feedback: Medicare payments are determined based on the Total RVU X Conversion Factor. The complete formula includes [(Work RVU X Work GPCI) + (RVUPE X PE GPCI) + (MP RVU X MP GPCI)] = Total RVU X Conversion Factor = Medicare payment

The Clinical Prior Authorization (PA) Program assists in the monitoring of: a. drug interactions. b. drugs not on Medicaid's formulary. c. procedures that need prior authorizations. d. Medicaid eligibility requirements.

b. drugs not on Medicaid's formulary.

The Clinical Prior Authorization (PA) Program assists in the monitoring of: a. drug interactions. b. drugs not on Medicaid's formulary. c. procedures that need prior authorizations. d. Medicaid eligibility requirements.

b. drugs not on Medicaid's formulary. Response Feedback: Clinical Prior Authorization (PA) Program was implemented to manage drug classes not listed on Medicaid's formulary as well as drugs that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons, as well as monitoring drug expenditures.

Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurance company. This transfer of information is known as: a. Cross-under b. Shared billing c. Cross-over d. Data sharing

c. Cross-over Response Feedback: The transfer of claims information from Medicare to Medigap is called cross-over.

TRICARE is the healthcare program for which department of the US government? a. Department of Military Service b. Department of Finance c. Department of Defense d. Centers for Medicare and Medicaid Services

c. Department of Defense Response Feedback: TRICARE, formerly known as CHAMPUS, is the Department of Defense healthcare program for military families and retirees.

Medicaid's minimum eligibility is based on which of the following criteria: a. Under the age of 50 b. U.S. Citizenship c. Federal poverty level d. All of the above

c. Federal poverty level Response Feedback: Medicaid eligibility must meet a variety of conditions and allow for variances from state to state, however, the minimum eligibility factor that all Medicaid programs have in common is the federal poverty level (FPL) which is a pre-determined annual income amount for a family of four.

Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding. I. Outpatient hospital services II. Podiatry services III. Home health services IV. Federally Qualified Health Center services V. Inpatient hospital services VI. Chiropractic services VII. Occupational therapy a. II, III, VII b. I, III, IV, VI, VII c. I, III, IV, V d. IV, V, VI, VII

c. I, III, IV, V Response Feedback: Rationale: Outpatient hospital services, home health services, Federally Qualified Health Centers services, and inpatient hospital services are among some of the mandatory services required to secure matching federal funding. A complete listing of mandatory and optional benefits can be accessed at the following website. Source: https://www.medicaid.gov/chip/state-program-information/index.html

The term for a supplemental policy for Medicare is: a. Medifill b. Medicare Plus c. Medigap d. Medicare Secondary

c. Medigap Response Feedback: Medigap is a Medicare supplemental policy to help cover costs that are not covered by Medicare.

Andrew has selected TRICARE Prime as his health plan. Who will be responsible for coordinating his health care, maintaining his medical records and referrals to specialists when needed? a. PCP - Primary Care Provider b. PCC - Primary Care Coordinator c. PCM - Primary Care Manager d. PCN - Primary Care Networker

c. PCM - Primary Care Manager

Andrew has selected TRICARE Prime as his health plan. Who will be responsible for coordinating his health care, maintaining his medical records and referrals to specialists when needed? a. PCP - Primary Care Provider b. PCC - Primary Care Coordinator c. PCM - Primary Care Manager d. PCN - Primary Care Networker

c. PCM - Primary Care Manager Response Feedback: TRICARE Prime is a managed care model in which the insured will select their primary care manager who will be responsible for coordination of care, medical record maintenance and referrals.

A Medicare patient receiving inpatient care in a critical access hospital would be covered under a. Part C b. Part B c. Part A d. Part D

c. Part A

Medicare Supplement Insurance policies or Medigap is sold by: a. Medicare b. Medicaid c. Private insurance companies d. Healthcare providers

c. Private insurance companies

To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service is payable, noncovered, or bundled into another service? a. PC/TC indicator b. Global surgery indicators c. Status codes d. Both A & B

c. Status codes

Medicaid claims must be filed: a. within 95 days. b. within 365 days. c. based on the individual state's timely filing requirement. d. within 180 days.

c. based on the individual state's timely filing requirement.

Medicaid claims must be filed: a. within 95 days. b. within 365 days. c. based on the individual state's timely filing requirement. d. within 180 days.

c. based on the individual state's timely filing requirement. Response Feedback: Medicaid timely filing requirements will vary from state to state. Billers need to be aware of the filing limits within the individual state.