CPB PRACTICE EXAM QUESTIONS AND ANSWERS, Graded A. Verified. WHO IS COVERED BY CHAMPVA?

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CPB PRACTICE EXAM QUESTIONS AND ANSWERS, Graded A. Verified. WHO IS COVERED BY CHAMPVA? A) VETERANS WITH SERVICE - CONNECTED DISABILITIES AND THEIR FAMILIES B) ACTIVE DUTY MILITARY AND THEIR FAM... ILIES C) RETIRED MILITARY AND THEIR FAMILIES D) ACTIVE DUTY MILITARY OVER THE AGE OF 65 - ✔✔-A) VETERANS WITH SERVICE - CONNECTED DISABILITIES AND THEIR FAMILIES RATIONALE: THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERANS AFFAIRS (CHAMPVA) COVERS VETERANS WHO ARE PERMANENTLY AND TOTALLY DISABLED DUE TO A SERVICE-RELATED DISABILITY AND THEIR SPOUSE AND CHILDREN. PATIENT IS BROUGHT TO THE LOCAL URGENT CARE AFTER FALLING FROM A LADDER WHILE HANGING EXTERIOR LIGHTS ON HIS HOUSE. X-RAYS REVEALED A CLOSED FRACTURE OF HIS LEFT FEMUR. THE PATIENT IS COVERED BY HIS EMPLOYER'S GROUP HEALTH PLAN AND HE ALSO HAS A HOMEOWNER'S LIABILITY INSURANCE POLICY. WHICH INSURANCE SHOULD BE BILLED? A) THE HOMEOWNER'S INSURANCE FIRST, FOLLOWED BY THE GROUP HEALTH PLAN B) THE EMPLOYER'S GROUP HEALTH PLAN C) THE HOMEOWNER'S INSURANCE ONLY D) FILE THE EMPLOYER'S GROUP HEALTH PLAN AS PRIMARY AND LIST THE HOMEOWNER'S INSURANCE AS SECONDARY. - ✔✔-B) THE EMPLOYER'S GROUP HEALTH PLAN RATIONALE: THE HEALTH INSURANCE PLAN IS BILLED FIRST AND THEN THROUGH THE PROCESS OF SUBROGATION IT WILL BE DETERMINED IF A LIABILITY PAYER SHOULD BE CONSIDERED PRIMARY. 3. PRIVATE COMPANIES CONTRACT WITH CMS TO ADMINISTER: A) MEDICARE PART A & B B) MEDICARE PART B C) MEDICARE PART C D) MEDICARE PART A, B, & C - ✔✔-D) MEDICARE PART A, B, AND C RATIONALE: MEDICARE PART A, B, AND C ARE ALL ADMINISTERED BY PRIVATE COMPANIES THAT CONTRACT WITH CMS AS MEDICARE ADMINISTRATIVE CONTRACTORS OR MACs. WHAT IS A CO-PAYMENT? A) AN AMOUNT PAID EVERY MONTH BY THE POLICYHOLDER TO MAINTAIN HEALTH INSURANCE COVERAGE B) A PERCENTAGE OF THE ALLOWED AMOUNT THAT THE PATIENT IS RESPONSIBLE FOR. C) A FLAT AMOUNT PAID TO THE HEALTHCARE PROVIDER WHEN THE POLICYHOLDER IS SEEN FOR AN OFFICE VISIT. D) THE ADJUSTED AMOUNT BASED ON THE INSURANCE POLICY REQUIREMENT. - ✔✔-C) A FLAT AMOUNT PAID TO THE HEALTHCARE PROVIDER WHEN THE POLICY HOLDER IS SEEN FOR AN OFFICE VISIT. WHICH OF THE FOLLOWING STATEMENTS IS TRUE REGARDING THE NON-PAR MEDICARE ALLOWED FEE SCHEDULE? A) THE NON-PAR PROVIDER CAN BILL THE PATIENT THE DIFFERENCE BETWEEN THE CHARGE AND THE MEDICARE ALLOWABLE. B) THE NON-PAR LIMITING CHARGE IS 115% OF THE NON-PAR MEDICARE PHYSICIAN FEE SCHEDULE C) THE NON-PAR PHYSICIAN FEE SCHEDULE IS 115% OF THE PAR MEDICARE PHYSICIAN FEE SCHEDULE D) THE NON-PAR LIMITING CHARGE IS 95% OF THE PAR MEDICARE PHYSICIAN FEE SCHEDULE. - ✔✔-B) THE NON-PAR LIMITING CHARGE IS 115% OF THE NON-PAR MEDICARE PHYSICIAN FEE SCHEDULE. RATIONALE: PER CMS, THE NON-PAR LIMITING CHARGE IS 115% OF THE NON-PAR MEDICARE PHYSICIAN FEE SCHEDULE. WHAT IS A MEDIGAP POLICY? A) A POLICY THAT COVERS HEALTHCARE SERVICES THAT MEDICARE DOES NOT COVER. B) A POLICY THAT WILL NOT REIMBURSE FOR OUT-OF-POCKET COSTS NOT COVERED BY MEDICARE C) A SUPPLEMENTAL INSURANCE OFFERED BY CMS. D) A POLICY REQUIRED BY MEDICARE. - ✔✔-A) A POLICY THAT COVERS HEALTHCARE SERVICES THAT MEDICARE DOES NOT COVER. MEDICARE PART A IS AVAILABLE TO INDIVIDUALS UNDER THE AGE OF 65 WHO HAVE: A) DIABETES MELLITUS TYPE I OR II B) CKD (CHRONIC KIDNEY DISEASE) C) ESRD AND MEET CERTAIN REQUIREMENTS D) ANY CHRONIC HEALTH CONDITION - ✔✔-C) ESRD AND MEET CERTAIN REQUIREMENTS. RATIONALE: MEDICARE PART A COVERAGE IS AVAILABLE TO INDIVIDUALS BELOW THE AGE OF 65 WHO HAVE; 1) RECEIVED SOCIAL SECURITY OR RRB DISABILITY BENEFITS FOR 24 MONTHS, 2) END-STAGE RENAL DISEASE AND MEET CERTAIN REQUIREMENTS WHICH OF THE FOLLOWING STATEMENTS IS TRUE REGARDING MEDICAID? A) MEDICAID ELIGIBILITY POLICIES ARE THE SAME FOR STATES OF SIMILAR SIZE AND GEOGRAPHIC REGION. B) MEDICAID ELIGIBILITY IS CLEAR AND CONSISTENT FROM STATE TO STATE C) MEDICAID PROGRAMS RECEIVE MATCHING FFEDERAL FUNDING ONLY IF CERTAIN HEALTHCARE SERVICES ARE PROVIDED TO ELIGIBLE INDIVIDUALS. D) MEDICAID PROGRAMS MUST PROVIDE MEDICAL ASSISTANCE FOR ALL POOR PERSONS. - ✔✔-C) MEDICAID PROGRAMS RECEIVE MATCHING FEDERAL FUNDING ONLY IF CERTAIN HEALTHCARE SERVICES ARE PROVIDED TO ELIGBLE INDIVIDUALS. MEDICAID PROGRAMS MUST PROVIDE CERTAIN HEALTHCARE SERVICES TO ELIGIBLE INDIVIDUALS IN ORDER TO RECEIVE MATCHING FEDERAL FUNDS KNOWN AS FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP). THE PERCENTAGE IS DETERMINED ON A YEAR TO YEAR BASIS USING A FORMULA THAT COMPARES THE STATE'S PER CAPITA AVERAGE INCOME WITH THE NATIONAL AVERAGE. STATES WITH LOWER AVERAGE INCOME PER CAPITA RECEIVE A HIGHER FMAP. WHEN SUBMITTING A MEDIGAP POLICY, WHICH OPTION IS AN EXAMPLE OF HOW THE PATIENT'S ID NUMBER SHOULD APPEAR IN ITEM 9A OF THE CMS-1500 CLAIM FORM? A) 123456789 B) 123456789A C) MGAP 123456789 D) AETNA 123456789 MEDIGAP - ✔✔-C) MGAP 123456789 RATIONALE: IN ITEM 9A ENTER MEDIGAP FOLLOWED BY THE POLICY NUMBER AND GROUP NUMBER IF APPLICABLE. THESE SHOULD BE SEPARATED BY SPACES IE. MEDIGAP 123456 222. MG OR MGAP ARE ALSO ACCEPTABLE. MEDICAID COVERS EPSDT SERVICES. WHAT IS THE DEFINITION OF THIS ACRONYM? A) EARLY POSTOPERATIVE SCREENING, DIAGNOSTIC, AND TREATMENT B) EARLY PREGNANCY SCREENING, DIAGNOSTIC, AND TREATMENT C) ESTABLISHED PATIENT SCREENING, DIAGNOSTIC, AND TREATMENT D) EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT - ✔✔-D) EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT. RATIONALE: THE ACRONYM EPSDT STANDS FOR EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT AND REFERS TO ROUTINE PEDIACTRIC PEDIATRIC CHECKUPS THAT INCLUDE DENTAL, HEARING, VISION, AND OTHER SCREENING SERVICES TO DETECT POTENTIAL PROBLEMS IN ALL CHILDREN ENROLLED IN MEDICAID. A MEDICARE PATIENT HAS BEEN TREATED FOR FOUR (4) DIAGNOSES DURING HIS LAST VISIT: HYPERTENSION, TYPE 2 DIABETESL OSTEOARTHRITIS, & CKD. HOW MANY DIAGNOSES CAN BE REPORTED IN BOX 24E (DIAGNOSIS CODE POINTER) CMS-1500 CLAIM FORM FOR EACH SERVICE PROVIDED FOR THIS PATIENT? A) ONE B) TWO C) THREE D) FOUR - ✔✔-A) ONE RATIONALE: MEDICARE REQUIRES THAT ONLY ONE DIAGNOSIS BE REPORTED FOR EACH SERVICE PROVIDED. COMMERICAL PAYERS MAY OR MAY NOT HAVE THIS SAME REQUIREMENT TO COMPARE UNITS OF SERVICE WITH CPT AND HCPCS LEVEL II CODES, CMS ADDED WHICH OF THE FOLLOWING TO THE NCCI PROGRAM? A) MEDICALLY UTILIZED EDITS B) MEDICALLY UNDETERMINED EDITS C) MEDICALLY UNLIKELY EDITS D) MEDICALLY UNUSUAL EDITS - ✔✔-C) MEDICALLY UNLIKELY EDITS RATIONALE: MUE (MEDICALLY UNLIKELY EDITS) DETERMINE CPT AND HCPCS LEVEL II CODES THAT HAVE A MAXIMUM NUMBER OF UNITS OF SERVICE (UOS) THAT CAN REASONABLY BE PERFORMED BY THE SAME PROVIDER ON THE SAME PATIENT ON THE SAME DATE OF SERVICE. WHICH OF THE FOLLOWING SCENARIOS WOULD SUPPORT BILLING INCIDENT-TO SERVICES? A) NEW PATIENT SEEN BY A MID-LEVEL PROVIDER WHO IS AN EMPLOYEE OF THE PHYSICIAN. B) ESTABLISHED PATIENT SEEN BY A MID-LEVEL PROVIDER FOR FOLLOW-UP FOR BLOOD PRESSURE CHECK, PHYSICIAN IS IN THE OFFICE SUITE. C) ESTABLISHED PATIENT SEEN BY A MID-LEVEL PROVIDER FOR AN ESTABLISHED PROBLEM, THE PHYSICIAN IS PERFORMING HOSPITAL ROUNDS. D) NEW PATIENT TO THE PRACTICE, PHYSICIAN IN EXAM ROOM NEXT DOOR, MID-LEVEL PROVIDER IS AN EMPLOYEE OF THE PHYSICIAN. - ✔✔-B) ESTABLISHED PATIENT SEEN BY A MID-LEVEL PROVIDER FOR FOLLOW-UP FOR BLOOD PRESSURE.CHECK, PHYSICIAN IS IN THE OFFICE SUITE. RATIONALE: MEDICARE'S INCIDENT - TO BILLING FOR MID-LEVEL PROVIDERS ALLOW FOR SERVICES TO BE BILLED UNDER THE PHYSICIAN'S PROVIDER NUMBER WHEN MEDICARE PATIENTS ARE SEEN IN COLLABORATION WITH A PHYSICIAN. NEW PATIENTS MUST BE SEEN BY THE PHYSICIAN TO ESTABLISH CARE. PHYSICIAN MUST BE READILY AVAILABLE ONSITE IN ORDER TO BILL INCIDENT-TO SERVICES. WHAT IS LINKED BY NCDs AND LCDs? A) DIAGNOSIS CODES TO PROCEDURES OR SERVICES THAT ARE DETERMINED TO BE PAYABLE FOR MEDICARE PATIENTS B) DIAGNOSIS CODES TO PROCEDURES OR SERVICES THAT ARE DETERMINED TO BE REASONABLE FOR MEDICARE PATIENTS. C) DIAGNOSIS CODES TO PROCEDURE OR SERVICES THAT ARE DETERMINED TO BE REASONABLE AND MEDICALLY NECESSARY FOR MEDICARE PATIENTS D) DIAGNOSIS CODES TO PROCEDURES OR SERVICES THAT NEED TO HAVE A SIGNED ABN. - ✔✔-C) DIAGNOSIS CODES TO PROCEDURE OR SERVICES THAT ARE DETERMINED TO BE REASOABLE AND MEDICALLY NECESSARY FOR MEDICARE PATIENTS RATIONALE: NATIONAL AND LOCAL COVERAGE DETERMINATIONS (NCD & LCD) ARE CONTINUALLY BEING DEVELOPED TO LINK DIAGNOSES AND PROCEDURES BASED ON MEDICAL NECESSITY AND REASONABILITY. WHEN AN NCD/LCD REVIEW DETERMINES THAT A PROCEDURE OR SERVICE IS NOT REASONABLE OR MEDICALLY NECESSARY, THE PROVIDER IS ALLOWED TO BILL THE PATIENT ONLY IF AN ABN HAS BEEN SIGNED PRIOR TO PROVIDING THE PROCEDURE OR SERVICE. CPT CODES 64418 AND 19380 WERE REPORTED TOGETHER FOR THE INJECTION OF THE SUPRA CAPSULAR NERVE WITH ANESTHETIC AGENT (64418) WITH REVERSION OF A RECONSTRUCTED BREAST (19380). THE INJECTION WAS DENIED AS A BUNDLED SERVICE. WHAT WOULD BE THE NEXT STEP FOR THE BILLER? A) RESUBMIT CORRECTED CLAIM ADDING MODIFIER -59 TO 64418 B) RESUBMIT CORRECTED CLAIM ADDING MODIFIER -51 TO 64418. C) MOVE THE CHARGE FOR THE BUNDLED PROCEDURE TO PATIENT RESPONSIBILITY D) WRITE-OFF THE CHARGE FOR 64418 BECAUSE IT IS A BUNDLED PROCEDURE - ✔✔-D) WRITE-OFF THE CHARGE FOR 64418 BECAUSE IT IS A BUNDLED PROCEDURE. RATIONALE: SERVICES OR PROCEDURES THAT ARE DETERMINED TO BE BUNDLED AS PART OF THE PAYER'S CONTRACT MUST BE WRITTEN OFF. COSTS FOR THE BUNDLED PROCEDURE CANNOT BE SHIFTED TO PATIENT RESPONSIBILITY. BY SIGNING THE ASSIGNMENT OF BENEFITS IN IT [Show More]

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