AAPC-CIC Certified Inpatient Coder - Set 4 - Part 3

Correct Answer: Evaluated in the context of the medical record evidence

Under the Medicare medical review requirements, no presumptive weight is assigned to the physician's order or certification for medical necessity. Each is evaluated in the context of the evidence in the medical record. Option a is incorrect because the regulation states that no presumptive weight is assigned to the order or certification when medical necessity is determined, so it does not settle the question. Option b is incorrect because the utilization review plan is a separate condition of participation for hospitals, and the regulation does not substitute it for the order or certification evaluation. Option c is incorrect because the acknowledgement statement concerns the attending physician's diagnosis and procedure entries supporting payment; it does not make an order or certification conclusive on necessity.

Correct Answer: Medicare payable day of care

Under the payment in full provision, the full prospective payment amount is made for each stay during which there is at least one Medicare payable day of care. Limitation of liability days and guarantee of payment days count as payable days. Option b is incorrect because capital-related costs are one component covered within the total payment amount, not the kind of day that triggers full payment. Option c is incorrect because the regulation ties full payment to payable days of care, and says nothing here about a day being defined by an admission order. Option d is incorrect because extraordinarily costly cases receive an additional payment under a separate subpart, not a trigger for the full prospective payment amount.

Correct Answer: It is available only for final effective LCDs

The Medicare manual states that the LCD reconsideration process differs from an initial LCD request because it is available only for final effective LCDs. MACs accept requests only for LCDs published as an effective final. Option a is incorrect because the Medicare manual allows the whole LCD or any provision of it to be reconsidered, so provision-level requests are permitted. Option b is incorrect because requesters include beneficiaries and stakeholders such as medical professional societies, providers and any interested party doing business in the jurisdiction, not physicians alone. Option d is incorrect because the manual assigns CMS BFL approval to extending a notice period, which is a different step from submitting a reconsideration request.

Correct Answer: Medicare Administrative Contractor

Section 1869(f)(2)(B) of the Social Security Act defines an LCD as a determination by a Medicare Administrative Contractor on whether an item or service is covered on a contractor-wide basis. Option b is incorrect because the DAB takes part in reviewing LCDs on appeal, which is a separate role from making the original coverage determination. Option c is incorrect because a CAC appears in the glossary as an advisory body, and the statute gives the authority to issue an LCD to the MAC. Option d is incorrect because an ALJ reviews LCDs through the LCD Challenge Process and does not issue the contractor-wide coverage determination itself.

Correct Answer: Unassigned claims for physicians' services

The Refund Requirements apply to unassigned claims for physicians' services, but the Limitation on Liability provisions apply to all Part A services and all assigned Part B claims. Unassigned physician claims therefore fall only under the Refund Requirements. Option a is incorrect because Limitation on Liability applies to all Part A services, while the Refund Requirements do not apply to Part A claims, which reverses the relationship the stem describes. Option b is incorrect because a valid ABN is evidence used when determining beneficiary knowledge for liability, and it does not define a claim category that only the Refund Requirements reach. Option d is incorrect because the Limitation on Liability provisions apply to all assigned claims for Part B services, so these claims fall within that provision rather than outside it.

Correct Answer: Knowledge

LOL application depends on two factors: the statutory basis of the denial and knowledge. Deciding liability by who knew, or should have known, that Medicare would deny payment is the knowledge factor. Option a is incorrect because it covers services denied as an indirect result of an original denial, such as home health aide services, rather than who knew of the likely denial. Option c is incorrect because it describes a denial based on a statutory provision not referenced in §1879, so LOL does not apply and liability is not assigned this way. Option d is incorrect because it is the first factor, which asks whether the claim was denied for specific reasons, such as an item found not reasonable and necessary.

Correct Answer: will not be made

CMS written notice standards direct the provider or supplier to issue a written notice each time, and as soon as, it assesses that Medicare payment certainly or probably will not be made, transferring potential financial liability to the beneficiary. Option b is incorrect because a partial reduction is not the condition the guidance names; the written notice addresses expected nonpayment, which transfers potential financial liability to the beneficiary. Option c is incorrect because a payment request is not a stated trigger; the guidance bases the notice on the provider's assessment of Medicare payment outcome. Option d is incorrect because delay in payment is not the trigger in CMS guidance; the notice is tied to an assessment that payment will not be made.

Correct Answer: Signed blank written notice

A signed blank written notice is one the beneficiary signed before it was completed. Medicare guidance requires completion before delivery, and the contractor treats a notice blank when signed as invalid, giving the notifier no liability protection. Option a is incorrect because a blanket notice means giving written notices for all claims, items or services, without a genuine judgment about the individual claim, not signing before completion. Option b is incorrect because routine notice is the broad category given without a specific, identifiable reason to expect denial; the quoted excerpt names a narrower practice about timing of completion. Option d is incorrect because a generic notice is a routine notice that only states Medicare denial is possible or that the notifier never knows whether payment will be denied.

Correct Answer: The billing entity

Under the Medicare manual's rules on issuing the ABN, a notifier may direct an employee or subcontractor to deliver it, but the billing entity is always held responsible for effective delivery, whoever gives the notice. Option a is incorrect because contractors review ABN-related claims and judge validity, so they act as reviewers of the notice, not as the party accountable for delivering it. Option b is incorrect because a notifier may be an employee or subcontractor who hands over the notice, yet responsibility stays with the billing entity, not whoever collects the signature. Option c is incorrect because the guidance does not assign delivery responsibility to the ordering provider; it places responsibility on the entity that bills, regardless of who orders the test.

Correct Answer: Prompt refund to the beneficiary

When a notifier knew or should have known Medicare would not pay and fails to issue a required ABN, the notifier is precluded from collecting from the beneficiary and must make prompt refunds of funds already collected. Option b is incorrect because that fee may be charged only after a properly delivered ABN and the beneficiary's agreement to pay, which did not occur here. Option c is incorrect because a beneficiary who does not receive proper notice when required is relieved from liability, so liability cannot shift to that person. Option d is incorrect because the notifier is precluded from collecting funds from the beneficiary at all in this situation, so a fee schedule cap does not apply.