AAPC-COC Certified Outpatient Coder - Set 3 - Part 3

Correct Answer: Provide notice about primary payment responsibility

Under the regulation on a primary payer's notice of primary payment responsibility, a primary payer shown to have owed payment for services Medicare paid must give notice and MSP information to the entity designated by CMS. Option a is incorrect because matching requests are transmitted by the Commissioner of Social Security to the Secretary of the Treasury under the statute, a task outside the primary payer's duties. Option c is incorrect because the right to intervene belongs to CMS, which may join or intervene in actions tied to the events behind the payment, not to the primary payer. Option d is incorrect because subrogation runs the other way: CMS is subrogated to entities entitled to payment by a primary payer, so the primary payer does not acquire that right.

Correct Answer: The final conditional amount subject to recovery

Under 42 U.S.C. 1395y(b)(2)(B)(vii), the last statement of reimbursement amount downloaded within 3 business days before a settlement in the protected period constitutes the final conditional amount subject to recovery. Option a is incorrect because procurement costs are a separate deduction in the recovery formula and are not set by downloading a statement of reimbursement amount. Option b is incorrect because the expected date is given by a notice to the Secretary, which a claimant or applicable plan may submit beginning 120 days beforehand. Option c is incorrect because portal access depends on the beneficiary creating an account and the contractor posting the recovery case, not on any downloaded statement.

Correct Answer: The entity designated to receive repayments

Under the reimbursement rule, when primary payer responsibility is shown by something other than a CMS recovery demand letter, such as a settlement, the primary payer pays the entity designated to receive repayments. Option a is incorrect because a demand letter directs payment only when one has been received, and in this situation none exists to give directions. Option c is incorrect because the regulation places the reimbursement duty on the primary payer and entities that received its payment, with payment directed to CMS's designee, not routed through the beneficiary. Option d is incorrect because a provider is not the designated recipient of repayments; the regulation names the repayment entity or the location given in a demand letter.

Correct Answer: FLs 31, 32, 33, and 34

Medicare instructions assign occurrence codes and dates to FLs 31, 32, 33, and 34. The provider completes the a fields of these locators before the b fields, entering a two-character code with a six-digit MMDDYY date. Option b is incorrect because these are the Accident State and untitled locators, which are marked Not used, so any data entered in them will be ignored. Option c is incorrect because these locators are assigned to occurrence span codes with beginning and ending dates, which Medicare treats as a separate code type from occurrence codes. Option d is incorrect because these locators receive the appropriate value code when occurrence codes 01-04 and 24 are entered and another payer is involved, not the occurrence codes themselves.

Correct Answer: An 8-digit date in item 24a

Medicare lets providers choose 6-digit or 8-digit dates for items 11b, 14, 16, 18, 19 and 24a, but the choice must be consistent across all of them. Having chosen 8-digit dates, the supplier must use 8 digits in item 24a. Option a is incorrect because the legend requires a space between month, day, and year, shown as a dotted vertical line on the form. Option b is incorrect because the choice of 6 or 8 digits is made once for the whole group of items, so item 24a is not independent. Option c is incorrect because the instructions require the same digit length across items 11b, 14, 16, 18, 19 and 24a, so mixing 6-digit in 24a is not permitted.

Correct Answer: National Uniform Billing Committee (NUBC)

The National Uniform Billing Committee (NUBC) maintains the lists of approved coding for the UB-04. A/B MACs keep their own lists of codes used by Medicare, but the NUBC maintains the approved coding. Option b is incorrect because it approves new versions of the CMS-1500 before Medicare use; it does not maintain the code lists for the UB-04. Option c is incorrect because they maintain only the lists of codes Medicare uses on institutional claims, which is separate from the NUBC-approved coding for the form. Option d is incorrect because it maintains the paper Form CMS-1500 used for professional and supplier claims, not the institutional UB-04 and its approved coding lists.

Correct Answer: Medicare

When Medicare is the primary payer, the provider enters "Medicare" on line A of FL 50. This entry shows the provider has developed for other insurance and determined that Medicare is primary. Option a is incorrect because the health plan identifier belongs in FL 51, which supplies the plan ID, and does not name the payer in FL 50A. Option c is incorrect because the release of information certification indicator is reported in FLs 52A, B, and C as a "Y" or "I" code, not as payer identification. Option d is incorrect because the billing provider National Provider ID is a separate required entry in FL 56 and does not identify the payer.

Correct Answer: Reasonable cost of covered services

The Medicare manual restricts payment to a provider to the lower of the billed charge, the reasonable cost of covered services, or the fee schedule amount. Reasonable cost is therefore the third amount compared. Option a is incorrect because it is the method used to pay hospitals under the PPS for inpatient stays, a separate payment system rather than a component of the lower-of limit. Option b is incorrect because hospices are paid this way under their own method, so it works as a distinct payment basis and is not one of the limit's three amounts. Option c is incorrect because this payment applies to outpatient hospital services under OPPS and is set for the date of service, not part of the lower-of comparison.

Correct Answer: The individual's physician and the facility furnishing services

The Medicare manual states that the law does not permit federal supervision or control over the practice of medicine, so responsibility for treatment and control of care remains with the individual's physician and the hospital or other facility furnishing services. Option b is incorrect because State agencies certify to DHHS whether providers meet conditions of participation, a certification function that does not extend to directing treatment. Option c is incorrect because the Administrator conducts the program under delegation from the Secretary, but the law bars federal supervision or control over the practice of medicine. Option d is incorrect because an A/B MAC enrolls providers, processes claims and makes payments under an agreement with CMS, which is an administrative role rather than control of care.

Correct Answer: Separate payroll contributions by employees, employers, and self-employed persons

Part A is financed through separate payroll contributions paid by employees, employers, and self-employed persons. The proceeds are deposited to the Federal Hospital Insurance Trust Fund, which is used for hospital insurance benefits and administrative expenses. Option a is incorrect because this describes a funding source for Part B, where voluntary enrollees pay premiums into the Federal Supplementary Medical Trust Fund, not the main source for Part A. Option b is incorrect because these are sanctions that may be imposed for fraud and abuse against the program, not a stated financing mechanism for any part of Medicare. Option d is incorrect because general revenue contributions support Part B alongside premiums; for Part A they only cover persons who are not Social Security or railroad retirement beneficiaries.