AAPC-CPB Certified Professional Biller - Set 2 - Part 1

Correct Answer: The beneficiary

Under the distribution of collections rule, the agency first takes an amount equal to State Medicaid expenditures, then the Federal share is paid, and any remaining amount goes to the beneficiary and is treated as income or resources. Option a is incorrect because this agency administers the State child support enforcement plan and is not named as a recipient of the remainder in the distribution order. Option b is incorrect because the Medicaid agency has already taken its own share, equal to State Medicaid expenditures for the individual, before any remainder is determined. Option d is incorrect because a political subdivision that enforces and collects support receives an incentive payment, which is paid from the Federal share rather than from the remaining amount.

Correct Answer: Part B

The Medicare manual describes the program as two related health insurance programs: hospital insurance (HI), which is Part A, and supplementary medical insurance (SMI), which is Part B. Option a is incorrect because the manual treats Medicare+Choice as a plan an individual may choose to enroll in, not as one of the two related programs. Option c is incorrect because the manual labels Part A as hospital insurance (HI), which covers inpatient hospital, hospice, home health and skilled nursing facility services, not supplementary medical insurance. Option d is incorrect because the regulations define Medicaid as medical assistance under a State plan approved under title XIX, a separate program from Medicare's two parts.

Correct Answer: Outpatient physical therapy services

The Medicare manual's description of Supplementary Medical Insurance (Part B) lists outpatient physical therapy, occupational therapy, and speech-language pathology services among the covered services, alongside physicians' services and rural health clinic services. Option b is incorrect because a nursing facility is defined in the Medicaid regulations as an SNF or ICF participating in Medicaid, so it is not on the Part B list. Option c is incorrect because the Social Security Act establishes this program in section 1820 within the hospital insurance provisions, not as a listed Part B covered service. Option d is incorrect because Part B covers drugs and biologicals only when they are not usually self-administered by the patient, which excludes this category.

Correct Answer: mistaken payment

Medicare is secondary to workers' compensation plans. If Medicare paid for items or services that workers' compensation could have paid, the Medicare manual states that the Medicare payment constitutes mistaken payment. Option a is incorrect because that term covers money from a liability insurer, or an out-of-pocket payment by someone carrying liability insurance, which is a different payer situation altogether. Option c is incorrect because such a settlement gives less total compensation than full reimbursement would have, often because compensability is contested; Medicare's own payment is not labeled this way. Option d is incorrect because it names a workers' compensation settlement in which the beneficiary accepts one payment for all future medical expenses and disability benefits, not a Medicare payment category.

Correct Answer: Proper claim requirements

A proper claim is filed timely and meets all other filing requirements set by the plan, program, or insurer, such as a mandatory second opinion. A claim missing that step is not a proper claim. Option a is incorrect because this means proceeds obtained from a judgment, settlement, or an erroneous or conditional payment, which happens after payment rather than at claim filing. Option b is incorrect because this is an administrative mechanism that allocates part of a settlement, judgment or award for future medical expenses; it has nothing to do with plan filing rules. Option c is incorrect because this measures how soon an insurer pays after a claim is received or a service is furnished, not whether the claim met plan requirements.

Correct Answer: CHAMPUS eligibility is retained

Attainment of age 65 ends CHAMPUS eligibility except for listed groups, including beneficiaries entitled to Part A of Medicare who have enrolled in Part B. This spouse falls within that exception and keeps eligibility. Option a is incorrect because Part A entitlement ends eligibility only when no exception applies, and enrollment in Part B of Medicare is one of the listed exceptions. Option b is incorrect because the rule ties loss of eligibility to the first day of the month of Medicare entitlement, and only for those who do not retain CHAMPUS. Option d is incorrect because that notice is filed by a person who is not eligible for Part A, certifying that fact; this spouse is entitled to Part A.

Correct Answer: Public comment

Once a proposed LCD is published, the MAC must allow a minimum of 45 calendar days for public comment. A MAC that needs a longer comment period contacts the CMS Business Function Lead about an extension. Option b is incorrect because the CAC is an advisory body that reviews the quality of evidence and the MAC keeps the final decision, with no 45-day comment window attached. Option c is incorrect because MACs in the same jurisdiction consult on new LCDs under the statute, but that duty carries no period of 45 calendar days after publication. Option d is incorrect because these are optional educational discussions held before a formal request is submitted, and they are not tied to a minimum number of days after publication.

Correct Answer: Bring it to the attention of CMS

The NCD Manual foreword states there should be no inconsistencies among coverage instructions in the related manuals and the NCD Manual. Any inconsistencies found are to be brought to the attention of CMS. Option a is incorrect because those manuals usually hold more general coverage descriptions and claims processing instructions, and the guidance expects no inconsistency with the NCD Manual rather than giving them priority. Option c is incorrect because an LCD challenge belongs to a Medicare beneficiary who needs a service an LCD would deny, documented by a treating physician; it does not address manual conflicts. Option d is incorrect because MAC discretion applies when an item is not mentioned in the NCD Manual or coverage is not explicitly excluded, which is not a manual conflict.

Correct Answer: billing and coding articles

CMS instructs that CPT and ICD-10-CM codes be removed from LCDs and placed in billing and coding articles or Policy Articles that are published to the MCD and related to the LCD. Option a is incorrect because a CAC summary records recommendations from the advisory committee consultation on a proposed LCD, so it has no role in holding code lists. Option b is incorrect because the evidence summary describes the item or service, the scientific evidence and the target population, and it is not where code lists are placed. Option d is incorrect because the Bibliography lists the articles and sources that led to the LCD, formatted per the AMA Manual of Style, not code lists.

Correct Answer: Impose a sanction, including termination

Under the monitoring provision for avoidance of at-risk patients, if the Secretary determines an ACO took steps to avoid such patients to reduce cost risk, the Secretary may impose an appropriate sanction, including termination from the program. Option a is incorrect because waiver authority lets the Secretary set aside requirements as needed to carry out the section, which relaxes obligations instead of penalizing patient avoidance. Option b is incorrect because the statute resets the benchmark at the start of each agreement period, and it is not a response to avoiding at-risk patients. Option c is incorrect because the statute states that Chapter 35 of title 44 does not apply to the program, so it cannot serve as a remedy.

Correct Answer: Networks of individual practices of ACO professionals

The statute lists networks of individual practices of ACO professionals as an eligible ACO group, alongside group practice arrangements, hospital partnerships or joint ventures, and hospitals employing ACO professionals, provided shared governance exists. Option a is incorrect because beneficiaries are the Medicare fee-for-service patients assigned to an ACO, not a group of providers of services and suppliers that may form one. Option c is incorrect because the statute's eligibility list names provider and supplier groups, and it does not mention state Medicaid agencies among the groups that may participate. Option d is incorrect because commercial payers are not among the listed groups; eligibility is tied to providers of services and suppliers working together to coordinate Medicare care.

Correct Answer: No duplication in participation in shared savings programs

The statute's no-duplication provision states that a provider of services or supplier participating in the independence at home medical practice pilot program, or another shared savings model, is not eligible to participate in an ACO. Option a is incorrect because this subsection covers the method for assigning beneficiaries to an ACO based on utilization of primary care services, not provider eligibility. Option b is incorrect because this subsection only lets the Secretary give preference to ACOs in similar arrangements with other payers; it creates no bar on participation. Option c is incorrect because this provision directs the Secretary to set standards that assess the quality of care furnished by ACOs, not to decide who may participate.

Correct Answer: Major surgical procedure

Under the federal regulation defining terms for Medicare Part B payment, a major surgical procedure is a surgical procedure for which a 10-day or 90-day global period is used for payment under the physician fee schedule. Option a is incorrect because describes professional services of listed practitioner types and incident-to supplies and services, not a procedure defined by a 10-day or 90-day global period. Option b is incorrect because names the narrow situation in which a payment may be raised or lowered after record review, not a class of procedure. Option d is incorrect because refers to the portion of an X-ray or imaging service subject to a payment reduction, and has no link to global periods.

Correct Answer: The same fee schedule RVUs apply to both

The Medicare Claims Processing Manual states there are no special RVUs for limited license physicians such as optometrists and podiatrists. Fee schedule RVUs apply to a service whether a medical doctor, doctor of osteopathy, or limited license physician performs it. Option b is incorrect because By Report payment is tied to specific services identified by status indicators, such as unusual or team surgery services, and not to the practitioner's license. Option c is incorrect because local relative values apply to services with national codes lacking national values, not to a practitioner's license type, which does not change the RVUs. Option d is incorrect because the manual states there are no special RVUs for limited license physicians such as podiatrists, so no reduced values exist for them.

Correct Answer: Only under very unusual circumstances

The Medicare manual states fees reflect average work effort and practice expenses, so A/B MACs (B) may increase or decrease payment only under very unusual circumstances, based on review of medical records and other documentation. Option a is incorrect because multiple visits to nursing homes appear on the list of situations where fee schedule amounts may not be adjusted by A/B MACs (B). Option b is incorrect because the Medicare manual says fees already represent average work effort and practice expenses, so a range in effort alone does not justify changing payment. Option c is incorrect because inherent reasonableness is listed among the items for which A/B MACs (B) may not adjust fee schedule amounts provided by CMS.

Correct Answer: The MAC typically cannot tell which entry is wrong

When a valid place of service conflicts with the procedure billed, such as an inpatient hospital POS with an office visit, the MAC typically will not know whether the procedure code or the place of service is incorrect, so it returns the claim as unprocessable. Option a is incorrect because item 32 holds the practice address used to find the payment locality, so it has no bearing on a POS and procedure mismatch. Option b is incorrect because that describes an invalid place of service, which is a separate edit; in this excerpt the place of service is already valid. Option d is incorrect because the guidance limits the Form CMS-1500 to one POS for MPFS services, but that is a different problem from an incompatible pairing.

Correct Answer: The service is a separately identifiable procedure unrelated to the comprehensive procedure

The correct coding policy states that a bundled service does NOT represent a separately identifiable procedure unrelated to the comprehensive procedure. A separately identifiable, unrelated service is the opposite of the principle, so it is the odd one out. Option a is incorrect because the policy states this directly as a principle, adding that failure to perform such a service may compromise the success of the procedure. Option c is incorrect because this is the first listed principle of the correct coding policy, tying bundling to what is standard practice for completing the overall procedure. Option d is incorrect because this matches the general coding policy that services integral to accomplishing a procedure are considered bundled into it and are a component part of the comprehensive code.

Correct Answer: major surgeries

The Medicare Fee Schedule Data Base postoperative period field marks codes with a "090" entry as major surgeries. Codes with "000" or "010" are minor procedures or endoscopies instead. Option b is incorrect because minor procedures and endoscopies carry the "000" or "010" indicators, so they do not belong with the "090" entry. Option c is incorrect because add-on codes carry the "ZZZ" indicator and have no postoperative work in the payment, with the global period applied to the primary code. Option d is incorrect because codes priced by the A/B MAC (B) usually carry the "YYY" indicator, which lets the contractor determine the global period.

Correct Answer: Agreed transfer of care

Medicare splits payment for postoperative, post-discharge care between two or more physicians when the physicians agree on the transfer of care. Without a transfer of care, other physicians' services are handled separately. Option a is incorrect because add-on codes carry no postoperative work of their own and take the global period of the primary code, so they do not divide care between physicians. Option b is incorrect because critical care services unrelated to the procedure are payable separately in some situations, which is a different rule from dividing postoperative payment among physicians. Option c is incorrect because the guidance describes separate payment or denial only for cases where no transfer of care occurs, not as the arrangement that splits postoperative payment.

Correct Answer: Different surgical procedure code for each physician

Both the surgeon's bill and the postoperative physician's bill carry the same date of service and the same surgical procedure code. Only the modifiers distinguish the services, so a different code for each physician is not required. Option b is incorrect because both the surgeon and the physician providing postoperative care must keep a copy of this agreement in the beneficiary's medical record. Option c is incorrect because modifier -54 for surgical care only and modifier -55 for postoperative management only separate the two bills, so this is expected. Option d is incorrect because the claim must show this date, entered in the remarks field or free text segment, so it is a genuine requirement of transfer billing.