AAPC-CPB Certified Professional Biller - Set 5 - Part 1

Correct Answer: Payment locality where the service was furnished

The Medicare manual states that jurisdiction for processing a request for payment under the MPFS is governed by the payment locality where the physician or supplier furnished the service, based on the ZIP code. Option a is incorrect because decides which hospital place of service code is reported for a registered patient, which is a coding rule, while jurisdiction follows the payment locality. Option b is incorrect because reflects the setting of the face-to-face service and is checked for validity on the claim; the manual ties jurisdiction to locality, not to this code. Option c is incorrect because is compared with the place of service so the MAC can edit for consistency with site-specific procedures; the manual does not name it as the jurisdiction factor.

Correct Answer: Good cause for late filing exists

Medicare guidance states that whenever a beneficiary is not notified of appeal rights or filing time limits, good cause must be found. A denial notice lacking the time limit is a listed example of good cause. Option b is incorrect because the MAC resolves the good cause question first, before taking any other action on the appeal, so it is not deferred to a later level. Option c is incorrect because provider, physician and supplier extension requests are not routinely granted and get careful examination, while this appellant is a beneficiary who receives more lenience. Option d is incorrect because dismissal is not the result here, because the guidance directs that good cause be found whenever a beneficiary is not notified of the time limits for filing.

Correct Answer: Anti-Markup Payment Limitation

The Medicare manual's summary of adjustments to fee schedule computations lists the Anti-Markup Payment Limitation among the adjustments applied to reach the final fee schedule amount, alongside site of service, multiple surgeries and bilateral surgery. Option a is incorrect because relative values are supplied separately for the global service, professional component and technical component, so these are provided values rather than a listed adjustment. Option b is incorrect because the fee schedule provides no special RVUs for limited license physicians such as optometrists and podiatrists; the same RVUs apply whoever performs the service. Option c is incorrect because By Report is a pay-on-report category identified by status indicators, and A/B MACs may not establish RVUs for it; it is not on the adjustment list.

Correct Answer: Pay on a "By Report" basis

The Medicare fee schedule database status indicators identify national codes and modifiers, including unusual services, that A/B MACs continue to pay on a "By Report" basis. MACs may not establish RVUs for them. Option a is incorrect because local relative values are for national codes lacking national RVUs, but By Report services are expressly excluded from MAC-established RVUs. Option b is incorrect because facility and nonfacility rates exist for procedures with separate rates by setting, which is a site of service matter and not individual pricing. Option d is incorrect because bundled services are those whose payment is folded into related services, whereas unusual services are identified for By Report payment instead.

Correct Answer: Pay the service without reducing the amount

Under the Medicare manual's rule of no adjustments in fee schedule amounts, a MAC may not reduce payment when a claim also indicates a refraction. CMS has already made that reduction in the fee schedule amount it provided. Option b is incorrect because the MAC may not adjust fee schedule amounts for refractions, because CMS has already built that reduction into the fee provided to the MAC. Option c is incorrect because local relative values apply to national codes lacking national relative values, not to a service whose fee schedule amount CMS has already supplied. Option d is incorrect because By Report pricing covers items such as unusual services and team surgery, and a refraction indication on a claim does not move a service into that category.

Correct Answer: Removal of cutaneous sutures and staples

Removal of cutaneous sutures and staples is listed under Miscellaneous Services in the Medicare manual's global surgical package. It is included in the payment when the surgeon who performs the surgery furnishes it, in any setting. Option a is incorrect because the package covers complications only when they do not require additional trips to the operating room, so those return trips fall outside it. Option b is incorrect because the guidance states that services by other physicians are not included in the global fee for a minor procedure, except as otherwise excluded. Option c is incorrect because with a 000 entry, visits beyond the day of the procedure are outside the payment amount, and separate payment is made.

Correct Answer: Notice given by telephone

Because the unsolicited telephone contact itself is prohibited by law, giving notice by telephone does not qualify as notice. Telephone notice may not be used when the expected denial rests on that prohibition. Option a is incorrect because keeping the ABN on file is the documentation step for supplier number denials, not a method of delivering notice that is barred. Option b is incorrect because mailing an ABN and obtaining the beneficiary's agreement to pay before calling is described as equivalent to written permission to telephone, so it is acceptable. Option d is incorrect because an ABN must clearly identify the particular item or service to qualify for waiver of the Refund Requirements, so this is required.

Correct Answer: Modifier "-57"

Evaluation and management services on the day before or day of major surgery that result in the initial decision to operate are outside the global package. Modifier "-57" (decision for surgery) identifies such a visit so it can be billed separately. Option a is incorrect because it marks surgical care only when physicians agree to transfer care during the global period, so it does not identify a decision-for-surgery visit. Option b is incorrect because it is reported for a return trip to the operating room for a related procedure in the postoperative period, which is a different situation. Option c is incorrect because the guidance directs that "-57" be used, not "-25", when an evaluation and management service on the day of surgery leads to the decision to operate.

Correct Answer: Modifier "-55"

When portions of the global period occur in different payment localities, the postoperative care is billed with modifier "-55" to the A/B MAC (B) servicing the locality where that care was performed. Option a is incorrect because it reports surgical care only, so it is placed on the surgery claim sent to the A/B MAC (B) for the surgery locality. Option b is incorrect because it identifies an unrelated procedure by the same physician during the postoperative period, which is a different billing situation. Option d is incorrect because it reports a return trip to the operating room for a related procedure during the postoperative period, not care in another locality.

Correct Answer: Modifier "-79"

Modifier "-79" reports an unrelated procedure by the same physician during a postoperative period. A new postoperative period begins when the unrelated procedure is billed. Option b is incorrect because it facilitates billing of staged or related procedures, such as those planned prospectively, so it does not fit an unrelated service. Option c is incorrect because it is attached to an evaluation and management service that is unrelated to the surgery, and does not report a procedure. Option d is incorrect because it reports a return trip to the operating room for a related procedure during the postoperative period, not an unrelated procedure.

Correct Answer: A service included in the global package

Prepayment edits flag services furnished within the global period, billed without a payment-supporting modifier and under the same provider or group number as the surgery. Such services are treated as included in the global surgical package. Option a is incorrect because the limitation of liability provision does not apply because these determinations are fee schedule reductions rather than denials based on medical necessity or custodial care. Option b is incorrect because separate payment depends on a modifier such as -24, -25, -57, -78, -79 or -58, and this visit was billed without one. Option d is incorrect because individual consideration pricing applies to surgeries billed with modifier -22 or -52 when the required statement and documentation are submitted, not to unmodified postoperative visits.

Correct Answer: By the number of days each physician was responsible

For split global care, when more than one physician bills for postoperative care, A/B MACs divide the postoperative allowed amount by the number of post-op days and multiply by the days each physician saw the patient. Option a is incorrect because a maximum of 50 percent applies to unlisted procedures billed for complications on return trips to the operating room, not to split global care. Option c is incorrect because Medicare does not divide the postoperative amount evenly; the guidance ties each physician's share to the days of responsibility for the patient's care. Option d is incorrect because the intra-operative percentage is a separate portion of the global package, which includes postoperative hospital visits, and it is not the basis for dividing postoperative care between physicians.

Correct Answer: Full value for the code

For a procedure with a "000" global period billed with modifier "-78", A/B MACs (B) pay the full value, because these codes have no pre-, post-, or intra-operative values to separate out. Option a is incorrect because that method applies to codes having intra-operative values, but a "000" global code carries no pre-, post-, or intra-operative values to split. Option b is incorrect because this cap is reserved for an unlisted procedure billed because no code exists to describe the treatment of the complications. Option c is incorrect because multiple surgery payment covers extra procedures done in the same session as the original surgery, not a return trip for complications.

Correct Answer: Additional separately payable surgical procedure

A multiple surgery is a separate procedure at the same session for which separate payment may be allowed. Intra-operative services, incidental surgeries and components of more major surgeries are not separately billable. Option a is incorrect because the Medicare manual lists intra-operative services among those treated as part of the primary procedure, so they receive no separate billing or payment. Option b is incorrect because an incidental surgery is named by the manual as a service that is not separately billable, and mandatory edits block payment for it. Option d is incorrect because the manual states that components of more major surgeries are not separately billable, so they are folded into the primary procedure.

Correct Answer: Continue adjudicating the appeal

Medicare appeals guidance directs reviewers to keep adjudicating appeals from a supplier under fraud or abuse investigation, remaining neutral, unless the MAC has been informed of a settlement or prosecution outcome withdrawing the claims or waiving appeal rights. Option a is incorrect because the UPIC receives information about a suspected civil or criminal violation, but the reviewer still decides the coverage or payment issues in the appeal. Option b is incorrect because dismissal rests on MAC notice that the appellant agreed in a settlement or prosecution to withdraw the claims or waive appeal rights, and no such notice exists here. Option c is incorrect because the reviewer must stay neutral toward a supplier under investigation, so claims on other matters cannot drive an automatic denial of these claims.

Correct Answer: Keeping LCDs consistent with national coverage, payment, and coding policies

The Medicare manual requires the MAC to ensure that all LCDs do not conflict with statutes, rulings, regulations, and national coverage, payment, and coding policies. An LCD that denies what an NCD covers fails that obligation. Option a is incorrect because this is a timing requirement that runs from the proposed LCD's publication date; it says nothing about whether the LCD's content agrees with an NCD. Option c is incorrect because the link requirement applies only when a MAC chooses to post LCDs on its own site, and it does not address coverage content. Option d is incorrect because this duty concerns where proposed and final LCDs and related articles are made public, so a draft can meet it and still contradict an NCD.

Correct Answer: Most recent medical and scientific evidence

The NCD Manual states that its coverage determinations will be revised based on the most recent medical and other scientific and technical evidence available to CMS, keeping national coverage policy current. Option b is incorrect because claims processing manuals hold general coverage descriptions and instructions that must stay consistent with the NCD Manual, so they do not drive its revisions. Option c is incorrect because transmittal numbers only identify the sheet that summarizes changes and appears on each manual page; they are a reference tool, not a basis for revision. Option d is incorrect because contractors make coverage decisions where the manual leaves discretion; the manual does not name their requests as the basis for revising its determinations.

Correct Answer: The Medicare Administrative Contractor

When an item or service is not mentioned in the NCD Manual, or coverage is not explicitly excluded, the Medicare Administrative Contractor has the discretion to make the coverage decision, consulting its medical staff and CMS when appropriate. Option a is incorrect because a treating physician documents a beneficiary's need for an item or service, as in an LCD challenge, but does not make the coverage decision. Option b is incorrect because this CMS division receives reports of inconsistencies among the manuals and the NCD Manual; it is not assigned the coverage decision for unmentioned items. Option c is incorrect because an aggrieved party is a Medicare beneficiary who uses the LCD challenge process under the Act, which is an appeal role rather than a decision-making one.

Correct Answer: MAC

CMS guidance states that the CAC is advisory in nature, with the final decision on all issues resting with the MAC. The CAC supplements the MAC's internal expertise but does not replace its decision authority. Option b is incorrect because this role receives contact from MACs about extending a comment period and receives attendee counts on request, not final decisions on LCD issues. Option c is incorrect because the Contractor Advisory Committee is described as advisory in nature, so it renders advice and does not hold the final decision. Option d is incorrect because interested parties may make presentations at open meetings, but formal comments go in writing to the MAC, which keeps the decision.

Correct Answer: Posting on the contractor website at least two weeks before the event

The Medicare manual requires MACs to post the planned agenda for the open meeting on their contractor website a minimum of two weeks before the event and to inform the public that it has been posted. Option a is incorrect because the final LCD and the Response to Comment article are what reach the MCD after the comment period; the agenda must be available well before the event. Option b is incorrect because the manual requires no CMS approval step for the agenda; it only requires the MAC to post it and tell the public. Option d is incorrect because the Medicare manual requires the agenda to be posted on the contractor website in advance, and it names no day-of mailing to CAC members.