AAPC-CPB Certified Professional Biller - Set 3 - Part 2

Correct Answer: Whether to cover the service carrier-wide

Under 42 CFR 400.202, an LCD is a decision by a fiscal intermediary or carrier on whether to cover a particular service on an intermediary-wide or carrier-wide basis. It excludes code assignment and payment amount. Option a is incorrect because payment amount is also excluded from an LCD, so a reviewer cannot read the payment figure from the determination itself. Option b is incorrect because code assignment is expressly excluded from an LCD; the regulation says an LCD does not include a determination of which procedure code applies to a service. Option c is incorrect because national coverage decisions are made by CMS as national coverage determinations, while an LCD is made by a fiscal intermediary or carrier for its own area.

Correct Answer: No-fault insurance

No-fault insurance pays medical expenses for injuries sustained in the use, occupancy or operation of an automobile, regardless of who may have been responsible for causing the accident. This is a recognized MSP situation where Medicare may be secondary. Option a is incorrect because it provides payment based on alleged legal liability for injury, illness or damage to property, so fault is central to it. Option b is incorrect because it describes a plan sponsored jointly or contributed to by two or more employers, or by employers and unions, rather than accident coverage. Option d is incorrect because it is a workers' compensation settlement in which the beneficiary accepts one payment covering all future medical expenses and disability benefits for a work injury or disease.

Correct Answer: The limiting charge for the surgical procedure

Medicare global surgery policy states that the maximum a nonparticipating physician may bill a beneficiary on an unassigned claim for services included in the global surgery package is the limiting charge for the surgical procedure. Option a is incorrect because individual consideration pricing applies to surgeries billed with the "-22" or "-52" modifier when the required statement and documentation accompany the claim, not to the unassigned billing cap. Option b is incorrect because when fragmented charges exceed the global fee, the claim is processed as a fee schedule reduction, so itemized totals do not set the beneficiary billing ceiling. Option c is incorrect because that amount is the fee schedule figure for a nonparticipating supplier, computed as 95 percent of the participating amount; the guidance names the limiting charge as the billing maximum instead.

Correct Answer: Informational remittance advice

Medicare Administrative Contractors send informational remittance advice to nonparticipating physicians, suppliers and non-physician practitioners billing non-assigned claims, unless the beneficiary or provider requests suppression. It carries a standard message about appeal rights under limitation on liability. Option b is incorrect because it is generated only when a provider or an entity working for the provider requests it, and the MAC may charge to recoup costs. Option c is incorrect because it describes the electronic format that must follow the HIPAA 835 standard, which says nothing about who receives a notice on non-assigned claims. Option d is incorrect because it names the paper format CMS established for MACs to mirror the electronic version, not the notice type sent for non-assigned claims.

Correct Answer: No appeal rights exist beyond those under limitation on liability

An informational RA is identical to other RAs but must carry a standard message telling nonparticipating providers billing non-assigned claims that they have no appeal rights beyond those afforded when limitation on liability applies. Option a is incorrect because the informational RA is required to say the provider has no appeal rights beyond those afforded when limitation on liability applies, so full rights are not granted. Option b is incorrect because non-assigned claims mean the provider bills and receives payment from the beneficiary rather than accepting direct Medicare payments, which is why the informational RA exists. Option c is incorrect because duplicate remittance advice is a separate matter; MACs may charge up to a set maximum to recoup costs when a provider requests copies.

Correct Answer: The date stamp the agency places on the claim

Under 42 CFR 447.45, the date of receipt is the date the agency receives the claim, as indicated by its date stamp on the claim. The timely payment periods are measured from that date. Option b is incorrect because notice of a Medicare disposition only starts a 6-month window for paying related Medicaid claims; it does not set the receipt date. Option c is incorrect because the date of receipt is tied to the agency's handling of the claim, not to when the provider furnished the service. Option d is incorrect because that describes the date of payment, which the regulation defines separately as the date of the check or other form of payment.

Correct Answer: I, II, and IV

TRICARE is the secondary payer to other health benefit and third-party plans, CHAMPUS recognizes no general assignment of benefits, and Medicaid prepayment review verifies that a claim is not a duplicate. The date of receipt is the date stamp, not the check date. Option a is incorrect because it leaves out statement IV, and Medicaid prepayment claims review does include verification that a claim does not duplicate or conflict with one reviewed earlier. Option c is incorrect because statement III confuses two dates, since the check date is the date of payment, and this choice also drops statement I on secondary payer status. Option d is incorrect because it relies on statement III, but receipt is the date the agency stamps the claim as received; it also omits the no-general-assignment rule.

Correct Answer: I, II, and IV

A conditional payment is conditioned upon reimbursement to Medicare, may be made when no-fault insurance cannot reasonably be expected to pay promptly, and promptly means payment within 120 days after the insurer receives the claim. Option a is incorrect because leaves out statement IV, which is also true: for no-fault insurance and workers' compensation, promptly is defined as payment within 120 days after the claim is received. Option c is incorrect because includes statement III and omits statement I; Medicare is barred from paying when liability insurance has already paid, and conditional payments are tied to reimbursement. Option d is incorrect because includes statement III, which reverses the rule, and drops statement II, which describes the standard trigger for a conditional payment under no-fault insurance.

Correct Answer: The GHP based on current employment status

Federal law makes Medicare secondary to the GHP based on current employment status and primary to the GHP based on retirement. Private coordination of benefits arrangements between the plans cannot change that order. Option a is incorrect because Medicare is primary to the retiree coverage, so Medicare pays before that plan rather than after it, regardless of COB arrangements. Option b is incorrect because Medicare is the residual payer only where WC, liability, no-fault or a primary GHP exists, and here it pays after the employment-based plan. Option d is incorrect because private COB arrangements cannot supersede the Federal law that makes Medicare secondary to certain GHPs, so they do not set this order.

Correct Answer: CMS responds to a properly documented request within 90 days

The regulation requires CMS to notify the State of its approval or disapproval within 30 days of receiving a properly documented waiver request. A 90-day response period is not part of the process. Option a is incorrect because rescission is an authority CMS holds at any time it determines the agency no longer meets the criteria for approving the waiver. Option b is incorrect because a rescinded waiver does not take effect immediately; the regulation allows 6 months from the rescission notice to meet the formerly waived requirement. Option c is incorrect because the regulation obliges an agency holding a waiver to report any event that changes the conditions on which the waiver was approved.

Correct Answer: Service, claim, and provider levels

Medicare remittance balancing requires every HIPAA compliant ASC X12 835 issued by a MAC to balance at the service, claim, and provider levels, in line with the version 5010 TR3 requirements. Option a is incorrect because the guidance lists no check level among balancing levels; it names service, claim, and provider levels, and check amount is a separate calculation. Option b is incorrect because payer is not a balancing level in the guidance, and this pairing omits the service and claim levels that the rule requires. Option d is incorrect because balancing is also required at the provider level, so a rule covering only service and claim levels leaves out one required level.

Correct Answer: Penalty applied

The Medicare manual defines adjustment as denied, zero payment, partial payment, reduced payment, penalty applied, additional payment, or supplemental payment. Penalty applied is therefore an adjustment reported on the remittance advice. Option a is incorrect because it is a notice sent to nonparticipating physicians and suppliers billing non-assigned claims, not an adjustment type in the definition. Option b is incorrect because it names rules regulating the liability an entity can accrue for non-covered services; it is not one of the listed adjustments. Option c is incorrect because it is the CMS-established paper format that mirrors the electronic remittance advice, so it describes a format and not an adjustment.

Correct Answer: Standard Paper Remittance

The Standard Paper Remittance (SPR) is the hard copy version of an ERA. CMS established it, and all MACs use it so the paper format mirrors the electronic remittance advice. Option a is incorrect because a duplicate is a repeat copy produced on request, in either paper or electronic form, rather than the format CMS established. Option b is incorrect because that standard governs the electronic version, which CMS requires exclusively for ERAs, so it does not describe a hard copy. Option d is incorrect because this is a notice sent to nonparticipating providers billing non-assigned claims, carrying a standard message about appeal rights, and not the CMS paper format.

Correct Answer: Appeal because no other party is available

A provider or supplier without an otherwise existing right to appeal may appeal when the beneficiary has died and no other party is available to appeal. The MAC makes that determination before proceeding. Option a is incorrect because the MAC must determine whether another party is available, for example by writing to the estate or asking the provider for written confirmation. Option b is incorrect because an estate that is available but does not want to appeal leads the MAC to dismiss the provider's request, because another party is available. Option c is incorrect because neither the contractor nor CMS is a party at the redetermination or reconsideration levels, so the MAC's status gives the provider no appeal right.

Correct Answer: Annotation with new option, signature and date

When a beneficiary changes his or her mind after signing, the notifier has the beneficiary annotate the original ABN. The annotation must clearly show the new option selection, the beneficiary's signature and the date of annotation. Option b is incorrect because the instructions direct the beneficiary to annotate the original ABN rather than replace it, so a fresh notice is not the required step. Option c is incorrect because witnesses are mentioned only for a beneficiary's refusal to sign or choose, where listing them is optional, not for a changed option. Option d is incorrect because the guidance asks for a clear indication of the new option with signature and date, and says nothing about the beneficiary explaining the reason.

Correct Answer: Routine foot care

Routine foot care is statutorily excluded from Medicare coverage, so an ABN is optional. CMS encourages issuing it as a courtesy that forewarns the beneficiary of impending financial obligation, without option boxes or signature. Option a is incorrect because Medicare denies an experimental item or service as not reasonable and necessary, and the beneficiary must be given an ABN. Option b is incorrect because custodial care is listed among the provisions that necessitate delivery of the ABN, so issuing the notice is mandatory there. Option c is incorrect because this violation of the prohibition on unsolicited telephone contacts is a listed provision requiring the ABN, not a courtesy use.

Correct Answer: DME MAC

Medicare guidance states that DME MACs have been given the responsibility of processing durable medical equipment, prosthetic, orthotic, and supply (DMEPOS) claims. They work under contracts for the non-provider Part B program. Option a is incorrect because it enrolls physicians and other practitioners and pays most Part B claims, but the guidance assigns prosthetic and orthotic supply claims to a different contractor. Option c is incorrect because it certifies to DHHS whether facilities meet conditions of participation, which is a certification function and not claims processing. Option d is incorrect because home health agencies bill this contractor and are paid by it, so its role centers on home health and hospice rather than supplies.

Correct Answer: Anesthesiology services

The exception applies to items or services other than the ancillary services described in the statute. Anesthesiology is one of those ancillary services, so notice and consent cannot remove the balance billing protection for it. Option b is incorrect because the statute's ancillary list names emergency medicine, anesthesiology, pathology, radiology and neonatology, and orthopedic surgery is absent from it, so the exception remains available. Option c is incorrect because dermatology does not appear among the listed ancillary services, so a provider who meets the notice and consent criteria may use the exception for it. Option d is incorrect because cardiology falls outside the ancillary categories the statute excludes from the exception, which means notice and consent can still permit balance billing for it.

Correct Answer: When the person knowingly receives or retains it

Under 42 CFR 401.305, a person has identified an overpayment when the person knowingly receives or retains it. The term "knowingly" takes its meaning from the False Claims Act definition, and the reporting and returning deadline starts from identification. Option a is incorrect because the 60-day period runs from the date of identification, so it follows identification and cannot be the event that defines it. Option b is incorrect because a cost report due date can affect the deadline for returning the overpayment, but it does not define when identification occurs. Option d is incorrect because the regulation ties identification to the person's own knowing receipt or retention, not to any notice or demand sent by a payer.

Correct Answer: Description of the sampling and extrapolation methodology

Under 42 CFR 401.305(d), a person who calculates an overpayment by statistical sampling must describe the statistically valid sampling and extrapolation methodology in the report submitted through the contractor's reporting process. Option a is incorrect because a settlement agreement results from the OIG or CMS disclosure protocols, which are an alternative way to meet reporting obligations, not a content item of the contractor report. Option c is incorrect because when a provider knows an outlier reconciliation will be performed, the regulation excuses it from estimating the change until the cost report is finally reconciled. Option d is incorrect because in Medicare guidance, receipt of the remittance advice starts the time limit for a beneficiary refund; it is not something the overpayment report must contain.