AAPC-CPB Certified Professional Biller - Set 4 - Part 2

Correct Answer: Whether recovery should be waived under §1870 of the Act

For appeals involving overpayments, the contractor reviews all aspects of the overpayment: its validity, whether the amount was correctly calculated and extrapolated, who is responsible, and whether recovery should be waived under §1870 of the Act. Option a is incorrect because resubmissions that do not revise the initial determination leave its appeal rights unchanged, and the guidance does not list resubmission among the overpayment review items. Option b is incorrect because the portal governs how a decision may be transmitted when the request arrived electronically, and it is not an aspect of the overpayment that the contractor reviews. Option c is incorrect because an appointed representative affects where the decision letter is mailed, which concerns communication of the decision and not the substance of the overpayment review.

Correct Answer: Given during an emergency

Under the written notice standards, a notice is not acceptable evidence of knowledge if it is given during any emergency or while the beneficiary is under great duress. Delivery during an emergency disqualifies this notice. Option b is incorrect because this disqualifier concerns timing before the service is furnished, and the scenario gives no indication that the notice was delivered that far in advance. Option c is incorrect because this defect applies to a notice handed to every beneficiary the notifier serves, but this notice was tied to one specific service for one beneficiary. Option d is incorrect because this defect describes a notice saying only that Medicare may not pay, whereas this notice stated Medicare would deny the service and named it.

Correct Answer: No, because it is routinely given to all beneficiaries

Under the written notice standards, a notice routinely given to all beneficiaries for whom the notifier furnishes items or services is not acceptable evidence of knowledge. The form also only states a possibility of nonpayment, which is another listed defect. Option a is incorrect because a written format is only a starting point, and a notice given in writing still fails when it falls under a listed exclusion. Option c is incorrect because timing alone does not make a notice acceptable; a notice must also avoid defects such as routine distribution and vague wording about possible nonpayment. Option d is incorrect because the provider or supplier is expected to issue the notice and is responsible for delivery, so contractor delivery is not required.

Correct Answer: Repayment with appropriate explanation

OIG guidance says a response can be as straightforward as generating a repayment with appropriate explanation to Medicare or the payer that made the overpayment. The action is taken as soon as possible after the problem is identified. Option b is incorrect because OIG guidance states there is no boilerplate solution for handling identified problems, so the specific action depends on the circumstances of the situation. Option c is incorrect because OIG guidance says preserving information about identifying the problem matters as much as preserving information on the practice's reaction and solution. Option d is incorrect because OIG guidance calls an appropriate response one of the most important components of an audit protocol, to be taken as soon as possible after identification.

Correct Answer: To establish beneficiary knowledge of non-coverage and shift financial liability

Under Section 1879 of the Act, the ABN is a way for providers and suppliers to establish beneficiary knowledge of non-coverage, so financial liability can shift to the beneficiary if Medicare denies the claim. Option a is incorrect because a medical screening examination belongs to EMTALA obligations, and Medicare guidance says written notice should wait until the hospital has met them. Option b is incorrect because competitive bidding appears only as a setting where a noncontract supplier may optionally use the ABN; the notice does not confirm enrollment in anything. Option d is incorrect because technical benefit requirements, such as required certification, are mostly a case where an ABN is not required, so the notice does not certify them.

Correct Answer: I and II

The ABN must be delivered for custodial care and for a hospice patient who is not terminally ill, both listed provisions requiring its use. Statutorily excluded care is optional, and Medicare Advantage services are outside ABN scope. Option b is incorrect because care statutorily excluded from coverage is not required to be covered by an ABN, although CMS strongly encourages issuing one, so statement III is optional. Option c is incorrect because the ABN is not used for items or services provided under the Medicare Advantage Program, and excluded care falls under optional use, so two statements fail. Option d is incorrect because it includes statement IV, yet Medicare Advantage services are outside the ABN's scope, which covers beneficiaries in the Medicare FFS program.

Correct Answer: Financial liability for non-covered care

Under the effective ABN delivery rules, a notifier who refuses to answer questions or refer the beneficiary to 1-800-MEDICARE has made a defective delivery, and the notifier is held financially liable for the non-covered care. Option a is incorrect because liability stays with the notifier when delivery is defective, so the beneficiary is not held responsible for the non-covered care. Option b is incorrect because exclusion and civil money penalties are tied to knowing and willful failure to make a required refund, not to defective delivery of an ABN. Option d is incorrect because a new ABN after one year relates to repetitive or continuous non-covered care, and it does not cure a defective delivery.

Correct Answer: Block-shaded text

The Medicare manual's contrast standard calls for dark ink on a pale background and states that reversed print and block-shaded (highlighted) text should not be used, so the highlighting is the deficiency. Option b is incorrect because attachments are permitted for additional items and services, provided they allow clear matching of items with reason and cost estimate information. Option c is incorrect because the manual calls for exactly this visually high-contrast combination, so it is the recommended practice rather than a deficiency. Option d is incorrect because the ABN is designed as a letter-sized form, yet the manual allows expansion to legal size if necessary.

Correct Answer: Give the billing entity a copy of the signed ABN

When the notifier that gives an ABN is not the entity that ultimately bills Medicare, such as a physician who draws a specimen for a laboratory, the notifier should give a copy of the signed ABN to the billing entity. Option a is incorrect because the notifier is directed to retain the ABN on file in case anyone questions whether the beneficiary knew of the potential financial liability. Option b is incorrect because retention is measured from discharge or completion of delivery of care when no other requirements apply under State law, not from claim payment. Option d is incorrect because annotation is described for a beneficiary who changes his or her mind or refuses to sign or choose an option, not for identifying who bills.

Correct Answer: The cost-sharing requirement

Under the federal rule on non-emergency services by nonparticipating providers at participating facilities, the provider may not bill or hold the enrollee liable for more than the cost-sharing requirement for the item or service. Option b is incorrect because the statute bars billing the enrollee any amount above the cost-sharing requirement, and it names no ceiling tied to what the provider chooses to charge. Option c is incorrect because that is the very balance billing the provision prohibits, because a remainder beyond the cost-sharing requirement cannot be billed to the enrollee or held against the enrollee. Option d is incorrect because ancillary services appear in the statute only in the exception provision, and the statute adds no fee on top of the cost-sharing ceiling.

Correct Answer: The cost-sharing limit on billing the enrollee no longer applies to that item or service.

When a nonparticipating provider meets the notice and consent criteria, the statute provides that the general prohibition in subsection (a) does not apply, so the limit of billing no more than the cost-sharing requirement is lifted. Option a is incorrect because the exception only lifts the billing prohibition for that service; the provider remains a nonparticipating provider, and nothing in the statute alters network status. Option b is incorrect because the exception concerns non-emergency items and services; emergency services fall under a separate section, and giving notice and consent does not change a service's category. Option c is incorrect because ancillary services, such as anesthesiology, pathology, radiology and neonatology, are carved out of the exception, so notice and consent cannot be used to reach them.

Correct Answer: It helps the practice if questioned about its compliance activities

OIG guidance notes that having all relevant documentation of compliance efforts, or of how a particular problem was handled, can benefit the practice should it ever be questioned regarding those activities, even though retention is not required. Option b is incorrect because internal audit results are themselves among the compliance documents a practice would retain, so records are kept alongside audits and do not substitute for them. Option c is incorrect because safe harbors concern the structure of arrangements such as personal services contracts, and have no connection to the retention of compliance records. Option d is incorrect because OIG guidance states there is no requirement that a practice retain its compliance records, so retention is a benefit, not a mandate.

Correct Answer: Payment of fair market value by referral sources

OIG guidance states that payment of fair market value by referral sources for compliance services will generally address anti-kickback and Stark self-referral concerns when a sponsoring entity performs services such as claims review. Option a is incorrect because keeping audit results is a records practice for compliance documents, and OIG guidance does not present it as the answer to referral-source arrangements. Option b is incorrect because examining denial history is a way to find coding and billing risk areas, not a step that resolves anti-kickback or self-referral concerns. Option d is incorrect because training and education is an area where collaboration is encouraged, but the guidance names fair market value payment, not participation, as the remedy for the stated concerns.

Correct Answer: Whether another entity's policies are adopted without changes

OIG guidance says the ongoing evaluation checks that standards and procedures are current, that individuals meet their responsibilities, and that claims are submitted appropriately. Using another entity's policies is a template option, not an evaluation focus. Option a is incorrect because OIG guidance names this as part of the ongoing evaluation, which checks that the practice's written standards and procedures remain up to date. Option b is incorrect because appropriate claim submission is expressly listed by OIG guidance as a measure of whether the program works, so it belongs to this evaluation. Option c is incorrect because the evaluation also asks whether the compliance program is working, and that includes how well staff perform the duties assigned to them.

Correct Answer: About eight to ten words per sentence

Medicare plain-language guidance tells MACs to keep sentences simple and direct, with most sentences reasonably short, about eight to ten words each. Short sentences keep the main point from getting lost. Option a is incorrect because when sentences run long, the main point gets lost in all the words, so the guidance steers away from them. Option c is incorrect because the guidance advises avoiding one sentence paragraphs where possible, so this choice would work against the recommended formatting. Option d is incorrect because the guidance tells writers to vary the length of their sentences rather than hold them to one uniform size.

Correct Answer: Modifier "-24"

Modifier "-24" reports an unrelated evaluation and management service by the same physician during a postoperative period. It is added to the appropriate level of service, and documentation must establish that the visit was unrelated to the surgery. Option a is incorrect because it reports an unrelated procedure by the same physician during a postoperative period, not an evaluation and management service. Option b is incorrect because it was established for staged or related surgical procedures done during the postoperative period of the first procedure. Option c is incorrect because it is used for a return trip to the operating room for a related procedure during the postoperative period.

Correct Answer: Narrative on scientific evidence for clinical indications

Under the Evidentiary Content requirement, the MAC must summarize supporting evidence in every proposed and final LCD. The minimum includes a narrative describing the scientific evidence supporting the clinical indications for the item or service. Option b is incorrect because meeting attendance details concern the CAC and open meeting logistics, which are separate from the evidentiary content required in the LCD. Option c is incorrect because those instructions belong on the MAC web site under the LCD Reconsideration Process label, not in the evidence summary. Option d is incorrect because codes are removed from LCDs and placed in billing and coding articles or Policy Articles published to the MCD instead.

Correct Answer: §1862(a)(1), the "not reasonable and necessary" exclusion

NCD non-coverage decisions are generally based on §1862(a)(1) of the Act, the "not reasonable and necessary" exclusion, unless another authority for denial is indicated. Limits tied to specified indications or circumstances also rest on it. Option a is incorrect because describes who makes the coverage decision when an item is not mentioned or not explicitly excluded; it is a decision-maker's discretion, not a statutory basis for NCD denials. Option b is incorrect because is one of the other manuals where coverage-related instructions may be found, and it must stay consistent with the NCD Manual, but it is not a statute. Option c is incorrect because is a manual in the system listed as containing coverage-related instructions that must be consistent with the NCD Manual, not the statutory authority for NCD non-coverage decisions.

Correct Answer: In writing to the MAC

The Medicare manual allows interested parties to present information at the open meeting, but states that all formal comments must be submitted in writing to the MAC. Presentations do not replace written comments. Option a is incorrect because the BFL is contacted by MACs about matters such as comment period extensions; formal comments go to the MAC, not CMS. Option b is incorrect because interested parties may present information at the open meeting, but the manual states formal comments are not accepted that way and must be written. Option d is incorrect because CAC members may attend open meetings, but the CAC is a separate body and is not the channel the manual designates for formal comments.

Correct Answer: AMA Manual of Style

MACs list all articles and sources that led to the LCD in the Bibliography, and the citations must be consistent with the American Medical Association (AMA) Manual of Style. Option b is incorrect because the FDA clearance to market is a hyperlink MACs may supply for regulated items or services, not a citation style for bibliography entries. Option c is incorrect because grouping by type of evidence is an optional way to organize the evidence summary, and it does not govern how bibliography citations are written. Option d is incorrect because HIPAA Privacy Rule requirements apply to reporting Medicare data in aggregate form within the evidence summary, not to citing articles.