AAPC-CPB Certified Professional Biller - Set 4 - Part 3

Correct Answer: Summarize them in the proposed LCD

The Medicare manual's Consultation Summary provision requires the MAC to summarize opinions received from healthcare professional experts and professional societies before drafting, and to include that information in the proposed LCD. Option a is incorrect because the billing and coding article carries the codes removed from the LCD, not the summary of expert opinions gathered before drafting. Option b is incorrect because the consultation summary belongs in the proposed LCD; deferring to the Final LCD applies to CAC recommendations, which are a different item. Option c is incorrect because the Bibliography lists the articles and sources that led to the LCD, which differs from a summary of consultation opinions.

Correct Answer: The notifier

The ABN instructions state that at least two copies are made so the beneficiary and notifier each have one, and that the notifier should retain the original whenever possible. The retained ABN also documents the beneficiary's knowledge of potential liability. Option a is incorrect because an ordering provider may serve as notifier, but the instructions give retention to the notifier by role, not to the ordering provider as such. Option c is incorrect because contractors make validity judgments when reviewing ABN-related claims and investigate complaints, but the instructions do not assign them the task of keeping the original. Option d is incorrect because the beneficiary is given a copy of the notice, so that the notifier and the beneficiary each hold one.

Correct Answer: Issue an ABN to the beneficiary

When an advance coverage determination is mandatory under the Act, such as for a supplier the Secretary has listed for many denied claims, an ABN must be issued to the beneficiary prior to furnishing the item. Option a is incorrect because the NOMNC is tied to the end of hospice care when a beneficiary is discharged, so it does not fit this supplier situation. Option b is incorrect because waiting for a denial skips the required notice; the ABN must be issued before the item is furnished when the determination is mandatory. Option d is incorrect because public notices can support a refund waiver for non-enrolled suppliers, but where an advance determination is mandatory the guidance calls for an ABN, not signage.

Correct Answer: Correction of a minor clerical error

Minor errors or omissions in an initial determination may be corrected only through the contractor's reopening process. Clerical errors are processed as reopenings, and an appeal request involving one is transferred to the reopenings unit. Option a is incorrect because establishing a fee schedule is a matter of general applicability reserved to CMS or the contractor, so it is neither appealable nor routed to reopening. Option b is incorrect because a payment amount determination for a particular item or service on a claim is an initial determination, so it is appealable and does not default to reopening. Option c is incorrect because a claim submitted on an incomplete or invalid form and returned or rejected is not an initial determination, so no appeal or reopening applies.

Correct Answer: not routinely

The Medicare Claims Processing Manual states that MACs should not routinely find good cause when a provider, physician, or other supplier files late. Such requests warrant careful examination, unlike beneficiary requests, which receive more lenience. Option b is incorrect because this reverses the manual's stance, which states that provider requests to extend the filing period warrant careful examination instead of routine approval. Option c is incorrect because automatic findings are not described in Medicare guidance for suppliers; good cause applies only when the record shows or the supplier alleges specific qualifying conditions. Option d is incorrect because the manual does not direct a finding in every case; a provider's untimely request must meet a listed condition before good cause is found.

Correct Answer: Provides instruction on proper and timely completion

Under the Medicare manual on curing a defective appointment, handling depends on the party. When a provider, physician or other supplier attempts the appointment, the MAC provides instruction on proper and timely completion. Option a is incorrect because this step applies when evidence suggests a beneficiary-related appeal or appointment was not submitted at the beneficiary's request, not when a provider or supplier appoints. Option b is incorrect because a decision letter is not sent to an individual unless a valid appointment is executed, so a defective appointment does not trigger this. Option c is incorrect because that is the approach for a beneficiary attempting the appointment, which the manual treats differently from an appointment attempted by a provider or supplier.

Correct Answer: Receipt of the request in the proper contractor's corporate mailroom

For misfiled redetermination requests, the proper contractor jurisdiction must complete and mail the notice within 60 days of receiving the misfiled request in its corporate mailroom, so that receipt starts the period. Option a is incorrect because the guidance measures the 60 days from when the proper contractor receives the misfiled request, so the other contractor's forwarding action starts nothing. Option c is incorrect because that date marks the initial determination on a line-item appeal, a decision made before any appeal, so it cannot start a clock tied to receiving the request. Option d is incorrect because that date is used to judge whether the request was filed on time, while the processing standard for a misfiled request runs from the proper contractor's receipt.

Correct Answer: 60 calendar days

Parties to the redetermination may request QIC review of a dismissal they believe is incorrect. The QIC must receive the request within 60 calendar days after receipt of the notice of dismissal. Option b is incorrect because 5 calendar days is the period after the date of the dismissal notice at which receipt of the notice is presumed, not the deadline for requesting review. Option c is incorrect because 120 days is the filing period for a redetermination request, counted from receipt of the initial determination, and does not govern review of a dismissal. Option d is incorrect because 6 months is the window for asking the contractor itself to vacate its dismissal for good and sufficient cause, which is a different remedy from QIC review.

Correct Answer: Identity and qualifications

The Medicare manual entitles the parties to know the identity and qualifications of any consultant whose evidence the MAC used, so the MAC includes both in the file for the ALJ and for the appellant on request. Option a is incorrect because the complainant's name and the impetus behind an investigation are items the UPIC and MAC weigh carefully before filing, unrelated to consultant disclosure. Option b is incorrect because notes or transcripts of beneficiary interviews are fraud investigation material, where the MAC and UPIC use discretion about placing it in the case file. Option d is incorrect because the manual does not call for a consultant's fees or billing history; it requires who the consultant is and what credentials the consultant holds.

Correct Answer: Plain English with a conversational style

The Medicare manual requires MACs to write in plain English/plain language, with a clear, simple, conversational style and good communication of key points, so that beneficiaries can understand appeals correspondence. Option a is incorrect because general guidelines tell MACs to avoid abbreviations and jargon, and words like access are named as jargon consumers find hard. Option b is incorrect because the manual directs MACs to avoid all capitals because such letters look impersonal and computer generated to the reader. Option c is incorrect because statutory citations are to be explained in layman's terms and placed as a parenthetical at the end of the sentence, not used as the main style.