AAPC-CPPM Certified Physician Practice Manager - Set 3 - Part 1

Correct Answer: Items or services the physician furnishes, orders, or prescribes are not paid

Under the Exclusion Statute, when OIG excludes a physician, Medicare, Medicaid, and other Federal health care programs will not pay for items or services the physician furnishes, orders, or prescribes. Option a is incorrect because an order or prescription given to a private-pay patient is still not reimbursable by any Federal health care program once the physician is excluded. Option c is incorrect because the exclusion bars billing directly and also indirectly through an employer or a group practice, so a group practice claim does not restore payment. Option d is incorrect because the exclusion also reaches items or services the physician orders or prescribes, not just those furnished personally, so the restriction is broader than this.

Correct Answer: It is not appealable because the law bars review of those components

Section 1848(i)(1) of the Act prohibits administrative and judicial review of the individual components used to compute Medicare physician fee schedule payment amounts, so this is not an initial determination. A payment amount for a particular service on a claim remains appealable. Option b is incorrect because appointment of a representative concerns who may act for a beneficiary, and it does not make a non-appealable computation issue reviewable. Option c is incorrect because redetermination is available only for initial determinations, and the individual fee schedule components are listed among actions that are not initial determinations. Option d is incorrect because reconsideration by a QIC follows redetermination and cannot create appeal rights for an issue that is not an initial determination to begin with.

Correct Answer: Mandated Medigap transfer

Medicare guidance calls a claim in which the beneficiary assigns Medigap benefits to a participating physician, practitioner or supplier a "mandated Medigap transfer." Participating status means an agreement to accept assignment for all Medicare patients. Option a is incorrect because the claim-based crossover is the process that moves claim data to the Medigap insurer, and the guidance does not describe any exemption by that name. Option c is incorrect because policies offered by an employer to employees or former employees are explicitly excluded by law from the Medigap definition, so such a transfer is not described. Option d is incorrect because Medigap assignment and transfer policy does not apply to nonparticipating physicians, so no waiver of that kind exists in the guidance.

Correct Answer: Immediate finding of supplier liability

Medicare guidance states that protection under the financial liability provisions generally cannot be afforded after a formal finding of fraud or abuse. Such a finding results in an immediate finding of liability for the provider or supplier. Option a is incorrect because the beneficiary is held liable only when knowledge is shown, such as through a valid ABN, and a fraud or abuse finding does not shift liability that way. Option b is incorrect because the guidance describes no split of liability; when both parties have knowledge the beneficiary is held liable, and a fraud finding leads to supplier liability. Option d is incorrect because program payment applies when neither the beneficiary nor the provider or supplier knew or could have known, which a formal fraud or abuse finding contradicts.

Correct Answer: I and III

Under the Limitation on Liability provisions, a beneficiary who knew or should have known, as shown by a valid ABN and consent, is responsible for payment. If neither party knew, Medicare pays the assigned claim. Option a is incorrect because statement II reverses the rule; when the beneficiary and the provider or supplier are both found to have knowledge, the beneficiary is held liable. Option c is incorrect because both statements fail: the beneficiary, not the provider, is liable when both had knowledge, and a favorably paid claim undermines the earlier ABN as evidence. Option d is incorrect because adding statement IV is wrong, since a valid ABN followed by a covered payment determination cannot serve as proof of knowledge for similar future claims.

Correct Answer: The enrolled healthcare provider or supplier

The ABN is a written notice issued by healthcare providers and suppliers for Part B items and services. Apart from DME suppliers, only those enrolled in Medicare can issue it to fee-for-service beneficiaries. Option a is incorrect because the ABN is not used for items or services under the Medicare Advantage Program, so a plan has no role in issuing it. Option b is incorrect because the ABN does not apply to prescription drugs under the Medicare Prescription Drug Program, so that plan does not issue it here. Option c is incorrect because the contractor is the body that may hold a notifier financially liable for missing or defective notice; it does not issue the ABN to the beneficiary.

Correct Answer: As a courtesy forewarning of financial obligation

Routine foot care is explicitly excluded under the Social Security Act, so an ABN is optional. When issued, it serves as a courtesy to the beneficiary, forewarning of impending financial obligation. Option b is incorrect because option boxes and signatures are not requested when the ABN is used for never-covered care; the guidance says the beneficiary should not be asked. Option c is incorrect because mandatory delivery applies to denials such as care not reasonable and necessary, and excluded care like routine foot care falls outside those provisions. Option d is incorrect because CMS guidance relieves the provider or supplier from adhering to the issuance guidelines when the ABN is given for statutorily excluded care.

Correct Answer: Funds collected under a signed ABN must still be refunded

When the beneficiary signs an ABN agreeing to accept responsibility for payment before services are delivered, the physician may retain the collected funds. A refund requirement for those funds is therefore not part of the physicians' services RR. Option a is incorrect because when payment is reduced rather than fully denied, Medicare policy has the physician refund whatever was collected beyond the Medicare payment for the less extensive service. Option c is incorrect because the physicians' services RR provision states that it covers both participating and non-participating physicians, so this is a genuine feature of the requirement. Option d is incorrect because Medicare policy excuses the refund when the physician did not know and could not reasonably be expected to know the service would not be paid as reasonable and necessary.

Correct Answer: National Committee on Vital and Health Statistics

In assisting the Secretary, the HIPAA statute directs reliance on recommendations of the National Committee on Vital and Health Statistics. The Secretary must also publish those recommendations in the Federal Register and consult other agencies and organizations. Option b is incorrect because it is one of the organizations the Secretary must consult before a standard is adopted, not the body whose recommendations the Secretary relies on. Option c is incorrect because the statute lists it among the consulted organizations, so it has a consultation role rather than the advisory role of recommending standards. Option d is incorrect because it appears in the consultation list alongside other groups; the statute does not make its recommendations the basis for the Secretary's adoption of a standard.

Correct Answer: Whether a personnel surplus or shortage exists

The HR demand forecast gives the number of people needed, and the internal supply forecast gives the number of current employees available. Examining both lets HR professionals determine whether the company faces a personnel surplus or shortage. Option a is incorrect because that information comes from the job analysis, which studies the tasks of a job and feeds the job description and specification, not from comparing forecasts. Option b is incorrect because task and responsibility lists come from the job analysis; the two forecasts address headcount needed and headcount available, not job content. Option d is incorrect because the internal labor market is the pool of a firm's own employees used first to fill a vacancy; it is a recruiting source, not a forecast result.

Correct Answer: Personally provide at least one treatment session and sign the progress report

When incident-to services are furnished by personnel who are not therapists, the ordering or supervising physician/NPP must personally provide at least one treatment session during each progress report period and sign the progress report. Option b is incorrect because recertification is tied to a revised plan of care accompanying a progress report, not to each session, so this misstates the requirement. Option c is incorrect because weekly or daily reports are left to clinician discretion; clinicians are encouraged, not required, to report more often than the minimum. Option d is incorrect because the discharge note is a progress report covering the last reporting period to discharge, and signing it alone does not meet the per-period participation duty.

Correct Answer: Provider request examined carefully; beneficiary given more lenience

Providers, physicians and suppliers are expected to file on time, so their extension requests warrant careful examination and are not routinely granted. For a beneficiary request, more lenience should be given. Option a is incorrect because the guidance expressly distinguishes the two groups, expecting providers to file timely and calling for more lenience toward beneficiaries, so the standards are not identical. Option b is incorrect because the guidance reverses this: extension requests from providers, physicians or suppliers should not be routinely granted, while beneficiaries receive more lenience. Option d is incorrect because the MAC must resolve good cause before taking any other action on a late-filed appeal, so dismissal without a finding is not directed.

Correct Answer: De novo review

De novo means "anew" or "afresh." Adjudicators at each level of appeal make a new, independent and thorough evaluation of the claim and are not bound by the prior adjudicator's findings or decision. Option a is incorrect because that term refers to a Social Security Act provision giving financial relief to beneficiaries, providers and suppliers, not to how adjudicators evaluate claims. Option b is incorrect because effectuation is a contractor responsibility for carrying out decisions made by the QIC; it does not describe the evaluation standard applied at each appeal level. Option c is incorrect because adjudicators are not bound by the findings of a prior determination or decision, so they do not defer to earlier adjudicators' conclusions.

Correct Answer: 60 days after the overpayment was identified

Section 1128J(d)(2) requires an overpayment to be reported and returned by the later of 60 days after identification or the due date of any corresponding cost report. With no cost report, the 60-day date controls. Option a is incorrect because the statute gives no fixed calendar date; the period runs from identification, so a year-end deadline has no basis in the statute. Option c is incorrect because the statute ties the deadline to identification of the overpayment or a due cost report, and an audit start date plays no part. Option d is incorrect because the statute measures the deadline from the date the overpayment was identified, not from the original payment date, and it sets a 60-day period.

Correct Answer: Improper inducements, kickbacks and self-referrals

OIG guidance treats improper inducements, kickbacks and self-referrals as a separate risk area for physician practices, not as one of the bulleted coding and billing risk areas that draw frequent investigations and audits. Option b is incorrect because the OIG names this first among the billing risk areas that have been frequent subjects of its investigations and audits. Option c is incorrect because this appears in the OIG's bulleted list of billing risk areas, so it belongs to the set the stem describes. Option d is incorrect because the OIG lists this as a billing risk area; it arises when the same item or service is billed more than once.

Correct Answer: The number carries no information about the provider

Under 45 CFR 162.406(a), the NPI is a numeric identifier with a check digit and no intelligence about the health care provider, meaning the number itself conveys no information about the provider it identifies. Option a is incorrect because the regulation sets the NPI as the standard unique health identifier for health care providers and permits use for any other lawful purpose, so it is not limited to Medicare. Option b is incorrect because the standard calls the NPI a 10-position numeric identifier, so alphabetic characters contradict the excerpt, and length is a different feature from intelligence. Option c is incorrect because the check digit in the 10th position is a separate feature named in the same sentence, not what the phrase about intelligence describes.

Correct Answer: Within 30 days of the change

Under the implementation specifications for health care providers, a covered health care provider must communicate to the NPS any changes in its required data elements within 30 days of the change. Option b is incorrect because a request from an entity governs disclosure of the NPI in a standard transaction, which is a separate duty from reporting data changes to the NPS. Option c is incorrect because updates to NPS data are not held until an enrollment application; the standard gives a specific deadline running from the date of the change. Option d is incorrect because the standard sets a fixed period measured from the change itself, not a trigger tied to the next claim the practice sends.

Correct Answer: 1 calendar year

The Medicare time limits regulation requires a claim to be filed no later than the close of the period ending 1 calendar year after the date of service, subject to the listed exceptions. Option a is incorrect because the regulation sets a longer period than half a year; a claim filed after six months but within the regulatory period is still timely. Option b is incorrect because a two-year window is not the general rule; the regulation closes the period one calendar year after service, apart from the stated exceptions. Option d is incorrect because a 90-day window is much shorter than the period the regulation allows, which runs to the close of one calendar year.

Correct Answer: No appeal rights

Claim submissions that are incomplete, invalid, or do not meet Medicare claim requirements and are returned or rejected are listed as actions that are not initial determinations, so no appeal rights attach to them. Option a is incorrect because claim submissions that are incomplete, invalid, or fail Medicare claim requirements are listed among actions that are not initial determinations, so this path is unavailable. Option b is incorrect because reopening is the route for minor errors or omissions in an initial determination, and a rejected claim is not an initial determination at all. Option c is incorrect because the duplicate-service note applies only when a supplier disputes whether a service was truly a duplicate, which is a different issue from an invalid claim format.

Correct Answer: Specific written beneficiary authorization

The Medicare manual permits providers, physicians/practitioners and suppliers to furnish certain limited eligibility and claims information to other payers for complementary insurance purposes, subject to specific written beneficiary authorization. Option b is incorrect because the guidance says that identifying a complementary insurer on a title XVIII billing form does not by itself constitute a request for release. Option c is incorrect because the guidance allows providers to furnish only certain limited information about eligibility status and related claims, so unlimited release goes beyond what is permitted. Option d is incorrect because the manual requires the request for the information to be specific, so a broad, nonspecific request does not satisfy the guidance.