CCSP Domain's 5 & 6
test fully solved &
updated 2024
The patient is seen at Wolf Place Physician Practice. The total
charge for the visit is $250.00. The physician is a participating (PAR)
physician and the patient has met the deductible for 20XX. The
Medicare fee schedule amount for the E/M code is $200.00. What is
the amount that the federal government will reimburse the
physician?
a.) $250.00
b.) $200.00
c.) $190.00
d.) $160.00
d.) $160.00
CMS will reimburse the physician for 80 percent of the Medicare Fee
Schedule Amount, which is $200.00. $200.00 × .80 = $160.00. The
Medicare beneficiary is responsible for the remaining 20 percent
(Casto and White 2021, 125-126).
What is a claim called that contains all required data elements
needed to process and pay the claim quickly?
a.) Open
b.) Clean
c.) Closed
d.) Final
b.) Clean
The goal in claims submittal is to submit each claim as a clean
claim, which means it contains all of the required and accurate
information. A clean claim is essential in order to receive timely and
accurate reimbursement (Huey 2021, 382-383).
The clinical documentation integrity (CDI) performance measure
that indicates the number of times a physician responds to a CDI
,intervention divided by the number of CDI interventions issued is
the:
a.) Physician response time rate
b.) Physician agreement with CDI specialist rate
c.) Physician response to CDI specialist rate
d.) Physician clarification rate
c.) Physician response to CDI specialist rate
The physician response rate is how long it takes for a physician to
respond to a CDI query.
The physician clarification rate is the number of clarifications placed
by a CDI intervention that had an impact on the code
and the physician agreement with CDI specialist rate is the number
of times a physician agrees with a CDI intervention divided by the
number of CDI interventions issued (Casto and White 2021, 195).
In RBRVS, this is an across-the-board national multiplier that is
determined by CMS each year. It is the dollar amount that converts
the relative value units into a payment amount:
a.) Geographic practice cost indices
b.) Pass-through payment
c.) Payment indicator
d.) Conversion factor
d.) Conversion factor
The conversion factor is an across-the-board multiplier that is
determined each year. It transforms the total of the RVUs into a
payment amount (Casto and White 2021, 123).
Dr. Emerson's claim for patient John Doe, age 55, was denied by the
insurance company. The final diagnosis code was I05.9, Rheumatic
mitral valve disease, unspecified, and the service performed was
33206, Insertion of new or replacement of permanent pacemaker
with transvenous electrode(s); atrial. This was a replacement of a
pacemaker that was inserted two years ago. The most probably
cause of the denial is:
a.) Pacemaker placement is prohibited with the patient's age.
b.) Medical necessity was not shown by the diagnosis.
c.) An additional CPT code should be used to show the insertion of
the lead into the atria.
d.) There must be a five-year time period between pacemaker
insertions or replacements.
,b.) Medical necessity was not shown by the diagnosis
The diagnosis code does not prove medical necessity for placement
of a pacemaker.
No additional CPT codes are needed as the insertion of the electrode
is included in 33206 (Handlon 2020, 247).
A measure that assesses the ability to comply with documentation,
coding, and billing requirements is the:
a.) Denial rate
b.) Clean claim rate
c.) PEPPER rate
d.) Capture rate
a.) Denial Rate
The denial rate is the measure that assesses the ability to comply
with documentation, coding, and billing requirements.
The PEPPER metric is used to identify billing patterns different from
the majority of other providers in the nation.
The capture rate is the metric used to identify coding of secondary
diagnoses.
The clean claim rate assesses the ability to comply with billing edits
(Casto and White 2021, 187).
Medicare's allowed fee for an in-office procedure is $200. Dr. Smith
is a PAR physician, and Dr. Jones is a nonPAR physician who does not
accept assignment. How much will Dr. Smith and Dr. Jones,
respectively, receive from CMS?
a.) $160, $152
b.) $200, $152
c.) $160, $0
d.) $200, $0
c.) $160, $0
Dr. Smith receives 80 percent of the Medicare allowed amount,
which is $160. Dr. Jones receives nothing from CMS because he does
not accept assignment. The patient receives the benefits (Huey
2021, 371).
In calculating the fee for a provider's service, each of the three
relative value units is multiplied by the:
, a.) National conversion factor
b.) Geographic practice cost indices
c.) Per diem amount set by CMS
d.) Usual and customary fees for the HCPCS code
b.) Geographic practice cost indices (GPCIs)
Each of the three RVUs is adjusted through the GPCIs to adjust for
costs in different areas of the country.
The national conversion factor is an across-the-board multiplier that
converts the RVUs into a dollar amount.
A per diem concept is not used in RBRVS.
Usual and customary fees are no longer used (Casto and White
2021, 122-124).
The physician has ordered an esophagogastroduodenoscopy (43235)
for his patient. Which of the following ICD-10-CM codes would most
likely justify the medical necessity of the examination?
a.) K28.3, Acute gastrojejunal ulcer without hemorrhage or
perforation
b.) K26.3, Acute duodenal ulcer without hemorrhage or perforation
c.) K63.5, Polyp of colon
d.) J02.9, Acute pharyngitis, unspecified
b.) K26.3, Acute duodenal ulcer without hemorrhage or perforation
An EGD is not advanced to the jejunum.
Colonic polyps would be found on a colonoscopy and
pharyngitis would not require an EGD to diagnose.
However, an EGD would be used to diagnose and treat duodenal
ulcers (AMA 2023, 342).
Which of the following is used to determine Medicare coverage by a
Medicare Administrative Contractor, rather than nationwide, basis
and assist providers with correct billing and claims processing?
a.) National Coverage Determinations
b.) Local Coverage Determinations
c.) Program Transmittals
d.) Correct Coding Initiative
test fully solved &
updated 2024
The patient is seen at Wolf Place Physician Practice. The total
charge for the visit is $250.00. The physician is a participating (PAR)
physician and the patient has met the deductible for 20XX. The
Medicare fee schedule amount for the E/M code is $200.00. What is
the amount that the federal government will reimburse the
physician?
a.) $250.00
b.) $200.00
c.) $190.00
d.) $160.00
d.) $160.00
CMS will reimburse the physician for 80 percent of the Medicare Fee
Schedule Amount, which is $200.00. $200.00 × .80 = $160.00. The
Medicare beneficiary is responsible for the remaining 20 percent
(Casto and White 2021, 125-126).
What is a claim called that contains all required data elements
needed to process and pay the claim quickly?
a.) Open
b.) Clean
c.) Closed
d.) Final
b.) Clean
The goal in claims submittal is to submit each claim as a clean
claim, which means it contains all of the required and accurate
information. A clean claim is essential in order to receive timely and
accurate reimbursement (Huey 2021, 382-383).
The clinical documentation integrity (CDI) performance measure
that indicates the number of times a physician responds to a CDI
,intervention divided by the number of CDI interventions issued is
the:
a.) Physician response time rate
b.) Physician agreement with CDI specialist rate
c.) Physician response to CDI specialist rate
d.) Physician clarification rate
c.) Physician response to CDI specialist rate
The physician response rate is how long it takes for a physician to
respond to a CDI query.
The physician clarification rate is the number of clarifications placed
by a CDI intervention that had an impact on the code
and the physician agreement with CDI specialist rate is the number
of times a physician agrees with a CDI intervention divided by the
number of CDI interventions issued (Casto and White 2021, 195).
In RBRVS, this is an across-the-board national multiplier that is
determined by CMS each year. It is the dollar amount that converts
the relative value units into a payment amount:
a.) Geographic practice cost indices
b.) Pass-through payment
c.) Payment indicator
d.) Conversion factor
d.) Conversion factor
The conversion factor is an across-the-board multiplier that is
determined each year. It transforms the total of the RVUs into a
payment amount (Casto and White 2021, 123).
Dr. Emerson's claim for patient John Doe, age 55, was denied by the
insurance company. The final diagnosis code was I05.9, Rheumatic
mitral valve disease, unspecified, and the service performed was
33206, Insertion of new or replacement of permanent pacemaker
with transvenous electrode(s); atrial. This was a replacement of a
pacemaker that was inserted two years ago. The most probably
cause of the denial is:
a.) Pacemaker placement is prohibited with the patient's age.
b.) Medical necessity was not shown by the diagnosis.
c.) An additional CPT code should be used to show the insertion of
the lead into the atria.
d.) There must be a five-year time period between pacemaker
insertions or replacements.
,b.) Medical necessity was not shown by the diagnosis
The diagnosis code does not prove medical necessity for placement
of a pacemaker.
No additional CPT codes are needed as the insertion of the electrode
is included in 33206 (Handlon 2020, 247).
A measure that assesses the ability to comply with documentation,
coding, and billing requirements is the:
a.) Denial rate
b.) Clean claim rate
c.) PEPPER rate
d.) Capture rate
a.) Denial Rate
The denial rate is the measure that assesses the ability to comply
with documentation, coding, and billing requirements.
The PEPPER metric is used to identify billing patterns different from
the majority of other providers in the nation.
The capture rate is the metric used to identify coding of secondary
diagnoses.
The clean claim rate assesses the ability to comply with billing edits
(Casto and White 2021, 187).
Medicare's allowed fee for an in-office procedure is $200. Dr. Smith
is a PAR physician, and Dr. Jones is a nonPAR physician who does not
accept assignment. How much will Dr. Smith and Dr. Jones,
respectively, receive from CMS?
a.) $160, $152
b.) $200, $152
c.) $160, $0
d.) $200, $0
c.) $160, $0
Dr. Smith receives 80 percent of the Medicare allowed amount,
which is $160. Dr. Jones receives nothing from CMS because he does
not accept assignment. The patient receives the benefits (Huey
2021, 371).
In calculating the fee for a provider's service, each of the three
relative value units is multiplied by the:
, a.) National conversion factor
b.) Geographic practice cost indices
c.) Per diem amount set by CMS
d.) Usual and customary fees for the HCPCS code
b.) Geographic practice cost indices (GPCIs)
Each of the three RVUs is adjusted through the GPCIs to adjust for
costs in different areas of the country.
The national conversion factor is an across-the-board multiplier that
converts the RVUs into a dollar amount.
A per diem concept is not used in RBRVS.
Usual and customary fees are no longer used (Casto and White
2021, 122-124).
The physician has ordered an esophagogastroduodenoscopy (43235)
for his patient. Which of the following ICD-10-CM codes would most
likely justify the medical necessity of the examination?
a.) K28.3, Acute gastrojejunal ulcer without hemorrhage or
perforation
b.) K26.3, Acute duodenal ulcer without hemorrhage or perforation
c.) K63.5, Polyp of colon
d.) J02.9, Acute pharyngitis, unspecified
b.) K26.3, Acute duodenal ulcer without hemorrhage or perforation
An EGD is not advanced to the jejunum.
Colonic polyps would be found on a colonoscopy and
pharyngitis would not require an EGD to diagnose.
However, an EGD would be used to diagnose and treat duodenal
ulcers (AMA 2023, 342).
Which of the following is used to determine Medicare coverage by a
Medicare Administrative Contractor, rather than nationwide, basis
and assist providers with correct billing and claims processing?
a.) National Coverage Determinations
b.) Local Coverage Determinations
c.) Program Transmittals
d.) Correct Coding Initiative
