Adult-Gerontology Primary Care Nurse Practitioner Exam Regulatory Frameworks & Compliance 5 — Questions and Answers
Question 1: A 66-year-old patient newly eligible for Medicare asks about the late enrollment penalty for Part B. She delayed enrollment for 2 years after becoming eligible because she was covered by her spouse's employer plan. Will she owe a penalty?
- Yes, any delay beyond 3 months after turning 65 results in a permanent penalty
- No, creditable coverage through a spouse's active employer plan qualifies as a Special Enrollment Period exception (Correct answer)
- No penalty applies to anyone who enrolls within the first year after Medicare eligibility
- Yes, she will owe a 10% premium penalty for each full 12-month period she was without Medicare Part B
Correct answer: No, creditable coverage through a spouse's active employer plan qualifies as a Special Enrollment Period exception
Coverage through a spouse's active employer group health plan is creditable coverage, so the individual qualifies for a Special Enrollment Period and avoids the Part B late enrollment penalty.
Question 2: During a medication review, an AGPCNP discovers a 77-year-old patient has been receiving duplicate prescriptions for oxycodone from two different providers. Which immediate regulatory action is most appropriate?
- Continue prescribing without interruption while scheduling a patient education session
- Document the finding, address the patient directly about the duplicate prescriptions, and notify the other prescriber if appropriate, consistent with PDMP obligations and DEA regulations (Correct answer)
- Report the patient to the DEA for drug diversion without first discussing with the patient
- Discharge the patient from the practice immediately to avoid liability
Correct answer: Document the finding, address the patient directly about the duplicate prescriptions, and notify the other prescriber if appropriate, consistent with PDMP obligations and DEA regulations
The NP should document the discrepancy, engage the patient in a non-punitive conversation, and coordinate with the other prescriber to prevent concurrent opioid prescribing per PDMP obligations and safe prescribing guidelines.
Question 3: An AGPCNP employed by a federally qualified health center (FQHC) wants to understand how FQHCs are reimbursed by Medicare. Which reimbursement model applies?
- FQHCs are paid the same fee-for-service rates as private practices
- FQHCs receive a prospective payment system rate (PPS) per encounter that bundles most primary care services (Correct answer)
- FQHC services are not covered by Medicare
- FQHCs receive bundled payments only for surgical services
Correct answer: FQHCs receive a prospective payment system rate (PPS) per encounter that bundles most primary care services
Medicare reimburses FQHCs using the Prospective Payment System, paying an all-inclusive per-visit rate that covers most primary care encounters rather than fee-for-service individual CPT billing.
Question 4: A patient on Medicare Part D requests a non-formulary medication that the NP believes is medically necessary. Which process allows the patient to obtain coverage for the non-formulary drug?
- The patient may purchase the drug out-of-pocket and Medicare will reimburse them retroactively
- The NP may file a coverage determination exception request demonstrating medical necessity (Correct answer)
- Non-formulary medications can never be covered under Part D
- The patient must switch to a different Part D plan that covers the medication before the next open enrollment period
Correct answer: The NP may file a coverage determination exception request demonstrating medical necessity
Part D plans must have an exceptions process allowing providers to request coverage of non-formulary drugs by submitting documentation of medical necessity.
Question 5: Which component of the ACA's preventive care mandate requires health insurers to cover USPSTF Grade A and B preventive services without cost-sharing for non-grandfathered plans?
- Section 1557 non-discrimination provisions
- Section 2713 preventive services without cost-sharing requirements (Correct answer)
- The essential health benefits (EHB) benchmark requirement
- The individual mandate penalty provision
Correct answer: Section 2713 preventive services without cost-sharing requirements
ACA Section 2713 requires non-grandfathered health plans to cover USPSTF Grade A and B recommendations, ACIP-recommended immunizations, and HRSA guidelines without cost-sharing.
Question 6: An AGPCNP is being audited by Medicare for an E/M upcoding pattern. Which CMS documentation guideline supports billing a Level 4 established patient office visit (99214)?
- A medically appropriate history and/or exam, plus moderate medical decision making or 30-40 minutes of total time on the date of encounter (Correct answer)
- A comprehensive history with 10 or more organ systems reviewed and a complete physical exam
- A focused history with straightforward medical decision making
- Any visit where the provider spends more than 20 minutes face-to-face with the patient
Correct answer: A medically appropriate history and/or exam, plus moderate medical decision making or 30-40 minutes of total time on the date of encounter
Under the 2021 AMA/CMS E/M guidelines, 99214 requires a medically appropriate history and/or exam with moderate complexity MDM OR 30-40 minutes of total provider time on that date.
Question 7: A long-term care facility's NP wants to order a urinalysis and culture for an 82-year-old resident with new confusion but no urinary symptoms. Which regulatory framework guides appropriate antibiotic stewardship in this setting?
- CMS Conditions of Participation for skilled nursing facilities require treatment of all positive urine cultures regardless of symptoms
- CDC and CMS antibiotic stewardship guidelines recommend against treating asymptomatic bacteriuria in most older adults, and SNFs must have stewardship programs under CMS F-tag 881 (Correct answer)
- HIPAA prevents sharing urine culture results with the facility's infection control team
- OBRA 1987 mandates empiric antibiotic treatment for any resident with acute confusion
Correct answer: CDC and CMS antibiotic stewardship guidelines recommend against treating asymptomatic bacteriuria in most older adults, and SNFs must have stewardship programs under CMS F-tag 881
CMS F-tag 881 requires SNFs to have antibiotic stewardship programs; CDC guidelines recommend against treating asymptomatic bacteriuria in most elderly patients because it does not improve outcomes and promotes resistance.
Adult-Gerontology Primary Care Nurse Practitioner Exam Regulatory Frameworks & Compliance 5
A 66-year-old patient newly eligible for Medicare asks about the late enrollment penalty for Part B.
She delayed enrollment for 2 years after becoming eligible because she was covered by her spouse's employer plan.
Will she owe a penalty?