Mixed Deck — All CMS Topics Flashcards

Under the Medicare Fee Schedule, what three components make up a procedure's Relative Value Unit (RVU)?

Answer: Physician work, practice expense, and malpractice expense

Each CPT code's total RVU is the sum of three components: physician work RVU, practice expense RVU, and malpractice (professional liability insurance) expense RVU.

Under Original Medicare, which entity is primarily responsible for managing a beneficiary's overall treatment plan across multiple providers?

Answer: The beneficiary's primary care physician typically coordinates care

Under Original Medicare's fee-for-service model, the primary care physician generally coordinates care without a formal care manager mandate.

How does Medicare coordinate benefits when a beneficiary is covered by both Medicare and an employer group health plan from a small employer (fewer than 20 employees)?

Answer: Medicare is primary and the employer group health plan is secondary for small employers

For employers with fewer than 20 employees, Medicare is the primary payer and the employer group health plan pays secondary, unlike large employers where the group plan pays first.

A Medicare-certified ambulatory surgical center (ASC) must implement which minimum safety standard to prevent patient falls in the procedure area?

Answer: Non-slip flooring and secured equipment pathways with fall risk assessments

CMS requires ASCs to maintain a safe physical environment with fall prevention measures, including non-slip surfaces and pre-procedure fall risk assessments.

What does Medicare Part B typically cover in terms of billing?

Answer: Outpatient services and preventive care

Medicare Part B typically covers outpatient services and preventive care. This includes doctor's visits, outpatient therapy, durable medical equipment, mental health services, and various screenings and vaccinations. It helps cover costs for services received outside of an inpatient hospital stay, which is generally covered by Part A.

Which of the following best describes confidentiality in Certified Medicare Specialist?

Answer: Protecting sensitive information from unauthorized disclosure

Confidentiality involves protecting sensitive information and only sharing it with authorized parties who need it.

What is the primary purpose of the Medicare Compliance and Ethics Program required for Medicare Advantage organizations?

Answer: To prevent, detect, and correct non-compliance with CMS requirements

Compliance and ethics programs are designed to prevent, detect, and correct non-compliance with CMS requirements and fraudulent or abusive conduct.

Under CMS guidelines, which of the following constitutes an 'immediate jeopardy' finding related to infection control in a nursing home?

Answer: Staff reusing single-use syringes across multiple residents

Reusing single-use syringes across residents creates an immediate risk of bloodborne pathogen transmission and meets CMS criteria for immediate jeopardy.

Which of the following best describes the Extra Help (Low Income Subsidy) program for Medicare Part D?

Answer: A federal program that helps eligible low-income beneficiaries pay Part D premiums, deductibles, and copays

Extra Help is a federal Social Security Administration program that reduces Part D costs including premiums, deductibles, and copays for Medicare beneficiaries with limited income and resources.

A 67-year-old client has been working and covered by employer group health insurance. She retires and loses coverage. How long does she have to enroll in Medicare Part B without penalty?

Answer: 8 months from the loss of employer coverage

The Special Enrollment Period for losing employer coverage is 8 months from the date employment ends or employer coverage ends, whichever comes first.

Under the CMS Conditions of Participation, which entity has primary authority to investigate quality-of-care complaints in Medicare-certified facilities?

Answer: State Survey Agencies

State Survey Agencies conduct inspections and investigate complaints at Medicare-certified facilities on behalf of CMS under the Conditions of Participation.

Under Medicare's coverage of preventive services, what is the beneficiary cost-sharing requirement for an Annual Wellness Visit (AWV)?

Answer: No cost-sharing; the AWV is covered at 100% with no deductible or coinsurance

The Annual Wellness Visit is a fully covered preventive service under Medicare Part B with no deductible or coinsurance required from the beneficiary.

A beneficiary enrolled in Original Medicare undergoes surgery and requires post-acute care coordination. Which resource helps ensure smooth transitions and reduce readmissions?

Answer: Transitional Care Management (TCM) services

Transitional Care Management services (TCM) are billed under Medicare Part B to support patients transitioning from inpatient settings back to community care.

Which scenario best illustrates a violation of CMS standard precautions in a Medicare-certified home health setting?

Answer: A nurse recaps a used needle with two hands before disposal

Recapping needles with two hands is a prohibited practice under standard precautions because it dramatically increases the risk of needlestick injury.

Which skill is most important for success in Clinical Procedures & Protocols within Certified Medicare Specialist?

Answer: Continuous learning and adaptation

Continuous learning ensures professionals stay current with evolving practices in Clinical Procedures & Protocols.

What is a fundamental principle of Clinical Procedures & Protocols in Certified Medicare Specialist practice?

Answer: Following established standards and best practices

Following established standards and best practices ensures quality and consistency in Clinical Procedures & Protocols.

How many days does a beneficiary typically have to file a Medicare redetermination request with the MAC?

Answer: 120 days

Beneficiaries generally have 120 days from receipt of the Medicare Summary Notice to request a redetermination.

Which provision of the Affordable Care Act strengthened Medicare fraud enforcement by increasing civil monetary penalties?

Answer: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative

The HEAT initiative, strengthened under the ACA, brought together HHS and DOJ to enhance anti-fraud activities and imposed stiffer civil monetary penalties.

What does the Medicare Part D 'coverage gap' (formerly 'donut hole') compliance requirement specify for plan sponsors?

Answer: Plans must provide at least a 75% discount on covered brand-name drugs during the coverage gap

Under the ACA and subsequent legislation, Part D plans must ensure beneficiaries in the coverage gap receive at least a 75% discount on covered brand-name drugs, with manufacturers providing 70% and plans covering 5%.

Which agency oversees Medicare compliance and enforcement?

Answer: CMS

The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for overseeing Medicare compliance and enforcement. CMS administers the Medicare program, develops policies, and ensures that providers and plans adhere to federal regulations. This oversight is critical for maintaining the program's integrity and protecting beneficiaries.