Administrative — CMA practice questions

Modified wave scheduling is:

1. Multiple patients at start of hour + spaced through the rest
2. One patient per slot
3. Random walk-ins
4. Phone-only

Answer: A — Multiple patients at start of hour + spaced through the rest

B) Stream. A) Correct. C) Walk-in. D) Wrong.

Prior authorization (PA) is best described as:

1. The patient's signed informed consent for the service
2. Payer pre-approval that a service is medically necessary and will be covered if other claim requirements are met
3. The HIPAA authorization for use/disclosure
4. The provider's enrollment with the payer

Answer: B — Payer pre-approval that a service is medically necessary and will be covered if other claim requirements are met

A) Different document (clinical consent). B) PA is a utilization-management tool — not a coverage guarantee, but a necessary step for certain services. C) HIPAA authorization is separate. D) Enrollment is separate from PA.

In a Health Maintenance Organization (HMO), the patient typically must:

1. Choose a primary care provider (PCP) who coordinates care and provides referrals
2. See any specialist without a referral
3. Pay 100% out-of-pocket for in-network care
4. File their own claims

Answer: A — Choose a primary care provider (PCP) who coordinates care and provides referrals

A) HMO model centers on the PCP gatekeeper. B) That model is more PPO/EPO. C) HMOs have copays + low cost-sharing in network. D) Network providers file claims.

TRICARE primarily covers:

1. Senior citizens at age 65
2. Active duty military, retirees, and their dependents
3. Low-income individuals
4. Federal civilian employees

Answer: B — Active duty military, retirees, and their dependents

A) Medicare. B) TRICARE serves the military health system population. C) Medicaid + CHIP. D) FEHB.

HCPCS Level II codes are most commonly used to bill:

1. Durable medical equipment (DME), drugs, supplies, ambulance services
2. Physician E/M services
3. Inpatient hospital DRG groups
4. Diagnoses

Answer: A — Durable medical equipment (DME), drugs, supplies, ambulance services

B) E/M is CPT. A) HCPCS Level II covers items + services not in CPT Category I, e.g., wheelchairs (E codes), injectable drugs (J codes), ambulance (A codes). C) DRGs are separate. D) Diagnoses use ICD-10-CM.

CPT codes are used for:

1. Diagnoses
2. Patient ID
3. Insurance
4. Procedures + services performed

Answer: D — Procedures + services performed

A) ICD-10. D) Correct. B/C) Wrong.

The standard claim form for institutional (hospital) billing is:

1. CMS-1500
2. UB-04 / CMS-1450
3. ADA dental claim
4. CMS-855

Answer: B — UB-04 / CMS-1450

A) Professional. B) UB-04 (CMS-1450) for institutional. C) Dental. D) CMS-855 is for provider enrollment.

An Electronic Remittance Advice (ERA) is most accurately:

1. The patient's bill
2. An electronic version of the explanation of benefits sent to the provider summarizing payments and adjustments
3. The provider's enrollment form
4. The claim form itself

Answer: B — An electronic version of the explanation of benefits sent to the provider summarizing payments and adjustments

A) Patient receives the EOB. B) ERA = 835 transaction, the electronic counterpart of the EOB sent to the provider. C) Enrollment form is CMS-855. D) Claim transmission is the 837.

Under EHR 'meaningful use' / promoting interoperability requirements, common objectives include all of the following EXCEPT:

1. Electronic prescribing
2. Patient access to their electronic health information
3. Posting de-identified diagnoses on the public clinic website
4. Health information exchange with other providers

Answer: C — Posting de-identified diagnoses on the public clinic website

A/B/D) Standard objectives. C) Public posting, even of de-identified data, is not part of the program objectives + raises separate considerations.

Modifier -59 is appended to indicate:

1. A separately identifiable E/M service
2. A repeat clinical lab test
3. A return to the OR for a related procedure during the postoperative period
4. A distinct procedural service (different site, encounter, or procedure not normally reported together)

Answer: D — A distinct procedural service (different site, encounter, or procedure not normally reported together)

A) -25. D) -59 (or X{EPSU} subsets) defines a distinct procedural service. C) -78. B) -91.

Appointment scheduling types?

Stream/time-specified (15-min slots), wave (multiple patients per hour), modified wave (e.g., 2 at start + 1 at mid-hour), double-booking, cluster (similar procedures grouped).

Common insurance terms?

Premium (monthly cost). Deductible (out-of-pocket before insurance pays). Copay (fixed per-visit fee). Coinsurance (% of bill). Out-of-pocket max.

Medicare A, B, C, D?

A = hospital. B = outpatient + physician. C = Medicare Advantage (private alternative). D = prescription drugs.