Medicare Specialist Claims Processing & Billing Procedures Flashcards
7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medicare Specialist Claims Processing & Billing Procedures flashcards as text
A physician performs a surgical procedure and separately bills for a visit on the same day. Without a modifier, what will likely happen to the office visit claim?
Answer: It will be bundled/denied per the global surgery package rule, which includes pre- and post-operative care
Medicare's global surgery package bundles pre-operative, intraoperative, and post-operative services into one payment; a separate E&M on the day of surgery is typically denied without modifier 25 or 57.
What is the significance of the 'place of service' (POS) code on a CMS-1500 claim?
Answer: It can affect the Medicare payment rate, as facility vs. non-facility settings have different fee schedule amounts
POS codes identify where the service was rendered and directly affect reimbursement, since Medicare pays lower non-facility practice expense RVUs when services are provided in a facility setting.
A Medicare patient is admitted for inpatient rehabilitation. Under which prospective payment system is this service reimbursed?
Answer: Inpatient Rehabilitation Facility PPS (IRF-PPS) using CMGs
Inpatient Rehabilitation Facilities (IRFs) are reimbursed under the IRF-PPS using Case Mix Groups (CMGs) based on functional impairment and clinical complexity.
Which modifier should a provider use when billing Medicare for the professional component of a radiology service when the technical component is billed separately?
Answer: Modifier 26
Modifier 26 is appended to a radiology CPT code to indicate only the professional component (interpretation and report) is being billed.
Under Medicare's Advance Beneficiary Notice (ABN) rules, when MUST a provider issue an ABN to a Medicare beneficiary?
Answer: When the provider believes Medicare will likely deny the service as not medically necessary or not covered, so the beneficiary can decide whether to proceed and accept financial responsibility
Providers must issue an ABN when they reasonably expect Medicare will deny a service so the beneficiary can make an informed decision and, if they proceed, be held financially liable.
A Medicare claim is denied with reason 'not medically necessary.' The provider disagrees. What is the FIRST level of the Medicare appeals process?
Answer: Redetermination by the MAC
The first step in the Medicare appeals process is a Redetermination, which is a review by the same MAC that processed the original claim.
What does the term 'clean claim' mean in Medicare billing?
Answer: A claim that contains all required data elements and can be processed without additional information
A clean claim is one that contains all required information and passes all edits, allowing it to be processed and paid without requesting additional data from the provider.