Payment Adjudication Flashcards

What are Medically Unlikely Edits (MUEs) in Medicare claim adjudication?

Answer: Maximum number of units of service that a provider can bill for a HCPCS/CPT code per beneficiary per date of service under most medical circumstances

MUEs are unit-of-service edits that establish the maximum units Medicare will allow for a specific HCPCS/CPT code per beneficiary per date of service, preventing billing for more units than are medically plausible.

What is a crosswalk in medical coding and billing?

Answer: A reference tool that maps codes between different code sets or between old and new versions of the same code set

A crosswalk maps equivalent or related codes between different coding systems (e.g., ICD-9-CM to ICD-10-CM, CPT to HCPCS) or between different versions of the same code set, facilitating accurate code conversion.

What is the purpose of the Medicare Physician Quality Reporting System (PQRS) / MIPS in claim adjudication?

Answer: A quality reporting program that collects performance data from providers and adjusts Medicare payments based on quality of care metrics

MIPS (Merit-based Incentive Payment System, successor to PQRS) is Medicare's value-based payment program that adjusts physician fee schedule payments (up or down) based on performance in quality, cost, improvement activities, and promoting interoperability.

What is a demand bill in Medicare billing?

Answer: A claim submitted at the patient's request when Medicare is expected to deny it, allowing the patient to obtain an official Medicare denial for potential secondary payer billing or appeals

A demand bill is submitted at the beneficiary's written request when the provider believes Medicare will deny the claim. The beneficiary wants an official Medicare denial so they can bill their secondary insurer or appeal.

What does 'coordination of benefits' mean in the context of claim adjudication?

Answer: The process by which multiple insurance plans determine the order and amount each plan pays for a covered service to prevent duplicate payment

COB in adjudication is the process by which primary and secondary insurers coordinate to ensure that combined payments do not exceed the provider's charge or the patient's total liability, preventing overpayment.

What is a transition-of-care (TOC) in revenue cycle management?

Answer: The movement of a patient between healthcare settings (e.g., hospital to SNF, hospital to home with home health), requiring specific billing codes and communication between providers

Transition of care refers to the movement of patients across care settings. CPT codes 99495–99496 (Transitional Care Management) bill for care coordination services provided after hospital discharge to reduce readmissions.