CCC CCC Reimbursement & Payer Policies 2 — Questions and Answers
Question 1: Which payer policy concept prevents a cardiologist from billing for the same service under both the professional and technical component when only the professional portion was provided?
- Place of service rules
- Incident-to billing
- Split/shared billing
- Component billing restrictions (Correct answer)
Correct answer: Component billing restrictions
Component billing rules require that only the component actually performed (professional or technical) be billed separately when the full service is not provided by the same entity.
Question 2: What is the purpose of the National Correct Coding Initiative (NCCI) edits in cardiology billing?
- To set maximum charge amounts
- To prevent improper billing of code pairs that should not be billed together (Correct answer)
- To assign diagnosis codes to procedures
- To approve new cardiology CPT codes
Correct answer: To prevent improper billing of code pairs that should not be billed together
NCCI edits identify pairs of CPT codes that Medicare considers mutually exclusive or bundled, preventing improper separate billing.
Question 3: Under Medicare's outpatient prospective payment system (OPPS), cardiology services in a hospital outpatient setting are reimbursed using:
- Diagnosis-related groups (DRGs)
- Ambulatory payment classifications (APCs) (Correct answer)
- Resource-based relative value units (RVUs)
- Capitation rates
Correct answer: Ambulatory payment classifications (APCs)
Hospital outpatient services including cardiology are paid under APCs, which group similar services for a fixed payment amount.
Question 4: A cardiology coder notes that a claim was denied with reason code CO-4. This typically means:
- Service was not covered by the plan
- The procedure code is inconsistent with the modifier (Correct answer)
- Duplicate claim submitted
- Service requires prior authorization
Correct answer: The procedure code is inconsistent with the modifier
CO-4 denial indicates the procedure code is inconsistent with the modifier used, requiring the coder to review and correct the modifier pairing.
Question 5: Incident-to billing in a cardiology practice allows a non-physician practitioner's services to be billed under the supervising physician's NPI at 100% of the fee schedule if:
- The physician is on-call remotely
- The service is an extension of the physician's treatment plan with direct supervision present in the suite (Correct answer)
- The patient consented in writing
- The non-physician holds an independent cardiology license
Correct answer: The service is an extension of the physician's treatment plan with direct supervision present in the suite
Incident-to billing requires the supervising physician to be present in the office suite and the service to be part of the physician's established treatment plan.
Question 6: What is the role of the Medicare Administrative Contractor (MAC) as it relates to cardiology coding?
- To write new CPT codes for cardiac procedures
- To process and adjudicate Medicare claims and issue local coverage determinations (LCDs) (Correct answer)
- To credential cardiology coders
- To negotiate fee schedules with cardiologists
Correct answer: To process and adjudicate Medicare claims and issue local coverage determinations (LCDs)
MACs process Medicare claims, adjudicate payments, and publish LCDs that define covered indications for cardiology services in their jurisdiction.
CCC CCC Reimbursement & Payer Policies 2
Which payer policy concept prevents a cardiologist from billing for the same service under both the professional and technical component when only the professional portion was provided?