CCC Reimbursement & Payer Policies Flashcards
6 cards from real CCC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CCC Reimbursement & Payer Policies flashcards as text
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?
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.
What is the purpose of the National Correct Coding Initiative (NCCI) edits in cardiology billing?
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.
Under Medicare's outpatient prospective payment system (OPPS), cardiology services in a hospital outpatient setting are reimbursed using:
Answer: Ambulatory payment classifications (APCs)
Hospital outpatient services including cardiology are paid under APCs, which group similar services for a fixed payment amount.
A cardiology coder notes that a claim was denied with reason code CO-4. This typically means:
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.
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:
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.
What is the role of the Medicare Administrative Contractor (MAC) as it relates to cardiology coding?
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.