CCC Reimbursement & Payer Policies Flashcards

Which Medicare program part primarily covers outpatient cardiology services such as ECGs and stress tests performed in a physician office?

Answer: Medicare Part B

Medicare Part B covers outpatient physician and diagnostic services, including office-based cardiology procedures.

What does the term 'global period' refer to in cardiology reimbursement?

Answer: The number of days post-procedure during which follow-up visits are included in the procedure fee

The global period is the post-operative timeframe (typically 0, 10, or 90 days) during which related follow-up care is bundled into the original procedure payment.

A cardiology practice submits a claim for a service that is already bundled into a previously billed procedure. This practice is known as:

Answer: Unbundling

Unbundling occurs when separate codes are billed for services that should be reported as a single bundled code, which is a compliance violation.

Which modifier is used to indicate that a procedure was performed by two surgeons, each with distinct roles, during a cardiac surgery?

Answer: Modifier -62

Modifier -62 is appended when two surgeons each perform a distinct part of a procedure, commonly used in complex cardiac surgeries.

Prior authorization in cardiology billing is primarily required to:

Answer: Ensure medical necessity is approved by the payer before a non-emergency service is rendered

Prior authorization confirms payer approval of medical necessity before scheduled procedures, reducing claim denials.

The Medicare Physician Fee Schedule (MPFS) values procedures using which three components of the Resource-Based Relative Value Scale (RBRVS)?

Answer: Work RVU, practice expense RVU, and malpractice RVU

MPFS payment is calculated from the sum of work RVU, practice expense RVU, and malpractice expense RVU, each multiplied by the conversion factor.