CLC Laboratory Financial Management & Reimbursement

Question 1

Which coding system is primarily used for billing laboratory tests to Medicare?

Accepted Answer

Current Procedural Terminology (CPT) codes

Answer

ICD-10-CM diagnosis codes

Answer

DRG (Diagnosis-Related Group) codes

Answer

HCPCS Level III local codes

Question 2

What document must a laboratory provide to a Medicare patient BEFORE performing a test that may be denied as not medically necessary?

Accepted Answer

Advance Beneficiary Notice (ABN)

Answer

Certificate of Medical Necessity (CMN)

Answer

Notice of Non-Coverage (NONC)

Answer

Denial of Coverage Letter (DCL)

Question 3

Under the Protecting Access to Medicare Act (PAMA), Medicare payment rates for clinical diagnostic laboratory tests are based on:

Accepted Answer

The weighted median of private payer rates reported by applicable laboratories

Answer

Annual CMS negotiations with laboratory trade associations

Answer

Historical Medicare fee schedule with CPI inflation adjustments

Answer

State-level rate-setting by Medicare Administrative Contractors

Question 4

A Local Coverage Determination (LCD) is primarily used in laboratory billing to:

Accepted Answer

Specify ICD-10 diagnoses supporting medical necessity for covered tests

Answer

Set geographic payment rates for laboratory tests

Answer

Establish the maximum number of tests per patient visit

Answer

Define CLIA certificate requirements by laboratory type

Question 5

Which modifier is used on a Medicare claim to indicate that an Advance Beneficiary Notice was issued because the service may be denied as not medically necessary?

Accepted Answer

Modifier GA

Answer

Modifier 22

Answer

Modifier 59

Answer

Modifier 25

Question 6

The 'Anti-Markup Rule' in laboratory billing prohibits:

Accepted Answer

Marking up the cost of tests referred to outside laboratories when billing Medicare

Answer

Laboratories from charging above the Medicare fee schedule

Answer

Applying discounts to laboratory tests without CMS approval

Answer

Billing for more than one specimen collection per patient encounter

Question 7

Which of the following best describes a 'National Coverage Determination' (NCD) compared to a Local Coverage Determination (LCD)?

Accepted Answer

NCDs apply nationwide and are issued by CMS; LCDs apply to specific MAC jurisdictions

Answer

NCDs are issued by state health departments; LCDs are issued by CMS

Answer

NCDs cover outpatient services only; LCDs cover inpatient laboratory tests

Answer

NCDs set payment rates; LCDs set quality standards