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

CPT codes, maintained by the AMA, are the primary coding system used to bill clinical laboratory procedures to Medicare and other payers.

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

An Advance Beneficiary Notice (ABN) must be issued before rendering the service so the patient can decide whether to proceed and accept financial responsibility.

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

PAMA requires that Medicare CDLT payment rates reflect the weighted median of private payer rates collected from applicable laboratories, shifting to market-based pricing.

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

LCDs issued by Medicare Administrative Contractors specify which ICD-10-CM diagnosis codes support medical necessity, determining when Medicare will cover a given test.

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 GA is appended to a claim line to indicate that a valid ABN was on file, documenting that the patient was notified of potential non-coverage.

(CLC) Certified Laboratory Consultant Practice Test

(CLC) Certified Laboratory Consultant Practice Test

CLC Laboratory Financial Management & Reimbursement