CMC Reimbursement & Claims Processing 3 — Questions and Answers
Question 1: When a Medicare patient has end-stage renal disease (ESRD) and employer group health plan coverage, which payer is primary during the first 30 months?
- Medicare is always primary for ESRD patients
- The employer group health plan is primary for the first 30 months (Correct answer)
- Medicaid is primary for ESRD patients
- The payer with the most recent enrollment date is primary
Correct answer: The employer group health plan is primary for the first 30 months
For ESRD patients with employer group health plan coverage, the group health plan is primary during a 30-month coordination period before Medicare becomes primary.
Question 2: A provider submits a claim for a service performed on January 15. Medicare's timely filing limit is 12 months from the date of service. What is the last date the claim can be submitted?
- December 31 of the same year
- January 14 of the following year
- January 15 of the following year (Correct answer)
- March 31 of the following year
Correct answer: January 15 of the following year
Medicare requires claims to be submitted within one calendar year (12 months) from the date of service, so a service on January 15 must be filed by January 15 of the following year.
Question 3: What does NCCI stand for in medical coding and billing?
- National Coverage Coding Initiative
- National Correct Coding Initiative (Correct answer)
- National Claims Compliance Index
- Network Coverage Coordination Instructions
Correct answer: National Correct Coding Initiative
NCCI (National Correct Coding Initiative) is a CMS program that promotes correct coding by preventing improper payment of Medicare Part B claims.
Question 4: Which type of edit would prevent payment for a surgical approach code billed separately from the primary procedure?
- Medically Unlikely Edit (MUE)
- Column 1/Column 2 NCCI edit (Correct answer)
- Claim frequency edit
- Place of service edit
Correct answer: Column 1/Column 2 NCCI edit
Column 1/Column 2 NCCI edits bundle component codes (Column 2) with comprehensive codes (Column 1), preventing separate payment for integral parts of a procedure.
Question 5: Under the Medicare Physician Fee Schedule, which component of the Resource-Based Relative Value Scale (RBRVS) reflects the overhead costs of running a practice?
- Physician Work RVU
- Practice Expense RVU (Correct answer)
- Malpractice RVU
- Geographic Practice Cost Index
Correct answer: Practice Expense RVU
Practice Expense RVUs account for the overhead costs associated with providing a service, such as staff salaries, supplies, and equipment.
Question 6: A claim for CPT code 99213 is denied because the provider did not obtain preauthorization. Which CARC best fits this denial?
- CO-4
- CO-15
- CO-197 (Correct answer)
- CO-50
Correct answer: CO-197
CO-197 indicates the precertification or authorization was absent or exceeded, meaning the service required prior approval that was not obtained.
Question 7: What is the primary purpose of a Remittance Advice (RA) sent to a provider?
- To notify the provider of upcoming audits
- To detail how claims were adjudicated and the amounts paid or denied (Correct answer)
- To provide the provider with updated fee schedules
- To request additional clinical documentation for pending claims
Correct answer: To detail how claims were adjudicated and the amounts paid or denied
A Remittance Advice (RA), or Electronic Remittance Advice (ERA) in electronic form, details each claim's adjudication including payments, denials, and adjustments.
CMC Reimbursement & Claims Processing 3
When a Medicare patient has end-stage renal disease (ESRD) and employer group health plan coverage, which payer is primary during the first 30 months?