Medicare Specialist Claims Processing & Billing Procedures Flashcards

A hospital submits an inpatient claim under Medicare Part A. Under which payment system is it typically reimbursed?

Answer: Inpatient Prospective Payment System (IPPS) using MS-DRGs

Medicare pays acute care hospitals for inpatient stays under the IPPS using Medicare Severity Diagnosis Related Groups (MS-DRGs).

What is the purpose of a Medicare Summary Notice (MSN)?

Answer: It is sent to beneficiaries explaining what Medicare paid and any patient liability

The MSN is sent to Medicare beneficiaries to inform them of services billed, what Medicare paid, and their cost-sharing responsibility.

Which of the following best describes a Medicare 'crossover' claim?

Answer: A claim automatically forwarded from Medicare to a secondary insurer (e.g., Medicaid or Medigap) after Medicare adjudication

A crossover claim is one that Medicare automatically forwards to a secondary payer (such as Medicaid or a Medigap plan) after making its primary payment determination.

Under Medicare's National Correct Coding Initiative (NCCI), what is a 'column 2' code?

Answer: A component code that is bundled into the column 1 code and cannot be billed separately without an appropriate modifier

In NCCI edits, the column 2 code is considered a component of the column 1 code and is generally not separately reimbursable unless a modifier indicates a distinct service.

A provider receives a Remittance Advice (RA) with claim adjustment reason code (CARC) 4. What does this indicate?

Answer: The claim or service lacks information needed for adjudication

CARC 4 indicates the claim or service lacks the information needed for adjudication; the provider must resubmit with the missing information.

For Medicare Part B claims, what does 'assignment' mean when a provider accepts it?

Answer: The provider agrees to accept the Medicare-approved amount as payment in full and cannot balance bill the beneficiary beyond cost-sharing

Accepting assignment means the provider agrees Medicare's approved amount is payment in full; they collect deductible/coinsurance but cannot balance bill.

Which type of edit in Medicare claims processing checks that the diagnosis code supports the medical necessity of the procedure billed?

Answer: Local Coverage Determination (LCD) / National Coverage Determination (NCD) edit

LCD and NCD edits verify that the submitted diagnosis code is on the approved list of covered indications, establishing medical necessity for the billed service.