Medicare Specialist Claims Processing & Billing Procedures Flashcards
7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medicare Specialist Claims Processing & Billing Procedures flashcards as text
A provider submits a corrected claim to Medicare to fix an error on the original paid claim. What type of bill (TOB) frequency code is used for corrected inpatient UB-04 claims?
Answer: Frequency code 7 (Replacement of prior claim)
Frequency code 7 on the Type of Bill designates a replacement (corrected) claim that substitutes for a previously submitted and processed claim.
Under the Medicare Fee Schedule, what three components make up a procedure's Relative Value Unit (RVU)?
Answer: Physician work, practice expense, and malpractice expense
Each CPT code's total RVU is the sum of three components: physician work RVU, practice expense RVU, and malpractice (professional liability insurance) expense RVU.
When must a provider obtain a Prior Authorization (PA) for certain Medicare Part B services under the expanded PA program?
Answer: PA is required for selected high-expenditure, high-volume, or frequently-abused non-emergency outpatient services identified by CMS
CMS's expanded prior authorization program requires PA for selected non-emergency outpatient Part B services that are high-cost, high-volume, or have a history of improper payments.
A Medicare beneficiary is in a qualifying hospital stay and is subsequently transferred to a Skilled Nursing Facility (SNF). How many days of hospital inpatient stay are required for full SNF Part A coverage to apply?
Answer: 3 days
Medicare Part A SNF coverage requires a qualifying inpatient hospital stay of at least 3 consecutive days (not counting the discharge day).
Which of the following is an example of an NCCI Mutually Exclusive edit (MUE)?
Answer: Billing for two units of a code limited to one unit per day by anatomic or clinical standards
Medically Unlikely Edits (MUEs) flag when units of service exceed what is clinically reasonable for a single patient on a single date, such as billing more units than anatomically possible.
A provider participates in Medicare and submits a claim for $300, but the Medicare-approved amount is $200. Medicare pays 80% after the deductible is met. What is the maximum the provider can collect from the patient?
Answer: $40 (20% coinsurance of approved amount)
As a participating provider accepting assignment, the maximum collectible from the patient is the 20% coinsurance of the Medicare-approved amount ($200 × 20% = $40); the $100 difference between billed and approved is written off.
When billing for Medicare home health services, which PPS system determines the payment episode and rate?
Answer: Patient-Driven Groupings Model (PDGM)
Since January 2020, Medicare home health is reimbursed under the Patient-Driven Groupings Model (PDGM), which uses 30-day payment periods based on clinical characteristics and functional levels.