CMS Clinical Procedures & Protocols 2 — Questions and Answers
Question 1: Under Medicare guidelines, which condition must be documented before a physician can order home health skilled nursing visits?
- Patient must be ambulatory and able to self-care
- Patient must be homebound and require skilled care on an intermittent basis (Correct answer)
- Patient must have a chronic condition lasting more than 12 months
- Patient must have a documented hospital stay within 30 days
Correct answer: Patient must be homebound and require skilled care on an intermittent basis
Medicare home health eligibility requires the patient to be homebound and need skilled nursing or therapy on an intermittent basis.
Question 2: A Medicare patient undergoes a colonoscopy and a polyp is removed during the same session. How is this typically billed?
- Only the colonoscopy is billed; polyp removal is bundled
- The polyp removal is billed separately using a surgical code (Correct answer)
- Both procedures are billed at 100% of the allowed amount
- The colonoscopy is downgraded to a diagnostic code only
Correct answer: The polyp removal is billed separately using a surgical code
When a therapeutic intervention such as polyp removal occurs during a diagnostic colonoscopy, the surgical procedure code replaces the diagnostic code and is billed separately.
Question 3: Which Medicare part covers outpatient physical therapy services provided in a hospital outpatient department?
- Medicare Part A
- Medicare Part B (Correct answer)
- Medicare Part C only
- Medicare Part D
Correct answer: Medicare Part B
Medicare Part B covers outpatient therapy services including physical, occupational, and speech-language therapy provided in hospital outpatient settings.
Question 4: A CMS specialist reviews a claim where a physician performed wound debridement using selective technique. What is the most critical documentation element to support medical necessity?
- Patient's BMI and nutritional status
- Wound size, depth, type of tissue removed, and clinical response (Correct answer)
- Number of prior debridements in the same episode
- Physician's board certification in wound care
Correct answer: Wound size, depth, type of tissue removed, and clinical response
Wound debridement claims require detailed documentation of wound characteristics, tissue type removed, and clinical response to justify medical necessity.
Question 5: Under the Medicare Physician Fee Schedule, what does the term 'global surgery period' refer to?
- The time frame a surgeon is paid for pre-operative consultations only
- The period during which all related pre- and post-operative services are included in the surgical fee (Correct answer)
- The 90-day window for filing surgical claims
- The total time a procedure takes from incision to closure
Correct answer: The period during which all related pre- and post-operative services are included in the surgical fee
The global surgery period bundles pre-operative, intraoperative, and post-operative services into one payment for a defined period (0, 10, or 90 days).
Question 6: Which modifier should be appended when a physician performs a bilateral procedure that is normally unilateral under Medicare guidelines?
- Modifier -50 (Correct answer)
- Modifier -59
- Modifier -25
- Modifier -76
Correct answer: Modifier -50
Modifier -50 indicates a bilateral procedure was performed and signals Medicare to adjust payment accordingly, typically at 150% of the unilateral fee.
Question 7: A Medicare beneficiary receives dialysis three times per week. Which payment model does Medicare use for End-Stage Renal Disease (ESRD) outpatient dialysis?
- Fee-for-service per session billed separately
- Prospective Payment System bundled rate per treatment (Correct answer)
- Reasonable cost reimbursement based on facility costs
- Value-based payment tied to patient outcomes only
Correct answer: Prospective Payment System bundled rate per treatment
Medicare reimburses ESRD outpatient dialysis under the ESRD Prospective Payment System, which provides a bundled per-treatment rate covering most related services.
CMS Clinical Procedures & Protocols 2
Under Medicare guidelines, which condition must be documented before a physician can order home health skilled nursing visits?