CMS Clinical Procedures & Protocols 3 — Questions and Answers
Question 1: A patient admitted to a skilled nursing facility after a 3-day inpatient hospital stay requires daily wound care. Which Medicare benefit covers this stay?
- Medicare Part B outpatient benefit
- Medicare Part A skilled nursing facility benefit (Correct answer)
- Medicare Advantage only, not Original Medicare
- Medicare Part D pharmaceutical benefit
Correct answer: Medicare Part A skilled nursing facility benefit
Medicare Part A covers skilled nursing facility stays when the beneficiary had a qualifying 3-day inpatient hospital admission and requires skilled care.
Question 2: Under Medicare's clinical laboratory fee schedule, which entity typically bills for laboratory services performed in a physician office laboratory (POL)?
- The hospital laboratory that performs quality checks
- The physician or group practice that operates the POL (Correct answer)
- CMS directly reimburses the laboratory technician
- The Medicare Administrative Contractor automatically pays
Correct answer: The physician or group practice that operates the POL
When a physician's office operates its own laboratory, the physician or group practice bills Medicare directly for those laboratory services.
Question 3: A surgeon performs an appendectomy and during the same operative session discovers and removes an inflamed Meckel's diverticulum. How should the second procedure be reported?
- It is always bundled and cannot be billed separately
- Report the additional procedure with Modifier -51 (multiple procedures) (Correct answer)
- Report it with Modifier -22 (increased procedural services)
- Use an unlisted procedure code because it was incidental
Correct answer: Report the additional procedure with Modifier -51 (multiple procedures)
When multiple procedures are performed during the same operative session, Modifier -51 is appended to the secondary procedure(s) to indicate multiple procedures.
Question 4: Which Medicare clinical protocol governs the maximum frequency of Pap smear coverage for average-risk women?
- Every 6 months if over age 65
- Once every 24 months for average-risk women (Correct answer)
- Annually for all women regardless of risk
- Only once per lifetime after menopause
Correct answer: Once every 24 months for average-risk women
Medicare covers a Pap smear once every 24 months for average-risk women and annually for high-risk women or those of childbearing age with a history of abnormal Pap smears.
Question 5: When a Medicare beneficiary receives chemotherapy in an outpatient hospital setting, which payment system governs reimbursement?
- Inpatient Prospective Payment System (IPPS)
- Outpatient Prospective Payment System (OPPS) (Correct answer)
- Clinical Laboratory Fee Schedule
- Resource-Based Relative Value Scale (RBRVS)
Correct answer: Outpatient Prospective Payment System (OPPS)
Hospital outpatient services including chemotherapy are reimbursed under the Outpatient Prospective Payment System (OPPS), which assigns Ambulatory Payment Classifications.
Question 6: A physician orders an MRI of the lumbar spine for a patient with low back pain lasting 4 weeks. What is the most important documentation element to avoid a Medicare denial?
- Confirmation of the patient's insurance prior to imaging
- Clinical indications, conservative treatment tried, and red flag symptoms if present (Correct answer)
- Radiologist's credentials and accreditation status of the facility
- Patient's consent form and preference for imaging over other diagnostics
Correct answer: Clinical indications, conservative treatment tried, and red flag symptoms if present
Medicare requires documentation of clinical indications, prior conservative treatment, and any red flag symptoms to establish medical necessity for advanced imaging.
Question 7: Which Medicare coverage guideline applies to the use of a Continuous Positive Airway Pressure (CPAP) device for obstructive sleep apnea?
- Coverage is automatic upon physician order without a sleep study
- A qualifying sleep study showing AHI ≥5 and documented symptoms are required, with a compliance trial after 90 days (Correct answer)
- Medicare covers CPAP only for beneficiaries under age 75
- CPAP is only covered under Medicare Part D as a durable medical device
Correct answer: A qualifying sleep study showing AHI ≥5 and documented symptoms are required, with a compliance trial after 90 days
Medicare requires a qualifying sleep study with an apnea-hypopnea index ≥5 and documented symptoms, and continued coverage depends on compliance demonstrated within 90 days.
CMS Clinical Procedures & Protocols 3
A patient admitted to a skilled nursing facility after a 3-day inpatient hospital stay requires daily wound care.
Which Medicare benefit covers this stay?