CMS Medicare Specialist Claims Processing & Billing Procedures 3

Question 1

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

Accepted Answer

Inpatient Prospective Payment System (IPPS) using MS-DRGs

Answer

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

Question 2

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

Accepted Answer

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

Answer

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

Question 3

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

Accepted Answer

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

Answer

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.

Question 4

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

Accepted Answer

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

Answer

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.

Question 5

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

Accepted Answer

The claim or service lacks information needed for adjudication

Answer

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

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Claims Processing & Billing Procedures 3