Payer-Specific Guidelines Flashcards
7 cards from real COBGC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Payer-Specific Guidelines flashcards as text
A payer denies a claim for a laparoscopic salpingo-oophorectomy citing 'lack of medical necessity.' What is the coder's best first step to appeal?
Answer: Obtain and submit clinical documentation supporting the indication, such as operative notes and pathology reports
A medical necessity denial requires a clinical appeal supported by documentation such as operative notes, imaging, and pathology that demonstrates the procedure was medically appropriate.
Which federal law mandates that group health plans cover maternity and newborn care for a minimum of 48 hours following a vaginal delivery?
Answer: The Newborns' and Mothers' Health Protection Act (NMHPA)
The NMHPA of 1996 prohibits group health plans from restricting hospital stays for mothers and newborns to less than 48 hours after a vaginal delivery or 96 hours after a cesarean section.
Under the Affordable Care Act, which women's preventive services must be covered by most non-grandfathered health plans WITHOUT cost-sharing?
Answer: Annual well-woman visits, gestational diabetes screening, BRCA counseling, and contraception
The ACA requires non-grandfathered health plans to cover HRSA-designated women's preventive services including well-woman visits, gestational diabetes screening, BRCA counseling, and FDA-approved contraceptive methods at no cost to the patient.
A physician orders an MRI pelvis for a patient with pelvic pain. The commercial payer requires a 'peer-to-peer' review. What does this process involve?
Answer: The ordering physician speaks directly with the payer's medical reviewer to justify the clinical necessity of the service
A peer-to-peer review is a phone consultation between the requesting clinician and the payer's medical director to discuss clinical criteria and justify the medical necessity of a requested service.
Which modifier should a coder append when billing for a colposcopy with biopsy that was determined to be medically necessary during a separately reported E/M visit on the same day?
Answer: -25
Modifier -25 is appended to the E/M code (not the procedure code) to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as a procedure.
A patient has a tubal ligation immediately following vaginal delivery. Most commercial payers will reimburse this procedure by applying which policy?
Answer: Paying separately for CPT 58611 as an add-on code to the delivery
CPT 58611 is an add-on code specifically for occlusion of the fallopian tube(s) at the time of cesarean or vaginal delivery and is payable in addition to the delivery code by most commercial payers.
When a commercial payer's allowed amount is less than the patient's deductible, what amount is the patient responsible for?
Answer: The payer's allowed (contracted) amount
Under a contracted fee schedule, the patient's financial responsibility is limited to the payer's allowed amount (not the billed charge), which is applied toward their deductible.