COC Coding, Billing & Reimbursement 2 — Questions and Answers
Question 1: What is the standard timely filing deadline for submitting Medicare Part B claims?
- 90 days from date of service
- 6 months from date of service
- 1 calendar year from date of service (Correct answer)
- 2 years from date of service
Correct answer: 1 calendar year from date of service
Medicare requires claims to be filed within 1 calendar year (12 months) from the date of service to be considered for payment.
Question 2: In Medicare O&P billing, what does it mean for a provider to accept 'assignment'?
- The process of assigning HCPCS codes to specific devices
- Agreement by the provider to accept Medicare's approved amount as full payment (Correct answer)
- The transfer of a patient's benefits to a different provider
- Mandatory enrollment in the Medicare program
Correct answer: Agreement by the provider to accept Medicare's approved amount as full payment
Accepting assignment means the provider agrees to accept the Medicare-approved amount as payment in full and cannot bill the beneficiary more than the applicable coinsurance or deductible.
Question 3: After the annual deductible is met, what percentage of the Medicare-approved amount does Medicare Part B typically pay for covered O&P items?
- 100%
- 70%
- 80% (Correct answer)
- 90%
Correct answer: 80%
Medicare Part B typically pays 80% of the approved amount for covered O&P items after the annual deductible is met, with the beneficiary responsible for the remaining 20% coinsurance.
Question 4: What is the primary function of a Certificate of Medical Necessity (CMN) in O&P practice?
- To document the patient's current diagnosis codes
- To certify that a prescribed item is medically necessary for a specific patient (Correct answer)
- To verify a provider's professional licensure status
- To authorize payment coordination with a secondary insurer
Correct answer: To certify that a prescribed item is medically necessary for a specific patient
A CMN is a physician-signed document that certifies a prescribed item meets medical necessity criteria, often required by Medicare for specific categories of DME and O&P devices.
Question 5: How does Medicare define 'medical necessity' for O&P items and services?
- Any device that a licensed physician prescribes for a patient
- Services or items that are reasonable and necessary for the diagnosis or treatment of illness or injury (Correct answer)
- Devices that demonstrably improve a patient's quality of life
- Items that represent the least expensive clinically appropriate option
Correct answer: Services or items that are reasonable and necessary for the diagnosis or treatment of illness or injury
Medicare defines medically necessary services as those that are reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.
Question 6: Which of the following is a fundamental documentation requirement for most Medicare O&P claims?
- A photocopy of the patient's insurance card
- A detailed written order or prescription from the treating physician (Correct answer)
- A competitor price comparison for the device provided
- A completed patient satisfaction survey
Correct answer: A detailed written order or prescription from the treating physician
Medicare requires a detailed written order (prescription) from the treating physician as part of the baseline documentation requirements for coverage of O&P devices.
Question 7: What is a 'Medicare crossover claim'?
- A claim submitted simultaneously to both Medicare Part A and Part B
- A claim automatically forwarded from Medicare to a secondary insurer after Medicare processes its portion (Correct answer)
- A claim submitted by two different providers for the same patient on the same date
- A claim that spans multiple dates of service across two calendar years
Correct answer: A claim automatically forwarded from Medicare to a secondary insurer after Medicare processes its portion
A Medicare crossover claim is one that is automatically forwarded by Medicare to a secondary insurer, such as Medicaid or a Medigap policy, after Medicare has adjudicated and paid its portion.
COC Coding, Billing & Reimbursement 2
What is the standard timely filing deadline for submitting Medicare Part B claims?