Medicare & Medicaid Billing Flashcards

Which Medicare part covers inpatient hospital stays, skilled nursing facility care, and hospice services?

Answer: Medicare Part A

Medicare Part A is hospital insurance covering inpatient hospital stays, SNF care, home health, and hospice.

Under the Medicare Inpatient Prospective Payment System (IPPS), payment is primarily determined by:

Answer: The assigned Diagnosis-Related Group (DRG)

IPPS pays hospitals a predetermined rate based on the patient's DRG, regardless of actual costs incurred.

A Medicaid claim is rejected because the patient's eligibility lapsed on the date of service. What is the best next step?

Answer: Verify eligibility and bill the patient as self-pay if confirmed ineligible

If Medicaid eligibility cannot be confirmed for the date of service, the provider should bill the patient directly as self-pay after verification.

The Medicare Remittance Advice (RA) denial code CO-4 indicates:

Answer: The procedure code is inconsistent with the modifier

CO-4 means the service billed is inconsistent with the modifier used, requiring a corrected claim with the appropriate modifier.

Which form is used to bill Medicare for outpatient and professional services?

Answer: CMS-1500

The CMS-1500 form is used by physicians and other healthcare professionals to bill Medicare for outpatient and professional services.

Medicaid's 'spend-down' program is designed to help individuals who:

Answer: Have incomes too high to qualify for Medicaid but face high medical expenses

The spend-down program allows individuals with income above the Medicaid limit to qualify once medical expenses reduce their income to the eligibility threshold.

Under Medicare's Advance Beneficiary Notice (ABN) rules, an ABN must be given to the patient:

Answer: Before a service that Medicare may deny as not medically necessary

An ABN must be issued before providing a service that Medicare might deny, giving the patient an informed choice about whether to receive and pay for the service.