Medicare & Medicaid Billing Flashcards

What is the primary function of a Medicare Administrative Contractor (MAC)?

Answer: To process and pay Medicare Part A and Part B claims for a geographic jurisdiction

MACs are private contractors that process Medicare fee-for-service claims and perform related administrative functions within designated jurisdictions.

Which modifier is appended to a CPT code to indicate that only the professional component of a service was performed?

Answer: Modifier 26

Modifier 26 indicates the professional component only, while modifier TC indicates the technical component only for split-billing of diagnostic services.

A hospital bills Medicare for a patient who also has employer group health insurance (EGHI) through a current employer. Which payer is primary?

Answer: The EGHI plan is primary because it is employer-sponsored

Medicare Secondary Payer (MSP) rules require EGHI through a current employer to be primary when the employer has 20 or more employees.

Under Medicaid, the Federal Medical Assistance Percentage (FMAP) represents:

Answer: The federal government's share of each state's Medicaid expenditures

FMAP is the ratio at which the federal government matches state Medicaid spending, varying by state based on per capita income.

A claim is submitted with an ICD-10-CM code as the principal diagnosis, but CMS considers it a 'symptom' that should be replaced by its underlying cause. This is an example of a violation of which guideline?

Answer: UHDDS principal diagnosis selection guidelines

UHDDS guidelines for inpatient claims require the principal diagnosis to be the condition established after study that caused the admission, not a sign or symptom.

Which Medicare program was established to pay hospitals for treating a disproportionate share of low-income patients?

Answer: Disproportionate Share Hospital (DSH) Adjustment

The DSH adjustment provides additional Medicare payments to hospitals that serve a high percentage of Medicaid and low-income Medicare patients.

When a Medicaid beneficiary receives services from a non-participating (out-of-network) provider in a non-emergency situation, the typical outcome is:

Answer: The claim is denied and the provider cannot bill the patient

In most Medicaid managed care plans, out-of-network non-emergency services are denied, and federal rules generally prohibit providers from balance-billing Medicaid patients.