HAC Medicare & Medicaid Billing 2 — Questions and Answers
Question 1: Which Medicare part covers inpatient hospital stays, skilled nursing facility care, and hospice services?
- Medicare Part A (Correct answer)
- Medicare Part B
- Medicare Part C
- Medicare Part D
Correct answer: Medicare Part A
Medicare Part A is hospital insurance covering inpatient hospital stays, SNF care, home health, and hospice.
Question 2: Under the Medicare Inpatient Prospective Payment System (IPPS), payment is primarily determined by:
- Actual costs incurred during the stay
- The assigned Diagnosis-Related Group (DRG) (Correct answer)
- Number of days the patient is hospitalized
- The number of procedures performed
Correct answer: The assigned Diagnosis-Related Group (DRG)
IPPS pays hospitals a predetermined rate based on the patient's DRG, regardless of actual costs incurred.
Question 3: A Medicaid claim is rejected because the patient's eligibility lapsed on the date of service. What is the best next step?
- Write off the balance immediately
- Verify eligibility and bill the patient as self-pay if confirmed ineligible (Correct answer)
- Resubmit the claim without changes
- Bill Medicare as primary instead
Correct 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.
Question 4: The Medicare Remittance Advice (RA) denial code CO-4 indicates:
- Service not covered by plan
- The procedure code is inconsistent with the modifier (Correct answer)
- Claim/service lacks information needed for adjudication
- Duplicate claim submitted
Correct 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.
Question 5: Which form is used to bill Medicare for outpatient and professional services?
- UB-04 (CMS-1450)
- CMS-1500 (Correct answer)
- CMS-1490S
- ADA Dental Claim Form
Correct answer: CMS-1500
The CMS-1500 form is used by physicians and other healthcare professionals to bill Medicare for outpatient and professional services.
Question 6: Medicaid's 'spend-down' program is designed to help individuals who:
- Are enrolled in Medicare Part D
- Have incomes too high to qualify for Medicaid but face high medical expenses (Correct answer)
- Are dual-eligible for both Medicare and Medicaid
- Have exceeded their Medicare deductible
Correct 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.
Question 7: Under Medicare's Advance Beneficiary Notice (ABN) rules, an ABN must be given to the patient:
- After the service is rendered
- Before a service that Medicare may deny as not medically necessary (Correct answer)
- Only for inpatient hospital services
- Only when the patient requests one
Correct 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.
HAC Medicare & Medicaid Billing 2
Which Medicare part covers inpatient hospital stays, skilled nursing facility care, and hospice services?