RCC Medicare & Payer-Specific Radiology Billing 2 — Questions and Answers
Question 1: What Medicare rule limits self-referral for designated health services including radiology?
- Stark Law (Physician Self-Referral Law) (Correct answer)
- Anti-Kickback Statute
- False Claims Act
- HIPAA Privacy Rule
Correct answer: Stark Law (Physician Self-Referral Law)
The Stark Law prohibits physicians from referring Medicare patients to entities with which they have a financial relationship for DHS including radiology.
Question 2: Prior authorization for advanced imaging studies is most commonly required by which payer type?
- Commercial/private insurers and Medicare Advantage plans (Correct answer)
- Traditional Medicare FFS only
- Medicaid only
- TRICARE only
Correct answer: Commercial/private insurers and Medicare Advantage plans
Commercial insurers and Medicare Advantage plans typically require prior authorization for advanced imaging, while traditional Medicare FFS generally does not.
Question 3: Which Medicare coverage determination applies to a specific geographic area and addresses local coverage for radiology services?
- Local Coverage Determination (LCD) (Correct answer)
- National Coverage Determination (NCD)
- Coverage Advisory Committee
- Transmittal
Correct answer: Local Coverage Determination (LCD)
LCDs are issued by Medicare Administrative Contractors (MACs) and define coverage criteria at the regional level.
Question 4: Medicare's timely filing deadline for initial claims is generally how many months from the date of service?
- 12 months (Correct answer)
- 6 months
- 24 months
- 3 months
Correct answer: 12 months
Medicare requires claims to be filed within 12 months (one calendar year) from the date of service.
Question 5: A radiology claim denied as 'not medically necessary' should be appealed to which first level under Medicare?
- Redetermination by the MAC (Correct answer)
- Qualified Independent Contractor (QIC)
- Office of Medicare Hearings & Appeals (OMHA)
- Medicare Appeals Council
Correct answer: Redetermination by the MAC
The first level of Medicare appeal is Redetermination, filed with the Medicare Administrative Contractor (MAC).
Question 6: Which HCPCS Level II modifier indicates a mammography performed on a patient with implants?
- Modifier GG (Correct answer)
- Modifier TC
- Modifier 52
- Modifier 22
Correct answer: Modifier GG
Modifier GG is used to report performance and payment of a screening mammogram and a diagnostic mammogram on the same patient, same day.
RCC Medicare & Payer-Specific Radiology Billing 2
What Medicare rule limits self-referral for designated health services including radiology?