Medicare & Payer-Specific Radiology Billing Flashcards
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Read the first 6 Medicare & Payer-Specific Radiology Billing flashcards as text
What Medicare rule limits self-referral for designated health services including radiology?
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.
Prior authorization for advanced imaging studies is most commonly required by which payer type?
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.
Which Medicare coverage determination applies to a specific geographic area and addresses local coverage for radiology services?
Answer: Local Coverage Determination (LCD)
LCDs are issued by Medicare Administrative Contractors (MACs) and define coverage criteria at the regional level.
Medicare's timely filing deadline for initial claims is generally how many months from the date of service?
Answer: 12 months
Medicare requires claims to be filed within 12 months (one calendar year) from the date of service.
A radiology claim denied as 'not medically necessary' should be appealed to which first level under Medicare?
Answer: Redetermination by the MAC
The first level of Medicare appeal is Redetermination, filed with the Medicare Administrative Contractor (MAC).
Which HCPCS Level II modifier indicates a mammography performed on a patient with implants?
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.