- Diabetic neuropathy is an example of a(n)
When other insurers are initially liable for payment on a medical service or supply provided to a patient, Medicare classifies them as the _________ payer.
What term is used to describe the types and categories of patients treated by a health care facility or provider?
HCPCS level II modifiers consist of two characters that are
alphabetic or alphanumeric
one letter and one symbol
Provider services for inpatient medical cases are billed on what basis?
services not billed
New CPT codes go into effect
twice each year, on January 1 and July 1.
twice each year, on October 1 and April 1.
once each year, on October 1.
once each year, on December 1.
The legal business name of the practice is also called the
Modifiers are reported to
alter or change the meaning of the code reported to the CMS-1500 claim.
decrease the reimbursement amount to be processed by the payer.
increase the reimbursement amount to be processed by the payer.
indicate an alteration in the description of the procedure service performed.
Each relative value component is multiplied by the geographic cost practice index (GCPI), and then each is further multiplied by a variable figure called the
related work total
relative value unit
Qualified diagnoses are a necessary part of the patient’s hospital and office record; however, physician offices are required to report
qualified diagnoses for inpatients/outpatients
qualified diagnoses related to outpatient procedures
signs and symptoms in addition to qualified diagnoses
signs and symptoms instead of qualified diagnoses
RBRVS contains relative value components that consist of
geographic cost, work experience, expense to the practice.
intensity of work, expense to perform services, geographic location.
liability and work expense, practice expense, malpractice expense.
work expense, practice expense, malpractice expense.
Q codes are used
to identify services that would not ordinarily be assigned a CPT code (e.g, drugs, biologicals, and other types of medical equipment or services.
to identify professional health care procedures and services that do not have codes identified in CPT.
by state Medicaid agencies when no HCPCS level II permanent codes exist but are needed to administer the Medicaid program.
by regional MACs when exisiting permanent national codes do not include codes needed to implement a regional MAC medical review coverage policy.
“Incident to” relates to services provided by nonPARs that are defined as services
provided incidental to other services provided by a physician.
provided solely for the comfort and best interest of the beneficiary.
provided without the nonparticipating provider’s supervision.
that would otherwise not be reimbursed by the Medicare carrier.
Which special codes allow payers the flexibility of establishing codes if they are needed before the next January 1 annual update?
The prospective payment system providing a lump-sum payment that is dependent on the patient’s principal diagnosis, cormorbidities, complications, and principal and secondary procedures is
ambulatory payment classifications (APCs)
diagnosis-related groups (DRGs)
Medicare Physician Fee Schedule (MPFS)
resource-based relative value scale (RBRVS)
Level I HCPCS codes are created by the
Which statement is true of durable medical equipment?
It can withstand repeated use.
It is primarily used to serve a purpose of convenience.
It is routinely purchased by individuals who are not suffering from an illness or injury.
It is used by the patient in an outpatient rehabilitaiton facility.
Level II HCPCS codes are created by the
A bullet or black dot located to the left of a CPT code indicates
a deleted CPT code that should not be used.
a new, never previously published CPT code.
a revised CPT code from an earlier publication.
that special rules apply to the use of this code.
Which organization is responsible for providing suppliers and manufacturers with assistance in determining HCPCS codes to be used?
durable medical equipment, prosthetic, and orthotic supplies dealers.
statistical analysis Medicare administrative contractor.
HCPCS is a multilevel coding system that contains _________ levels.
CPT-4 is published annually by
CPT index terms that are printed in boldface are called
An example of a supplemental insurance plan is
The Medicare physician fee schedule amount for code 99213 is $100. Calculate the nonPAR allowed charge.
The purpose of the creation of HCPCS codes was to furnish health care providers with a :
mandate to use electronic claims submission
method for obtaining higher reimbursement from Medicare.
standardized language for reporting professional services, procedures, supplies, and equipment.
standardized way of reporting inpatient and outpatient diagnoses.
Medicare participating providers commonly report actual fees to Medicare but adjust fees after payment is received. The difference between the fee reported and the payment received is a
Nonparticipating (nonPAR) providers are restricted to billing at or below the
physician fee schedule
relative value scale
Modifiers are used with HCPCS codes to
change the original description of the service, procedure, or supply item.
decrease payment from Medicare.
increase payment from Medicare.
provide additional information regarding the product or service identified.
When is it appropriate to file a patient’s secondary insurance claim?
after a copy of the explanation of benefits is received by the practice
after the explanation of benefits is received by the patient
after the remittance advice is received by the medical practice
at the same time the primary insurance claim is filed, if the primary and secondary payers are different
Temporary additional payments over and above the OPPS payment made for certain innovative medical devices, drugs, and biologicals provided to Medicare beneficiaries are known as __________
Prospective price-based rates are established by the
actual charges for inpatient care reported to payers after discharge of the patient from the hospital.
payer, based on a particular category of patient.
reported health care costs from which a per diem rate has been determined.
When reporting CPT codes on the CMS-1500 claim, medical necessity is proven by
attaching a special report to the CMS-1500 claim.
linking the CPT code to its ICD-10-CM counterpart.
reporting ICD-10-CM codes for the patient’s condition.
sequencing CPT codes in a logical, chronological order.
The deadline for filing Medicare claims is
six months from the date of service
three years from the date of service
there is no deadline
none of the above
Birth dates are entered as ___________ on the CMS-1500 claim depending on block instructions.
DD MM YYYY or DDMMYYYY
MM DD YYYY or MMDDYYYY
MM DD YY or MMDDYY
YYYY MM DD or YYYYMMDD
A black triangle located to the left of a CPT code indicates that the code
has been deleted and should not be used.
has been revised from previous CPT publications.
has special rules that apply to its use.
is new to this edition of CPT.
Hospice provides which services for patients?
medical care in the home with the goal of keeping the patient out of the acute or long-term care setting
medical care, as well as psychological, sociological, and spiritual care
no copay if the patient has had a three-day minimum qualifying stay in an acute care facility
temporary hospitalization for a terminally ill, dependent patient for the purpose of providing relief from duty for the nonpaid caregiver of that patient
The ICD-10-CM system classifies
supplies and services
When office-based services are performed at a facility other than the physician’s office, Medicare payments are reduced because the physician did not provide the supplies, drugs, utilities, or overhead. This payment reduction is called a(n)
ambulatory payment classification
outpatient fee reduction
The reporting of diagnosis codes on the CMS-1500 claim is necessary to demonstrate
accuracy of the procedure code
quality of care
HCPCS “J codes” classify medications according to
generic or chemical name of drug, route of administration, and dosage.
generic or chemical name of drug, approval for Medicare coverage, and cost.
product name of drug, method of delivery, and cost.
product name of drug, route of administration, and dosage.
The diagnosis that is the most significant condition for which procedures/services were provided is the
CPT Appendix A contains information about
new code descriptions
Medicare administrative contractors must keep Medicare fees within a $20 million spending ceiling, as stated in the Balanced Billing Act (BBA). This is called
balanced budget rule
the Medicare spending limit
The document formerly known as the Explanation of Medicare Benefits is now known as the
Advance Beneficiary Notice
Medicare Payment Notice
Medicare Remittance Advice
Medicare Summary Notice
The hospital assigns CPT codes to report
inpatient ancillary services
inpatient and outpatient surgery
inpatient surgical procedures
outpatient services and procedures
The Medicare physician fee schedule amount for code 99213 is $100. The participating provider’s usual charge for this service is $125. Calculate the patient’s coinsurance amount.
The unique identifier that CMS will assign to providers as part of the HIPAA requirements is called the
Medicare is available to an individual who has worked at least
5 years in Medicare-covered employment, is at least 65 years old, and is a permanent resident of the U.S.
10 years in Medicare-covered employment, is at least 62 years old, and is a citizen of the U.S.
10 years in Medicare-covered employment, is at least 65 years old, and is a citizen or permanent resident of the U.S.
25 years in Medicare-covered employment, is at least 62 years old, and is a citizen of the U.S.
Which resources should be referenced when determining the potential for Medicare reimbursement?
CPT coding manual
HCPCS coding manual
ICD-10-CM coding manual
Medicare Carriers Manual and Coverage Issues Manual