CCC CCC Reimbursement & Payer Policies 1 — Questions and Answers
Question 1: Which Medicare program part primarily covers outpatient cardiology services such as ECGs and stress tests performed in a physician office?
- Medicare Part A
- Medicare Part B (Correct answer)
- Medicare Part C
- Medicare Part D
Correct answer: Medicare Part B
Medicare Part B covers outpatient physician and diagnostic services, including office-based cardiology procedures.
Question 2: What does the term 'global period' refer to in cardiology reimbursement?
- The total annual payment for a provider
- The number of days post-procedure during which follow-up visits are included in the procedure fee (Correct answer)
- The worldwide coverage policy of a payer
- The billing cycle for chronic cardiac conditions
Correct answer: The number of days post-procedure during which follow-up visits are included in the procedure fee
The global period is the post-operative timeframe (typically 0, 10, or 90 days) during which related follow-up care is bundled into the original procedure payment.
Question 3: A cardiology practice submits a claim for a service that is already bundled into a previously billed procedure. This practice is known as:
- Upcoding
- Unbundling (Correct answer)
- Downcoding
- Balance billing
Correct answer: Unbundling
Unbundling occurs when separate codes are billed for services that should be reported as a single bundled code, which is a compliance violation.
Question 4: Which modifier is used to indicate that a procedure was performed by two surgeons, each with distinct roles, during a cardiac surgery?
- Modifier -51
- Modifier -62 (Correct answer)
- Modifier -80
- Modifier -59
Correct answer: Modifier -62
Modifier -62 is appended when two surgeons each perform a distinct part of a procedure, commonly used in complex cardiac surgeries.
Question 5: Prior authorization in cardiology billing is primarily required to:
- Increase the fee schedule amount
- Ensure medical necessity is approved by the payer before a non-emergency service is rendered (Correct answer)
- Allow same-day payment processing
- Bypass claims adjudication
Correct answer: Ensure medical necessity is approved by the payer before a non-emergency service is rendered
Prior authorization confirms payer approval of medical necessity before scheduled procedures, reducing claim denials.
Question 6: The Medicare Physician Fee Schedule (MPFS) values procedures using which three components of the Resource-Based Relative Value Scale (RBRVS)?
- Diagnosis, procedure, and outcome
- Work RVU, practice expense RVU, and malpractice RVU (Correct answer)
- Surgeon skill, equipment cost, and overhead
- CPT code, ICD-10 code, and NDC code
Correct answer: Work RVU, practice expense RVU, and malpractice RVU
MPFS payment is calculated from the sum of work RVU, practice expense RVU, and malpractice expense RVU, each multiplied by the conversion factor.
CCC CCC Reimbursement & Payer Policies 1
Which Medicare program part primarily covers outpatient cardiology services such as ECGs and stress tests performed in a physician office?