CMS Medicare Specialist Claims Processing & Billing Procedures 2 — Questions and Answers
Question 1: Which Medicare claim form is used by institutional providers such as hospitals and skilled nursing facilities?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- CMS-1490S
- CMS-10114
Correct answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard institutional claim form used by hospitals, SNFs, and other facility-based providers.
Question 2: A Medicare claim is returned to a provider as 'unprocessable' (RTP). What is the primary distinction between an RTP and a claim denial?
- An RTP means the claim was partially paid
- An RTP means the claim was never processed and must be corrected and resubmitted, while a denial has been adjudicated (Correct answer)
- An RTP and a denial are legally identical
- An RTP can only be appealed, not corrected
Correct answer: An RTP means the claim was never processed and must be corrected and resubmitted, while a denial has been adjudicated
An RTP (Return to Provider) means the claim lacked required data and was never entered into processing; it must be corrected and resubmitted, unlike a denied claim which has been adjudicated.
Question 3: Under Medicare Secondary Payer (MSP) rules, when a patient has both Medicare and an employer group health plan (EGHP) and the employer has 20+ employees, which pays primary?
- Medicare always pays primary
- The EGHP pays primary and Medicare pays secondary (Correct answer)
- They split costs 50/50
- The patient chooses which pays primary
Correct answer: The EGHP pays primary and Medicare pays secondary
For working aged beneficiaries whose employer has 20 or more employees, the EGHP is primary and Medicare is secondary under MSP rules.
Question 4: What is the timely filing deadline for initial Medicare Part B claims submitted by participating providers?
- 90 days from date of service
- 6 months from date of service
- 1 year from date of service (Correct answer)
- 2 years from date of service
Correct answer: 1 year from date of service
Medicare requires initial claims to be filed within one calendar year (12 months) from the date of service.
Question 5: A provider submits a claim with diagnosis code Z00.00 as the primary diagnosis for a Medicare patient receiving chemotherapy. What issue does this present?
- Z codes are never valid on Medicare claims
- The primary diagnosis should reflect the condition being treated (e.g., the cancer), not a routine exam code (Correct answer)
- Z00.00 is only valid for Part A claims
- This is acceptable as long as a secondary diagnosis is listed
Correct answer: The primary diagnosis should reflect the condition being treated (e.g., the cancer), not a routine exam code
For active treatment services like chemotherapy, the primary diagnosis should be the condition being treated (the malignancy), not a general encounter/routine exam code.
Question 6: Which modifier is appended to a CPT code to indicate a service was performed bilaterally?
- Modifier 50 (Correct answer)
- Modifier 51
- Modifier 59
- Modifier 76
Correct answer: Modifier 50
Modifier 50 is used to report bilateral procedures performed during the same operative session.
Question 7: When billing Medicare for durable medical equipment (DME), which MAC processes these claims?
- The local Part A MAC based on the provider's location
- The local Part B MAC based on the provider's location
- One of four national DME MACs based on the beneficiary's state (Correct answer)
- Any MAC the supplier chooses
Correct answer: One of four national DME MACs based on the beneficiary's state
DME claims are processed by one of four regional DME MACs (Durable Medical Equipment Medicare Administrative Contractors) determined by the beneficiary's state of residence.
CMS Medicare Specialist Claims Processing & Billing Procedures 2
Which Medicare claim form is used by institutional providers such as hospitals and skilled nursing facilities?