Reimbursement & Claims Processing Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reimbursement & Claims Processing flashcards as text
Which place of service (POS) code is used for services rendered in a patient's home?
Answer: POS 12
POS 12 designates the patient's home as the location where services were provided, which affects reimbursement rates under Medicare.
A claim is submitted with an incorrect NPI for the rendering provider. Under HIPAA, which transaction standard governs claim submission that requires this information?
Answer: X12 837P
The X12 837P transaction set is the HIPAA-standard electronic claim format for professional services and requires the NPI of the rendering, referring, and billing providers.
When billing for a global surgical package, which of the following services is NOT typically included in the global period payment?
Answer: Treatment of a new unrelated condition during the global period
Treatment of a new, unrelated condition that arises during the global period is billed separately and is not included in the global surgical package.
Under Medicare Part B, what percentage does a patient typically pay as coinsurance after meeting the annual deductible?
Answer: 20%
After meeting the annual Part B deductible, Medicare generally pays 80% of the approved amount and the beneficiary is responsible for 20% coinsurance.
A coder is reviewing a claim where the physician performed a surgical procedure and separately billed for an assistant surgeon. Which modifier should the assistant surgeon use?
Answer: Modifier 80
Modifier 80 is appended to indicate that the physician served as an assistant surgeon during the procedure, which typically reduces payment to a percentage of the primary surgeon's fee.
What is the key distinction between Medicare Part A and Part B coverage?
Answer: Part A covers inpatient hospital and skilled nursing facility care; Part B covers outpatient and physician services
Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health services, while Part B covers outpatient, physician, and preventive services.
Which CMS program targets improper payments by using data analytics to identify and stop fraudulent claims before payment is made?
Answer: Fraud Prevention System (FPS)
The Fraud Prevention System (FPS) uses predictive analytics to identify potentially fraudulent Medicare fee-for-service claims and can suspend payments before they are made.