Clinical Procedures & Protocols Flashcards

Under Medicare guidelines, which condition must be documented before a physician can order home health skilled nursing visits?

Answer: Patient must be homebound and require skilled care on an intermittent basis

Medicare home health eligibility requires the patient to be homebound and need skilled nursing or therapy on an intermittent basis.

A Medicare patient undergoes a colonoscopy and a polyp is removed during the same session. How is this typically billed?

Answer: The polyp removal is billed separately using a surgical code

When a therapeutic intervention such as polyp removal occurs during a diagnostic colonoscopy, the surgical procedure code replaces the diagnostic code and is billed separately.

Which Medicare part covers outpatient physical therapy services provided in a hospital outpatient department?

Answer: Medicare Part B

Medicare Part B covers outpatient therapy services including physical, occupational, and speech-language therapy provided in hospital outpatient settings.

A CMS specialist reviews a claim where a physician performed wound debridement using selective technique. What is the most critical documentation element to support medical necessity?

Answer: Wound size, depth, type of tissue removed, and clinical response

Wound debridement claims require detailed documentation of wound characteristics, tissue type removed, and clinical response to justify medical necessity.

Under the Medicare Physician Fee Schedule, what does the term 'global surgery period' refer to?

Answer: The period during which all related pre- and post-operative services are included in the surgical fee

The global surgery period bundles pre-operative, intraoperative, and post-operative services into one payment for a defined period (0, 10, or 90 days).

Which modifier should be appended when a physician performs a bilateral procedure that is normally unilateral under Medicare guidelines?

Answer: Modifier -50

Modifier -50 indicates a bilateral procedure was performed and signals Medicare to adjust payment accordingly, typically at 150% of the unilateral fee.

A Medicare beneficiary receives dialysis three times per week. Which payment model does Medicare use for End-Stage Renal Disease (ESRD) outpatient dialysis?

Answer: Prospective Payment System bundled rate per treatment

Medicare reimburses ESRD outpatient dialysis under the ESRD Prospective Payment System, which provides a bundled per-treatment rate covering most related services.