Chapter 11: Government Carriers Flashcards
1
Q
To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service or procedure is payable, non covered, or bundled into another service?
A. PC/TC Indicator
B. Global surgery indicators
C. Status codes
D. Both A & B
A
C. Status codes
Rationale: Status codes should be reviewed to determine the status of a code, i.e. A= Active code, B=Bundled, D=Deleted
2
Q
A 45 year old patient is diagnosed with N18.6. Based on this diagnosis, would this patient be eligible for Medicare coverage?
A
Yes, because he has ESRD which is a condition that qualifies for Medicare benefits regardless of age.
3
Q
Tricare and CHAMPVA timely filing is?
A
1 year from DOS
4
Q
How often is the conversion factor is updated by CMS?
A
Annually.
5
Q
Which Tricare plan(s) are active-duty members required to enroll in?
A
Tricare Prime - Addition Prime options:
1. Tricare Prime Remote
2. Tricare Prime Overseas
3. Tricare Prime Remote Overseas
6
Q
Which Tricare option allows enrollees the most choices by utilizing the fee for service model?
A
Tricare Select
7
Q
What does the Omnibus Budge Reconciliation Act of 1990 require?
A
It requires all Medigap insurance policies to conform to minimum standards. Every Medigap policy must follow federal and state laws and clearly be identified as Medigap Insurance
8
Q
Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the medigap insurance company. This transfer of information is known as:
A
Cross-over
9
Q
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program associated with?
A
Medicaid - they must inform all Medicaid eligible individuals under 21 yo that EPSDT services are available
10
Q
How often are Medicaid agencies required to report EPSDT performance information?
A
Annually – State Medicaid agencies must inform all Medicaid-eligible individuals under 21yo that EPSDT services are available, and report the performance information on an annual basis
11
Q
Tricare is the healthcare program for which department of the US Government?
A
Dept of Defense (DOD)
12
Q
A Medicare patient receiving inpatient care in a critical access hospital would be covered under which Part?
A
Part A
13
Q
The term for a supplemental policy for Medicare is?
A
Medigap
14
Q
The Clinical Prior Authorization (PA) Program was implemented into Medicaid to assist in the monitoring of, what?
A
Drugs not on Medicaids Formulary. To:
-manage drug classes that require additional monitoring
-ensuring drugs are being prescribed for appropriate reasons
-drug expenditures
15
Q
Which formula is Medicare’s Payment amount for services determined by?
A
Total RVU X Conversion factor (CF) = Medicare Payment
16
Q
What is Medicaids minimum eligibility?
A
Federal poverty level
17
Q
Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium?
A
Medigap insurance company
18
Q
What are Medicare statutorily excluded services?
A
Non covered items and services and non reimbursed by Medicare
19
Q
What is Medicaids timely filing limit?
A
timely filing limits will vary from state to state.
20
Q
What is Medicare and who is eligible?
A
Medicare is a government program for US Citizens who have paid into SS.
Eligible:
- over 65yo
- those with certain disabilities
- ESRD(regardless of age)
21
Q
MBI never uses, what letters?
A
S, L, O, I ,B, Z: To avoid confusion.
22
Q
MBI: How many digits total is an MBI #? which spots are always alphabetic? Which are always numbers?
A
MBI is 11 digits long. Spots 2,5,8,9 are always alphabetic
Spots 1,4, 7, 10 & 11 are always numbers
23
Q
What options are available to contract with medicare?
A
- Participating Provider
- Non-participating provider
- Opt out
*Once a physician opts out, they cannot opt in for 2 years.
24
Q
What “incident to” services?
A
“Incident to” services are performed “incident to” the physician services.
- claims are submitted under the physicians name as if he personally performed the service = reimbursed at 100%
— services not “incident to” are billed under the NPPS NPI #s and reimbursed at 85% of the physician rate.
25
What is an ABN and when must it be signed?
- AKA waiver of liability. (Advanced Beneficiary Notice)
- ABN guidelines followed by DME, Hospice and HH
- 1 page long only. Containing: reason it may not be covered, est. cost of service ~$100 or 25% of actual cost, pt cannot be asked to sign a blank one.
26
What do these 4 ABN Modifiers mean?
GA, GX, GY, GZ
GA - Waiver of liability statement issued as required by payer policy, individual case.
GX - Notice of Liability issues, Voluntary under payer policy (MC never covers)
GY - Item or service statutorily excluded, does not meet any benefit definition
- GY=office understand that it is not covered by needs the denial EOB to forward to secondary ins.
GX and GY can be used together!!
GZ - item or service expected to be denied as not reasonable and necessary
- ABN was NOT obtained.
27
Common situations where Medicare is Secondary Payer (MSP)
- coverage through current personal or spouses employer
- disabled & covered through a group health plan
- ESRD & Group Health plan
- was in an accident or occurrence in which no-fault or liability insurance was involved
28
What is Medicares Timely Filing Limit and what are the 4 exceptions?
Timely Filing limit is 12 months from the DOS.
4 exceptions:
1. Admin error
2. Retroactive MC enrollment
3. Retroactive MC involving state Medicaid agencies
4. Retroactive dis-enrollment from a MC Adv plan or program of all inclusive care of the elderly provider organization
29
What are the 4 parts of Medicare?
Part A: Hospital
Part B: Medical
Part C: Medicare Advantage commercial plans = Part A and B
Part D: Prescription
30
What is the eligibility for Part A if 65+?
If you or your spouse Receives or is eligible for:
- SS Benefits
- RR Benefits
- worked in a govt job
- if you are a dependent parent of a fully insured child who is deceased.
* Can pay monthly premium if not eligible
31
When processing Medigap claims, Item 9a of the CMS-1500 claim form must have the policy and/or group number of the Medigap insured preceded by, what?
MG, MEDIGAP, or MGAP
32
The MBI contains 11 characters, what goes in spots 3 and 6?
3,6 can contain a letter or number
33
People are eligible for Part B Medicare at age 65 if:
1. they reside in the US
2. entitled to premium-free Part A benefits
34
People who are not eligible for premium-free Part A benefits may be eligible for Part B Medicare if:
1. US Citizen
2. either citizens or aliens who have been lawfully admitted for permanent residence with 5 years of continuously living in the US at the time of filing
35
What do you need from the member in order to verify their information through EDI?
- Last and first name
- DOB
- MBI
- gender
36
Hospital care, SNF, Nursing home care, hospice, HH and inpt care are covered under which part of Medicare?
Part A
37
Clinical research, Ambulance services, DME, mental health, some preventive services, provider services, outpatient care are all covered under which part of Medicare?
Part B
38
Which part of Medicare covers all of Part A except hospice and all of Part B?
Part C - Medicare Advantage plans
- can offer vision, hearing, dental, and/or health and wellness programs
39
What are the AWV codes and how often can they be billed per beneficiary?
G0402 -IPPE during the first 12 months of being on Medicare
G0438 - AWV once in a lifetime after the first 12 months of being on Medicare
G0439 - subsequent AWV
40
How often does Medicare cover Alcohol Misuse screening and Counseling?
once a year under Part B
41
How often does Medicare cover Bone Density measurements?
once every 24 months unless medically necessary to perform sooner.
42
Medicare covers Cardiovascular Disease Screening Blood Tests once every 5 years under which part?
Part A - checks lipid and cholesterol
43
Colorectal Cancer Screening - Medicare coverage
Part B covers beneficiaries ages 50+.
- Multitarget sDNA test: asymptomatic, 50-85 yo
- Screening Colonoscopies: 10 years
- FOBTs - 12 months
- Flexible sigmoidoscopies: 48 months
- barium enemas: 48 months
44
Part B covers Glaucoma screening for patients at high risk. What are the 4 risk factors?
1. Diabetes
2. Family hx of glaucoma
3. African American & +50yo
4. Hispanic American & +65yo
45
Under Part B, What benefit covers up to 10hours within 12months, that teaches patients with diabetes to manage their condition and prevent complications?
Diabetes self-management training (DSMT)
46
What must be met in order for Part b to cover Lung Cancer Screening Counseling?
- 55-77yo
- no sign or sx of lung cancer
- tobacco smoking hx of at least 30pack years (1pack/yr= 1 pack a day for a year: 1 pack = 20 cigarettes)
- current smoker or quit within last 15 years
47
PSA = Prostate Cancer screening
Part B
annually
men +50 yo
48
Screening for cervical cancer with HPV tests
Part B
every 5 years
females 30-65yo w/o sx
49
Screening Mammogram
Part B
+40yo every 12months
35-39yo for baseline
50
Screening Pap Test
Part B
every 2 years if not high risk and annually if high risk
51
What are 4 categories of items and services that are not covered under Medicare (AKA Statutorily excluded)?
1. not medically necessary
2. non covered items and services
3. bundled or included in another service
4. items and services reimbursable by other organizations or furnished without charge
52
What are non-covered items and services that are enacted, created, or regulated by statute, or Medicare guidelines that are not reimbursed by Traditional Medicare?
Statutorily Excluded
53
Services that are not covered by Medicare include:
- long term care (custodial care)
- dental care
- eye exam & glasses
- cosmetic surgery
- acupuncture
- hearing aids and fitting exams
- routine foot care
54
On an ABN, what information does (A), (B), & (C) contain?
(A) = provider name, address and phone number
(B) = Patient name as it appears on the MC Card
(C) = optional (MRN #; never social or MBI)
55
On an ABN, what information does The Body (D, E, F) contain?
(D)= general description of the item/service
(E) = reasons medicare may not pay
(F) = estimated cost
56
On an ABN, what information does Option (G) contain?
3 Options the beneficiary must select from
57
On an ABN, what information does (H), (I), & (J) contain?
(H) = Additional information
(I, J) = signature and date
58
What are the 5 levels of Medicare appeals that must be submitted in writing?
Level 1 - Redetermination; 120 days
level 2 - Reconsideration; 180 days
Level 3 - Administrative Law Judge; 60 days
Level 4 - Appeals Council: 60 days
Level 5 - Judicial Review; 60 days
59
A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the services rendered are $300.00. Medicare’s approved amount would be $200.00. What can the office charge this patient?
$300; optout providers can bill whatever they desire - cannot bill to Medicare
60
A Medicare patient presents for her pelvic, Pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed? Why or why not?
No, ABN must be signed prior to obtaining the service
61
A Medicare patient presents with an injury sustained at his job. His injury status is verified by his company. After services are rendered, in what order are the claims submitted?
workers comp primary and medicare is secondary
62
What is a health insurance program for low-income individuals and families that cannot afford healthcare costs?
Medicaid
63
Is Medicaid overseen Federally or by state?
Both.
Federal - Primary oversight
State - eligibility standards, type and scope of services, and rate of payment
64
Medicaid and what program cover about 72.5 million Americans including children, pregnant women, parents, seniors, and individuals with disabilities?
Children's Health Insurance Program (CHIP)
65
If an infant is born to a pregnant woman who is receiving Medicaid at the time of delivery, until when is the infant automatically enrolled in Medicaid?
until their 1st birthday
66
The Early Periodic Screening Diagnostic Treatment (EPSDT) benefit provides what?
Comprehensive and preventive healthcare services for enrolled children under 21 yo.
67
Medicaid Claims Filing Requirements
- cannot pay recipients
- provider must submit claim and accept assignment
68
Does Medicaid require paper or electronic claims?
Some states require electronic.
others let provider decide if paper or electronic
69
What is Medicaid's timely filing limit?
Varies by state.
70
When does Medicaid update their billing regulations and guidelines?
some states update weekly, monthly or quarterly
71
What is Medicaid's appeal process?
Varies by state
72
Which Medigap plans cover Part B deductible?
C, F
- member is not new to Medicare
73
Which Medigap plan(s) do not cover Part A deductible?
A
74
What is a claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier?
Mandated Medigap transfer AKA cross-over
75
What are the qualifications to be eligible for CHAMPVA?
Dept. of VA covers dependents of a veteran who either is rated permanently and totally disabled, or died of a service connected disability, OR died on active service and dependents are not eligible for Tricare
- sometime veterans can qualify
76
Under Tricare, which patients is Case Management offered to?
Patients with chronic, high-risk, high-cost catastrophic or terminal illnesses at no cost for short or long term needs
77
Under which Tricare plan do you need to live within a Prime Service Area and is a managed care option that allows enrollees to choose their primary care manager?
Tricare Prime
78
Which Tricare plan applies no annual deductible and no annual enrollment fee for active-duty members and their families unless their families use the POS option?
Tricare Prime
* If the families choose the POS option, they pay annual enrollment fees and network copays
79
Under Tricare Select, non-network providers can determine what on a claim-by- claim basis?
If they are participating or nonparticipating with Tricare
80
Who is eligible for Tricare Select? (6)
1. Active-duty family members
2. Retired members and their families
3. Family members of Activated members, and non-activated/retired members & families (at age 60)
4. Survivors
5. Medal of Honor recipients and families
6. Qualified former spouses
81
Who is eligible for Tricare Prime? (5)
1. Active or retired members and their families
2. Activated, non-activated (qualify for Transitional Assistance Management Program), or retired Guard/Reserve members and their families (at age 60)
3. Survivors
4. Medal of Honor recipients and families
5. Qualified former spouses
82
Are there any fees under Tricare Select?
no enrollment or annual fees only deductible and coinsurance for outpatient care
83
What is Tricare for Life?
A Medicare-wrap around coverage for Tricare eligible beneficiaries who have Part A and B.
- Enrollment is automatic if they have Part A & B
- Pays after Medicare unless overseas
84
What is Tricare Reserve Select?
A premium-based plan available world wide.
85
Who is eligible for Tricare Reserve Select? (3)
Members and their families of the Selected Reserve who are not:
1. On active duty orders
2. Covered under Transitional Management Program
3. Not eligible or enrolled in the FEHB program
86
Are there fees under the Tricare Reserve Select Plan option?
Yes, it requires monthly premiums, annual deductible, and cost share.
87
Tricare Young Adult is an option for who?
Adult children can purchase this option after eligibility for regular Tricare ends at age 21 or 23 if enrolled in college.
88
What is needed to qualify for Tricare Young Adult? (3)
1. At least 21yo but no older than 26
2. Unmarried
3. Enrolled in approved higher learning institution
89
Which Tricare plan is an option available through community-based, not-for-profit healthcare systems that is currently available in 6 areas for the US?
US Family Health Plan
90
What type of insurance is CHAMPVA?
A fee-for-service insurance that allows enrollees to see any provider they choose.
91
Under which insurance plan is the Beneficiary Counseling and Assistance Coordinators (BCACs) available to its members?
Tricare
92
In order to be eligible for Tricare, where must a member register?
Defense Enrollment Eligibility Reporting System (DEERS)
93
Which numbers can a provider use to verify Tricare eligibility?
SSN (9 digits)
DBN Number (DoD Benefits Number)(11-digits)
94
Which number is 10-digits and NOT used for Tricare eligibility or for filing claims?
DoD ID Number
95
Which providers can see can see Tricare patients?
Network and Non-network providers
They both must be a Tricare authorized provider.
96
Which charges can be appealed through Tricare?
Charges denied as not covered or not medically necessary
97
What quantifies and reimburses physicians services relative to one another?
Resource-based Relative Value Scale (RBRVS)
98
What components does the RBRVS incorporate?
1. Physician Work
2. Practice Expense (PE)
3. Professional Liability Insurance (PLI)
99
What is a relative value unit (RVU) assigned to?
Physician work, PE, and PLI
100
Work RVU + PE RVU + PLI RVU = ?
Total RVU
101
What is the conversion factor?
The dollar amount by which each CPT codes Total RVU is multiplied to obtain the reimbursement for a given service
102
When and who updates the conversion factor (CF)?
CMS updates it annually
103
What is is applied for locality code differences for the Work, PE, and PLI components nationally?
Georgia Practice Cost Index (GPCI)
104
Total RVU x CF = Medicare Payment = ?
[(Work RVU x Work GPCI)+(PE RVU x PE GPCI)+(PLI RVU x PLI GPCI)]
105
What is a status code?
A code that reflects Medicare coverage and payment policy.
- payable
- noncovered
- bundled
106
What do the status codes A, B, C represent?
A - Active Code
B - Bundled Code
C - Carrier-priced Code
107
[(Work RVU x Work GPCI)+(PE RVU x PE GPCI)+(PLI RVU x PLI GPCI)] = ?
Total RVU x CF = Medicare Payment
108
Which status code identifies a code as Excluded by Regulation?
E
109
Which status code identifies a code as Not Valid for Medicare Purposes?
I
110
Which status code identifies a code as a Non-Covered Service?
N
111
Which status code identifies a code as Statutory Exclusion?
X
112
PC/TC Indicators indicate a service's technical and professional component breakdown. What do the indicators represent? (#'s 0-9)
0 = Physician service codes
1 = Diagnostic tests/radiology
2 = Professional Component ONLY
3 = Technical Component Only
4 = Global Test
5 = Incident to
6 = Laboratory physician
8 = physician interpretation codes
9 = not applicable
113
What can help in understanding if modifiers TC or 26 are applicable?
PC/TC Indicators
114
Code 93041 Rhythm ECG, 1–3 leads, tracing only without interpretation and report has an indicator of 3. How can you bill 93041?
3 indicates that it is a technical component only code.
It should NOT be billed with 26 and billing with TC is not necessary since it is a technical code
115
Code 93042 Rhythm ECG, 1–3 leads, interpretation and report only has an indicator of 2. How can you bill 93042?
2 = professional component only code.
it should NEVER be billed with TC and 26 is unnecessary
116
What do these Global Surgery Day Indicators represent?
XXX, YYY, ZZZ
XXX - Global surgery doesnt apply
YYY - Global surgery period concept determined by MAC
ZZZ - Code falls within global surgery period for another service
117
The Multiple Procedure Indicators, #s 0-7 & 9, indicate the applicable payment adjustment rule. What are the indicators?
*(SR = Special Rules & SP = Standard Payment)
0 = no payment adj
1 = SP adj rules in effect before Jan 1, 1996 apply (100%; 50%; 25%)
2 = SP adj rules apply (100%; 50%)
3 = SR for Endoscopic procedures if billed with another endoscopic proc. of the same family
4 = SR for TC of diagnostic imaging if billed with another diag imaging in same family (100%; 50%)
5 = -20% of the PE component for certain therapy services (-25% if institutional setting)
6 = SR for TC of mult. diagnostic CV services. 100% on highest payment under MPFS; then @ 75%
7 = SR for TC of multiple ophthalmology (100% of highest pay: then at 80%)
9 = concept does not apply
118
The Bilateral Procedure Indicators, #s 0, 1, 2, 3, & 9, indicate services subject to payment adjustment. What are the indicators?
0 = 150% pay doesnt apply (bilateral code available)
1 = 150% pay adj applies
2 = 150% pay adj doesnt apply. Code identifies a bilateral serv.
3 = Usual pay adj for bilat doesnt apply. pays 100% for each side.
9 = Concept doesn't apply
119
The Assistant at Surgery indicators, 0,1,2, & 9, indicates services where an assistant at surgery is never paid for, per the Medicare Claims Manual. What are the indicators?
0 = pay restriction applies unless supp. doc is submitted
1 = Statutory pay restriction applies (No pay)
2 = no pay restriction. (asst. paid)
9 = Concept does not apply
120
The Co-surgeon indicators, 0,1,2, & 9, indicates services for which two surgeons, each in different specialty, may be paid. What are the indicators?
0 = Co-surg not permitted for procedure
1 = Co-surg could be paid w/supp doc.
2 = Co-surg permitted; no doc required if from 2 specialties
9 = Concept does not apply
121
The Team Surgery indicators, 0,1,2, & 9, indicates services for which team surgeons may be paid. What are the indicators?
0 = Team surg not permitted
1 = Team surg paid w/ supp doc
2 = Team surg permitted; paid by report
9 = Concept does not apply
122
The Endoscopic Base Code Field identifies the endoscopic base code for any code with a multiple surgery indicator of 3. What are the 2 ways payment is calculated?
1. Non base code is billed with Base code = No payment on Base code is made.
2. +2 codes from the same family are billed, the first code is paid in full; (fee schd amnt for base code) - (fee schd amt for all other endo codes) = payment
* Ref: last example on CH 11 right before Sec. Review 11.2
123
What is the formula to get Medicares approved amount for nonpar providers?
nonpar approved amount = 95% of fee schedule
(MC approved fee for procedure "allowed amt") x 0.95 = Medicares approved fee for nonpar
124
What is the formula to get Medicares nonpar providers limiting charge?
Nonpar limiting charge is 115% of the Medicare approved amount for nonpar.
(MC apprv. amount for nopar) x (1.15[AKA 115%]) = Limiting charge
125
At what percentage is the Medicare Fee Schedule paid to Participating, & nonparticipating (assigned claim)?
Participating (100%)
Nonpar- assigned claim (95%)
