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ch 4. Outpatient Facility Billing
Outpatient Facility Billing
198
Health Care
Not Applicable
03/08/2017
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Term
The CMS-1500 claim form is used for reporting
 Definition
physician services in ASC
Term
The UB-04 claim form is used for reporting
 Definition
facility services in the outpatient hospital setting
Term
When submitting a claim the following questions are answered
 Definition
Who? is the provider who performed the service and the patient who received care.
What? CPT and HCPCS codes are reported to identify the services performed and supplies used.
Where? the location the services are rendered.
Why? the reason the services were performed. ICD-10 codes identify diagnoses treated.
Term
Medicare has national procedures and standards that encompass
 Definition
both inpatient and outpatient claims
Term
ACA
 Definition
Affordable Care Act. Obama passed March 23,2010
Term
What does the ACA mean
 Definition
requires insurance companies to cover all applicants within new minimum standards and to offer the same rates regardless of pre-existing conditions or sex.
requires all individuals not covered by an employer-sponsored health plan (Medicaid, Medicare or other public insurance program) to have an approved private -insurance policy or to pay a penalty. (there are exceptions).
Includes subsidies to help those with low incomes.
Term
There are only two types of payers
 Definition
Private insurance plans
government insurance plans
Term
commercial carriers are
 Definition
private payers that offer both group and individual plans.
The contracts they provide may vary, but may include hospitalization, basic and major medical coverage.
Term
Blue Cross Blue Shield
 Definition
Private payer. usually operate in the state in which they are based. Blue Cross offers the hospital benefits and Blue Shield provides medical and surgical benefits.
Term
The most significant government insurer is
 Definition
Medicare
Term
What is Medicare
 Definition
A federal health program administered by CMS. Provides coverage for people age 65 and over, for blind and disabled, people with permanent kidney failure or end stage renal disease(ESRD).
Term
What serves as the last word in coding requirements for Medicare and non-medicare payers
 Definition
CMS regulations
Term
The medicare program is made up of several parts and they are?
 Definition
Part A
Part B
Part C
Part D
Term
Medicare Part A covers
 Definition
helps cover inpatient hospital care, as well as care provided in SNF, hospice, and home health.
Term
Medicare Part B covers
 Definition
Physician services
outpatient care
other medical services including some preventative services not covered under Part A
Optional benefit, patient pays premium
Generally requires annual deductible and co-insurance.
Term
coders working in outpatient facilities and ASC mainly deal with Medicare part
 Definition
B
Term
Blue Cross Blue Shield
 Definition
Private payer. usually operate in the state in which they are based. Blue Cross offers the hospital benefits and Blue Shield provides medical and surgical benefits.
Term
The most significant government insurer is
 Definition
Medicare
Term
What is Medicare
 Definition
A federal health program administered by CMS. Provides coverage for people age 65 and over, for blind and disabled, people with permanent kidney failure or end stage renal disease(ESRD).
Term
What serves as the last word in coding requirements for Medicare and non-medicare payers
 Definition
CMS regulations
Term
The medicare program is made up of several parts and they are?
 Definition
Part A
Part B
Part C
Part D
Term
Medicare Part A covers
 Definition
helps cover inpatient hospital care, as well as care provided in SNF, hospice, and home health.
Term
Medicare Part B covers
 Definition
Physician services
outpatient care
other medical services including some preventative services not covered under Part A
Optional benefit, patient pays premium
Generally requires annual deductible and co-insurance.
Term
coders working in outpatient facilities and ASC mainly deal with Medicare part
 Definition
B
Term
Medicare part C is also known as
 Definition
Medicare Advantage
Term
Medicare part C
 Definition
combines benefits of part A, B and sometimes part D.
Managed by private insurers approved by Medicare and may include Preferred Provider Organizations (PPO), Health Maintenance Organizations(HMO) and others.
plans may vharge different co-payments, co-insurance, or deductibles for service.
Term
On Medicare Advantage Claims reimbursement is affected by
 Definition
the patients health status.
Term
The Centers for Medicare & Medicaid Services-Hierarchical Condition Category (CMS-HCC) risk adjustment model
 Definition
provides adjusted payments based on a patient's diseases and demographic factors.
Term
Medicare Part D
 Definition
is a prescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage.
Term
Medicaid is
 Definition
a health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments. Administered on a state-by-state basis(each state adheres to certain federal guidelines), and coverage varies
Term
Some state funded insurance programs that provide coverage for children up to 21 years of age may include
 Definition
Crippled Children's Services, Children's Medical Services, Children's Indigent Disability services, and Children with Special Healthcare Needs. Typically these programs are designed for beneficiaries with specific chronic medical conditions.
Term
When the facility contracts with the insurance carrier it is considered
 Definition
a participating provider (par provider)
Term
Participating providers are required
 Definition
to accept the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract.
Term
What happens to the difference between the allowed payment amount from the insurance and the facilities fees.
 Definition
The par provider is to adjust the difference (ie. write off).
Term
is the non-par provider required to make adjustment between the allowed amount and the facility charges
 Definition
no.
Term
non-par provider
 Definition
facility not contracted with the insurance carrier
Term
Limiting charge
 Definition
for Medicare services, even if a provider is non-par there are limits set on what can be charged for each CPT code.
Term
Medigap
 Definition
type of health insurance policy or other health benefit plan offered by a private entity to supplement Medicare benefits for patients. Does not include limited benefit coverage available to Medicare beneficiaries such as specified disease or hospital indemnity coverage. Excludes a policy or plan offered by an employeer to employees, as well as that offered by a labor organization to members or former members.
Term
Medicare Secondary Payer (MSP)
 Definition
secondary to workers compensation, automobile, and medical no-fault and liability insurance. Also to Employer Group Health Plans(EGHP) and certain employer health plans covering aged and disabled beneficiaries. the program prohibits payment if it can be made by another payer.
Term
ESRD beneficiaries and medicare
 Definition
Medicare is secondary payer during the first 30 months of the beneficiary's entitlement to ESRD benefits.
Term
ABN
 Definition
Advance Beneficiary Notice. a signed document that notifies patients that Medicare may not cover a certain procedure or service
Term
If the provider expects that Medicare may deny the items or services, the facility must
 Definition
advise the beneficiary before the items or services are furnished.
Term
ABN
 Definition
Advance Beneficiary Notice. a signed document that notifies patients that Medicare may not cover a certain procedure or service
Term
If the provider expects that Medicare may deny the items or services, the facility must
 Definition
advise the beneficiary before the items or services are furnished.
Term
ABNs are not required for
 Definition
care that is statutorily excluded from coverage under Medicare (care never covered) or fails to meet a technical benefit requirement (ex lacks required certification)
Term
A proper notice for an ABN is what?
 Definition
is an approved standard form.
Term
What happens to notices not using a mandatory standard notice form
 Definition
may be ruled defective.
Term
In the absence of an approved notice whats required for it to constitute the proper notice document
 Definition
a notice containing the proper language.
Term
ABN must meet
 Definition
acceptable notification standards to be valid.
Term
An example of a proper notice
 Definition
Form CMS R-131.
Term
When a procedure or service is provided without subsequent Medicare coverage and the ABN isn't signed by the patient who is responsible for the cost
 Definition
The provider is responsible
Term
When providers and beneficiaries ask Medicare contractors about coverage for services that require an ABN contractors must
 Definition
provide a written notice, within 45 days of receipt of requests, explaining coverage or noncoverage based on description of the physicians' services, medical necessity documentation, and other documents.
Term
If the determination from the Medicare contractor is not favorable
 Definition
the beneficiary may receive the service and have a claim submitted to the contractor.
Term
If the contractor denies a claim submitted to them the beneficiary may
 Definition
appeal through the regular appeals process.
Term
a beneficiary who decides against the prior determination process, but chooses to receive the service and seek coverage
 Definition
retains appeal rights.
Term
An ABN must
 Definition
be written in lay language
specify the items or services for which payment will be or will likely be denied.
specify the reason the provider believes Medicare payment will be or will likely be denied.
specify the estimated cost. Medicare expects the estimate will fall within $100 or 25% of the actual costs, whichever is greater.
Be delivered by a qualified notifier (hospital personnel) to the beneficiary or an authorized representative, before the items or services are furnished
Be received and comprehended by the beneficiary or authorized representative
Term
An ABN is considered defective when
 Definition
if the notice is unreadable, illegible, or incomprehensible; is given during an emergency; or the beneficiary (or authorized representative) is under great duress, is coerced, or misled by the notifier of the contents or delivery of the notice.
Term
In cases where the notice is given more than one year before items or services were furnished
 Definition
it is considered defective.
Term
The ABN notice is given routinely to all Medicare beneficiaries and/or the statement to
 Definition
merely indicate there is a possibility Medicare will not pay for the items or services without further explanation.
Term
The limit for use of a single ABN for an extended course of treatment is
 Definition
one year
Term
When is a previously furnished ABN acceptable
 Definition
when it specifies similar or reasonably comparative items or services for which denial is expected on the same basis as in earlier cases.
Term
When should the ABN be presented to the patient?
 Definition
before a procedure is initiated and before and before physical preparation of the patient (disrobing, in a treatment room)
Term
delivery of notice is permissible during an encounter when notifier determines prior to rendering the procedure that an ABN would be appropriate if
 Definition
the patient is capable of receiving notice and is given a reasonable opportunity to act. (prior to anesthesia).
Term
If the patient is in a state that they may not be able to understand their rights and the notice the facility should
 Definition
take appropriate steps in the absence of an authorized representative. ie brail for blind.
Term
How does CMS view the situation if the patient was not capable of comprehending the notice
 Definition
as the patient not receiving proper notice and not responsible for the items or services provided. The facility would then have to write off the charges.
Term
If the beneficiary changes their mind after completing and signing the ABN what should be done?
 Definition
The notifier should have the beneficiary annotate the original, previously completed ABN. The ABN must be provided as soon as possible.
Term
The annotation on the ABN must include
 Definition
a clear indication of his or her new option selection, along with the beneficiary's signature and date of annotation.
Term
If the notifier is unable to present the ABN to the beneficiary in person, for them to annotate then what should they do?
 Definition
The notifier may annotate the form to reflect the beneficiary's new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date, and return. The ABN must be provided as soon as possible.
Term
If after completing and signing the ABN, a beneficiary changes their mind and a related claim has been filed what action should be taken?
 Definition
The claim should be revised or cancelled, if necessary, to reflect the beneficiary's new choice.
Term
What if the beneficiary refuses to sign a properly executed ABN
 Definition
The facility should consider not providing the item or service to the patient unless the health and safety of the patient is compromised or there is a civil liability in the case of harm.
Term
What if the patient refuses to pay or sign the ABN but demands the service
 Definition
The facility should have a second person witness that the ABN was provided and beneficiary refused to sign. The facility should then file the claim as having provided the ABN and the beneficiary will be held liable.
Term
When facility needs a second person to witness a refusal ABN and there is no one on site
 Definition
the witness may be contacted via telephone to witness the patient refusal to sign the ABN.
Term
When the patient has refused to pay or sign the ABN but demands the service on the claim the coder
 Definition
appends the HCPCS code with modifier GA to procedure codes to indicate to CMS that the patient has signed an ABN form, and report occurrence code 32.
Term
The patient has two choices when it comes to services not covered by Medicare
 Definition
To pay out of pocket or not to obtain the service.
Term
Routine notice (blanket ABN) defined by CMS
 Definition
When there are no specific identifiable reasons documented as to what and why Medicare will not cover the item or service. Does not give the patient the specific items or services that may be denied. Not an effective method of executing an ABN.
Term
Blanket ABN
 Definition
does not give the patient the specific items or services that may be denied.
Term
For items or services that are statutorily noncovered is an ABN required?
 Definition
No. The facility may give the patient an ABN indicating the reason for expected denial. EX. Medicare never pays for this item/service. No claim need be submitted to Medicare unless the beneficiary demands it.
Term
What does the facility report when the patient demands a claim for a statutory noncovered item to be submitted to Medicare
 Definition
The facility reports condition code 21. When using code 21 you do not append modifier GY.
Term
What if an item or service has a frequency limitation and may not be paid.
 Definition
The facility should alert the Medicare patient in the ABN.
Term
When experimental items or services are furnished, the ABN should
 Definition
contain language to the effect that Medicare doesn't pay for services it considers to be experimental for research use.
Term
ABN can remain effective for
 Definition
may describe treatment of up to a year's duration, as long as no other triggering events occurs.
Term
triggering events
 Definition
typically occurs at three points during a course of treatment; initiation, reduction, and termination.
Term
If a new triggering event occurs with the one year period what must happen
 Definition
a new ABN must be given.
Term
Antidumping Statue
 Definition
AN ABN should not be given to a patient until the patient's condition has been stabilized. Includes completing a medical screening exam to determine the presence or absence of a medical emergency.
Term
Delaying medical screening examination or necessary stabilizing treatment by a hospital violates
 Definition
the antidumping statue
Term
When must an ABN be signed?
A. After the service is rendered?
B. Prior to providing the service?
C. Only when the service is statutorily excluded
D. If the patient requests prepayment determination
 Definition
Answer B. Prior to providing the service.
The patient must be notified in advance in order to make an informed decision. The ABN should be present to the patient before a procedure is initiated and before physical preparation of the patient(disrobing, attaching therapeutic equipment)
Term
The purpose of Medigap insurance is to:
A. Fill the gap in Medicare coverage by providing payment for deductibles and coinsurance or other limitations.
B. Fill the gap in Medicare coverage by providing payment for the deductible
C. Fill the gap in Medicare coverage by providing payment for the coinsurance.
D. Fill the gap in Medicare coverage by providing payment for coinsurance and other limitations.
 Definition
A. Fill the gap in Medicare coverage by providing payment for deductibles and coinsurance or other limitations.

Medigap fills in some of the gaps in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare.
Term
A routine ABN is appropriate who return to the facility more than once?
A. True
B False
 Definition
B False.
Routine is defined by CMS when there are no specific identifiable reasons documented as to what and why Medicare will not cover the item or service. A blanket ABN does not give the patient the specific items or services that may be denied.
Term
A hospital has an obligation to provide emergency services to a patient under what federal act?
A. Emergency Medical Treatment and Medical Care ACt
B. Emergency Active Labor Act for Medical Treatment
C. Emergency Medical Active Treatment Labor Act
D. Emergency Medical Treatment and Active Labor Act
 Definition
D. Emergency Medical Treatment and Active Labor Act.
Emergency Medical Treatment and Active Labor Act(EMTALA) is a federal act that mandates patients presenting to the emergency room need to have a medical screening. A hospital should not give financial responsibility forms or notices to a patient or attempt to obtain an agreement to pay for services before the individual is stabilized.
Term
When medicare is the secondary payer:
A. Medicare will pay the claim and submit the balance to the secondary payer.
B. Medicare payment for items or services is prohibited if another payer under certain conditions can make payment.
C. Medicare is the secondary payer for all ESRD claims.
D. Denial of payment when a patient has other insurance.
 Definition
B. Medicare payment for items or services is prohibited if another payer under certain conditions can make payment.
When Medicare is the secondary payer, the claims must be filed to the primary payer. Once the primary payer adjudicates the claim, Medicare will review the claim to determine if additional reimbursement is appropriate.
Term
In the event that the ABN is properly executed and they deny the claim what is the patients responsibility?
 Definition
The patient is fully responsible. Meaning must pay full amount the provider charges. Don't get the adjusted amount break as you do with insurance coverage.
Term
Asking the patient to pay for services that are bundled would be considered
 Definition
double billing
Term
What are condition codes and when are they used?
 Definition
Mandatory for claims when the ABN is signed or when the item or service is statutorily not-covered and/or the patient demands the facility to file the claim
Term
Demand billing
 Definition
when the patient demands that a bill be submitted to Medicare for review.
Term
Condition code 20
 Definition
Called Beneficiary requested billing
appropriate when noncovered services are provided without a signed ABN and patient demands that a bill be submitted to Medicare for review.
Only used when coverage is in question.
Never use this if an ABN is on file.
Providers can still collect payment(if medicare pays the claim, provider must return payment).
Term
Condition code 21
 Definition
Billing for denial notice
Reported when an item or service is statutorily noncovered and teh patient or other payer request billing Medicare to receive a denial so that the claim may be passed onto subsequent payers.
An ABN should not be used on a claim with this code.
patients are assumed liable for the charges.
Term
Occurrence code 32
 Definition
means that an ABN was given to a beneficiary on a specific date.
services on this claim must be statutorily covered, even if found to be non-covered due to lack of medical necessity.
can't be used on same claim with code 20 or 21.
After full adjudication the services are non-covered then patient liable for services.
Term
HCPCS has modifiers for ABNs to indicate
 Definition
whether an ABN has been properly executed prior to furnishing services to a Medicare beneficiary.
Term
A Medicare patient is schedule for a procedure Medicare does not lawfully pay for. The facility ask the patient to sign the ABN, but the patient refuses. The facility bills the patient for the service and the patient refuses to pay. Is the patient liable in this situation? Why?
 Definition
Yes. When the statute excludes the service, an ABN is not necessary and refusal to sign the ABN does not exempt the patient from payment responsibility.
Term
A Medicare patient was to undergo a procedure based on a diagnosis that was not medically necessary for Medicare reimbursement. The surgery technician presented the ABN appropriately to the patient, but the patient refused to sign the ABN. The surgery technician documented on the ABN that the patient refused to sign. The technician asked the nurse to witness the patient's refusal to sign. The patient insisted on undergoing the procedure and the surgeon agreed to perform the service. Medicare denied the claim because the diagnosis did not support medical necessity for the service. What is the most appropriate action?
A. The hospital may not collect anything form the patient because the patient never signed the ABN.
B. The hospital may collect only the deductible and coinsurance from the patient.
C. The hospital may not collect anything from the patient because medical necessity for the procedure is not a good reason for the patient to sign the ABN.
D. The hospital may bill the patient and collect the full amount of the bill.
 Definition
D.
If the patient demands the service, but refuses to pay or sign the ABN, the facility should have a second person witness the aBN was provided and the fact the beneficiary refused to sign. If there is only one person on site, a second person may be contacted via telephone to witness the patient refusal to sign the ABN.
Term
An ABN rendered in a timely manner is important for the facility to receive payment when Medicare does not cover the service, because the diagnosis does not support medical necessity. The facility may:
A. Notify the patient well in advance of the service being provided.
B. Have the patient sign the ABN after the service is performed.
C. Have the patient sign the ABN routinely after the patient is prepared for the service or procedure.
D. Have the patient sign the ABN after administration of anesthesia.
 Definition
A.
The Medicare beneficiary must be notified well in advance in order to make an informed decision.
Term
An ABN was presented to a 68 year old Medicare patient for services that might not be covered. The services facing denial were specified on the ABN. The ABN did not specify the reason Medicare might likely deny the claim. The patient signed the ABN and the claim was denied. The patient received a bill from the facility and insists she did not understand the ABN or what she was signing. Is the patient responsible for payment?
A. The patient is responsible for payment since she signed the ABN.
B. The ABN did not specify the reason Medicare might deny the claim so the patient is not responsible for payment.
C. The patient is responsible for payment and may appeal to Medicare.
D. None of the above.
 Definition
B.
Because the ABN didn't specify the reason the patient is not liable.
Term
An ABN must have the the following:
 Definition
Be written in lay language.
Specify the items or services for which payment will be or will likely be denied.
Specify the reason the reason the provider believes Medicare payment will be or will likely be denied.
Give an estimate or cost for the items and service being provided.
Be delivered by a qualified notifier(hospital personnel) to the beneficiary or authorized representative, before the items or services are furnished.
Be received and comprehended by the beneficiary or authorized representative.
Term
The purpose of an ABN is to?
A. notify the patient that the item or service is lawfully excluded.
B. Notify the patient that the item or service may be covered and to make sure the patient is aware of the charges.
C. Notify the patient that the item or service may not be covered.
D. Notify the patient that the services will be covered under specific conditions.
 Definition
C.
An ABN is a signed document that notifies the patient that Medicare may not cover a certain procedure or service as well as why the service may not be paid.
Term
What is the Outpatient Code Editor (OCE)
 Definition
A tool developed by Medicare in 1987 and used by Medicare FIs/MACs when processing outpatient claims. (hospital outpatient departments, community mental health centers (CMHC), and limited services from comprehensive outpatient rehabilitation facilities (CORF), home health agencies, and hospice services)
Term
The OCE performs two major functions:
 Definition
1. Edits claims data to identify errors and return a series of edit flags (demographic edits, procedure edits, and general coverage edits).
2. Assigns am ambulatory payment classification (APC) number for each service covered under OPPS and return information to be used as input to the Pricer program. functions only on a single claim and doesn't cross over to other claims.
Term
pricer program
 Definition
a tool used to estimate Medicare prospective payment system (PPS) payments.
Term
The original OCE consisted of how many edits
 Definition
14
Term
The OCE can accept up to how many line items per claim?
 Definition
450
Term
Each claim represents a collection of data that consists of demographic (header) data, and all services provided called
 Definition
line items
Term
Services are organized into a single claim record on UB-04 and passed as a unit to the
 Definition
OPPS OCE.
Term
The OCE will order line items by
 Definition
date of service.
Term
When the claim spans more than one calendar day, the OCE
 Definition
subdivides the claim into separate days to determine discounting and multiple visits on the same day.
Term
The header and line items are passed through the OCE by means of a
 Definition
control block of pointers.
Term
There are currently how many edits in the OCE
 Definition
98
Term
The edit returns consist of
 Definition
a list of edit numbers that occurred for each procedure, modifier, diagnosis, or date.
Term
The occurrence of an edit can result in one of six different dispositions
 Definition
Claim rejection
Claim denial
Claim Return to Provider
Claim Suspension
Line item rejection
line item denials
A single claim can have one or more edits in all six dispositions.
Term
Claim Rejection
 Definition
There are one or more edits present that cause the whole claim to be rejected. A claim rejection means that the provider can correct and resubmit the claim,but cannot appeal the claim rejection.
Term
Claim Denial
 Definition
There are one or more edits present that cause the whole claim to be denied. A claim denial means the provider cannot resubmit the claim, but can appeal the claim denial.
Term
Claim Return to Provider (RTP)
 Definition
There are one or more edits present that cause the whole claim to be returned to the provider. A claim RTP means the provider can resubmit the claim once the problems are corrected.
Term
Claim Suspension
 Definition
There are one or more edits present that cause the whole claim to be suspended. A claim suspension means that the claim is not RTP, but is not processed for payment until the MAC makes a determination or obtains further information
Term
Line Item Rejection
 Definition
There are one or more edits present that cause one or more individual line items to be rejected. A line item rejection means the claim can be processed for payment with some line items rejected for payment. The line item can be corrected and resubmitted but cannot be appealed.
Term
Line Item Denials
 Definition
There are one or more edits present that cause one or more individual line items to be denied. A line item denial means the claim can be processed for payment with some line items denied for payment. The line item cannot be resubmitted, but can be appealed.
Term
Edit 18 causes
 Definition
all other line items on the same day to be line item denied with edit 49. no other edits are performed on any lines with edit 18 or 49.
Term
If edit 27 is triggered
 Definition
no other edits are performed on the claim.
Term
edits 4 and 5 are not applicable
 Definition
for patients's reason for visit diagnosis
Term
edits 3 and 8 (sex conflict edits) are bypassed if
 Definition
condition code 45 is present on the claim
Term
For code g0428 with SI=E
 Definition
edit 9 is not applied/is bypassed.
Term
The non-opps hosp column is for
 Definition
non-opps hospital bill types allowed for the edit condition
Term
y* =
 Definition
edits apply to non-opps hospital claims
Term
Should a claim with OCE edits be submitted to the MAC.
 Definition
if the hospital considers the claim to be coded accurately and completely, it should be submitted.
Term
claims scrubbing software
 Definition
also called an APC scrubber. Most hospitals use this as part of the billing systems to alert them to potential edits prior to claim submission.
Term
the CMS-1500 is for
 Definition
physicians, NPPs, and ASC services to all payers. (other providers can also submit this form).
Term
Referring provider
 Definition
a provider who requests an item or service for the beneficiary.
Term
Ordering provider
 Definition
a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician's or non-physician practitioner's service.
Term
Supervising provider
 Definition
a provider who provided oversight of the rendering provider and the care being reported.
Term
The UB-04 (CMS 1450) is submitted for
 Definition
inpatient and outpatient hospital, CAHs, and CORFs.
Term
Revenue codes identify
 Definition
Revenue center
Inpatient or outpatient services
Type of service
Term
How are revenue codes handled on the claim form
 Definition
listed in numerical sequence
not repeated on same bill except when required by MAC or for coding more than one HCPCS code for the same revenue code item.
summed at the zero level
typically software will sequence the revenue codes and sum line items.
Term
instead of using revenue code 0272 multiple times on the claim
 Definition
list it once with multiple units and add all the fees together on the same line item.
Term
Medicare requires that all hospital outpatient medical and clinical services, including other diagnostic procedure codes subject to payment limitation and all-inclusive rates bill
 Definition
using HCPCS codes. This can be HCPCS level I codes (CPT) or HCPCS level II codes.
Term
who may designate specific revenue code assignments for HCPCS codes
 Definition
CMS or MAC
Term
CMS advises hospitals to use revenue codes for
 Definition
the cost center to which those services will be assigned.
Term
revenue codes are typically built into
 Definition
CDM (charge master description)
Term
Most of the services in the medicine section
 Definition
can be performed in the outpatient setting and are coded through the CDM.
Term
For outpatient hospital billing purposes the concept of technical component vs professional component
 Definition
the modifiers is not used on the UB-04.
Term
In the medicine section of CPT some procedures have a code for the professional component and a code for the technical component. the hospital should assign
 Definition
the CPT code representing the technical component of the service.
Term
If the hospital employs the cardiologist or radiologist they will also bill for the
 Definition
professional fee and bill on CMS-1500 form depending on the payer.
Term
modifier TC is required for services performed in
 Definition
ASC and should be included on the CMS-1500 for ASC services.
Term
OCE is an abbreviation for
A. Outpatient Code Editor
B. Outpatient Condition Edits
C. Outpatient Code Edits
D. Outpatient Condition Editor
 Definition
A
Term
revenue codes are typically built into
 Definition
CDM (charge master description)
Term
The OCE originally began with 14 edits. How many edits are in existence for 2016 v17.2?
A45
B 73
C 62
D 98
 Definition
D
Term
The abbreviation RTP indicates
A The claim is a line item rejection and cannot be resubmitted.
B The claim must be returned to the provider for correction.
C. The claim is suspended for further information.
D. The claim has a status indicator of S and is bundled into another procedure.
 Definition
B
RTP means return to provider. The claim must be returned to the provider for correction in order to properly process the claim.
Term
Which statement is true regarding diagnosis codes on the CMS-1500 claim form?
A ICD-9 and ICD-10 codes can be reported on the same claim with the appropriate ICD indicator for each code.
B. ICD-10 codes are reported with the ICD indicator 0.
C. ICD-9 codes are reported with the ICD indicator 1.
D. Diagnosis codes are not linked to procedure codes on the CMS-1500 claim form.
 Definition
B.
Do not report both ICD-9 and ICD-10 codes on the same claim form.
the ICD indicator for ICD-9 is 9 and ICD 10 is 0.
Diagnosis codes are linked to procedure codes.
Term
Which qualifier is used to report the provider number for the rendering provider?
A. 82
B. 0B
C. 1G
D. G2
 Definition
C
OB, 1G, and G2 are secondary identifier qualifiers.
82 is for the rendering provider
Term
MACs
 Definition
medicare administrative contractors (private insurance companies) contracts with CMS to perform processing functions on behalf of Medicare, including claims processing and adjudication functions.
Term
There are five levels of appeal, name them
 Definition
Redetermination
Reconsideration
Administrative Law Judge (ALJ)
Appeals Council Review
Judicial review in U.S. District Court
Term
providers and suppliers who do not accept assignment have what kind of appeal rights?
 Definition
Limited appeal rights
Term
Level 1 in the appeals process is
 Definition
Redetermination.
Term
The request for redetermination must include
 Definition
patient name
Medicare Health Insurance Claim (HIC) number
Specific service or item for which redetermination is being requested.
date of service
name and signature of person or representative requesting redetermination
all evidence should be submitted for reconsideration to support payment of claim.
Term
Some steps for filing the redetermination include
 Definition
attach copy of original claim
copy RA with denial
photocopy all other documents to justify
operative reports, path reports, lab reports, etc
detailed summary of item, service, and/or procedure
cover letter explaining why claim should be paid
mail certified with return receipt requested
keep copy of all documents in pending file
Send to MAC
Term
in redetermination the provider will receive notice via
 Definition
a Medicare redetermination notice (MRN) from your MAC or if the initial decision(determination) is reversed and the claim is paid in full, you will receive a revised RA.
Term
If redetermination is denied the provider may request
 Definition
a reconsideration.
Term
The second level appeal is
 Definition
reconsideration.
Term
MACs conduct reconsideration within how many days
 Definition
60 days of receipt of the request for reconsideration.
Term
how many days do you have to file for redetermination
 Definition
120 days from date of receipt of the RA that list the initial determination (denial).
Term
How many days does the MAC have to reconsider redetermination.
 Definition
The MAC has 60 days of receipt of request.
Term
reconsideration level of review is in what form?
 Definition
its a paper review.
Term
What happens in a reconsideration?
 Definition
QIC doesn't conduct hearings but independently reviews the initial determination including redetermination and all issues related to payment of the claim.
Term
reconsideration may include review of
 Definition
medical necessity issues by a panel of physicians or other health care professionals. providers and suppliers are required to submit all of the evidence they want considered in the claim.
Term
at the reconsideration level for appeals if evidence is not submitted what may happen?
 Definition
may be excluded at subsequent levels of review.
Term
how many days does the provider have to file request for reconsideration?
 Definition
Must be within 180 days of the receipt of the medicare redetermination notice or ra from MAC
Term
steps for filing the reconsideration
 Definition
attach copy of original claim
copy RA with all denials and the MRN
photocopy all other documents to justify appeal
operative reports, path reports, lab reports, etc
detailed summary of item, service, and/or procedure
cover letter explaining why you disagree with redetermination
mail certified with return receipt requested
keep copy of all documents in pending file
submit any evidence as noted in the redetermination as missing
submit any other evidence revelant to the appeal
Send to QIC
Term
if the QIC denies the reconsideration you may take what action?
 Definition
you may go to the next level of appeal.
Term
If there is new evidence to submit to the QIC regarding the claim for reconsideration will it be allowed?
 Definition
it will not be allowed unless cause can be presented as to why the evidence was not submitted initially.
Term
The third level of appeal is through
 Definition
an ALJ hearing
Term
The request for an ALJ hearing must be made
 Definition
withing 60 days of receipt of the reconsideration decision letter or after the expiration of the reconsideration period. Submit only the Medicare appeal number for the reconsideration you are appealing.
Term
The hearings are held by
 Definition
video-teleconference or by telephone.
Term
What if the appellant does not want a VTC or telephone hearing
 Definition
they may ask for an in-person hearing or they may also ask the ALJ to make a decision without a hearing.
Term
What must the AIC be for an ALJ hearing
 Definition
must be greater than or equal to 150 for 2016. This amount is updated annually.
Term
Timeframe for an ALJ to issue their decision on the hearing
 Definition
generally issue a decision within 90 days of receipt of the hearing request;however this timeframe may be extended.
Term
Should the ALJ not complete their decision within the timeframe what are they suppose to do?
 Definition
inform the appellant of his rights to escalate the case to the Appeals Court.
Term
due to all time high record receipt levels for ALJ they have asked
 Definition
that resubmission of a request not be made unless 22 weeks have lapsed since submission of the request.
Term
in order for the ALJ to handle the volume they ask us not to
 Definition
submit records. they communicate with prior levels of appeal to obtain the administrative record which has everything that has been submitted.
Term
When the request for a hearing is assigned to ALJ they will send
 Definition
a notice of assignment with the name and address of the ALJ assigned to the case.
Term
again if you are trying to submit evidence at the ALJ level you can
 Definition
send directly to ALJ withing 10 calendar days of receipt of the Notice of Hearing and a statement for new evidence why it was not previously submitted.
Term
If appellant is not satisfied with the third appeal level (ALJ) or wishes to escalate appeal because ALJ ruling timeframe passed. they can file for
 Definition
fourth level of appeal; a review by the Medicare Appeals Council.
Term
file a request for Appeals council review must be done
 Definition
within 60 days of being notified of the ALJs decision.
Term
The Medicare Appeals Council is part of
 Definition
the Departmental Appeals Board of HHS.
Term
whats the aic for Medicare Appeals Council
 Definition
there is no AIC.
Term
Generally, the Appeals Council issues a decision within
 Definition
90 days of request, although this timeframe may be extended. But if it extends from an escalated appeal then they have 180 days from the date of receipt of the request for escalation to issue a decision.
Term
The appellant in the Appeals Council can escalate
 Definition
to the judicial review level.
Term
The appeals council conducts the review with
 Definition
on the evidence in the record, unless a new issue is raised on appeal.
Term
do you have a right to a hearing at the appeals council level
 Definition
no
Term
When the appeals council decision overturns a previous denial
 Definition
the MAC is notified that it must pay the claim according to the appeal council decisions with 30-60 days.
Term
What is the fifth level of appeal?
 Definition
U.S. District Court.
Term
What is the timeframe a request for a hearing before the federal district court can be requested?
 Definition
within 60 days of receipt of the appeals councils decision or after the appeals council ruling timeframe expires.
Term
What is the AIC for appeals at the federal district court level?
 Definition
meet or exceed 1,500 for 2016. These amounts are adjusted annually.
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