Chapter 3 — Quiz

Twenty-four questions. All fee schedule amounts are constructed.

Multiple choice

1. Medicare Part A covers:

  • A. physician office visits
  • B. inpatient hospital, skilled nursing facility, home health, and hospice
  • C. outpatient prescription drugs
  • D. durable medical equipment

2. The Part A deductible applies:

  • A. once per calendar year
  • B. once per benefit period
  • C. once per admission
  • D. once per lifetime

3. A benefit period ends after the beneficiary has been out of a hospital or skilled nursing facility for:

  • A. 30 consecutive days
  • B. 60 consecutive days
  • C. 90 consecutive days
  • D. one calendar year

4. The out-of-pocket maximum in Original Medicare is:

  • A. indexed annually
  • B. equal to the Part B deductible
  • C. there is none
  • D. set by the MAC

5. A non-participating provider is paid at what percentage of the participating fee schedule amount?

  • A. 80%
  • B. 95%
  • C. 100%
  • D. 115%

6. The limiting charge is:

  • A. 115% of the participating fee schedule amount
  • B. 115% of the non-participating fee schedule amount
  • C. 95% of the participating fee schedule amount
  • D. 80% of the approved amount

7. The participating fee schedule amount is \$500.00. The limiting charge is:

  • A. \$575.00
  • B. \$546.25
  • C. \$475.00
  • D. \$525.00

8. A document binding on all Medicare Administrative Contractors nationwide is a(n):

  • A. LCD
  • B. NCD
  • C. billing and coding article
  • D. MSN

9. The list of ICD-10-CM codes that support medical necessity for a service under a local policy is most often found in:

  • A. the LCD itself
  • B. the companion billing and coding article
  • C. the Medicare Summary Notice
  • D. the NCCI Policy Manual

10. An Advance Beneficiary Notice is appropriate when:

  • A. the service is statutorily excluded
  • B. a normally covered service is expected to be denied as not reasonable and necessary
  • C. issued routinely to every beneficiary
  • D. the beneficiary has Medicare Advantage

11. A patient enrolled in a Medicare Advantage plan should have claims sent to:

  • A. the Medicare Administrative Contractor
  • B. the Medicare Advantage plan
  • C. both, for coordination
  • D. CMS directly

12. Medicaid is:

  • A. the primary payer when a patient also has Medicare
  • B. the payer of last resort
  • C. administered uniformly by CMS
  • D. a Medicare supplement

13. A 66-year-old actively employed at a company with 14 employees, covered by the employer plan. Primary payer:

  • A. the group health plan
  • B. Medicare
  • C. either
  • D. Medicaid

14. The 100-employee threshold applies to Medicare entitlement based on:

  • A. age 65
  • B. disability
  • C. end-stage renal disease
  • D. all of the above

15. A provider may not bill for Medicare deductibles and coinsurance a beneficiary who is:

  • A. over 80
  • B. a Qualified Medicare Beneficiary
  • C. enrolled in Part D
  • D. in a Medicare Advantage plan

Short answer

16. Name the four channels through which Medicare's methodology reaches non-Medicare claims.

17. The participating amount is \$320.00. Compute the non-participating amount, the limiting charge, and the beneficiary's net out-of-pocket if a non-par provider does not accept assignment and the deductible is met.

18. Give three services or situations where a commercial payer commonly does not follow Medicare.

19. What does a Medicare Administrative Contractor decide, and what does it not?

20. Explain a crossover claim and the one indicator on the remittance advice you must read.

21. Why is "I have Medicare" an insufficient basis for deciding where to send a claim?

22. (Chapter 2) Distinguish participation from assignment in commercial insurance, then explain how Medicare links them.

23. Name four things you would verify about an LCD you found through a search engine before relying on it.

24. (Chapter 1) Medicare's approved amount is \$168.24 on charges of \$367.00, the deductible is met, and there is no secondary. State all four numbers and both checks.

Answer key **1.** B. **2.** B. **3.** B. **4.** C — and the consequence is that most Original Medicare beneficiaries carry supplemental coverage. **5.** B. **6.** B — 115% of the **non-participating** amount, which is itself 95% of the participating amount. This two-step is the most commonly missed calculation on the credential exams. **7.** B — \$500.00 × 0.95 = \$475.00; × 1.15 = \$546.25. Answer A is the error of applying 115% to the participating amount. **8.** B. **9.** B. **10.** B. **11.** B. **12.** B. **13.** B — fewer than 20 employees, so Medicare is primary. **14.** B. **15.** B. **16.** Pricing (the Medicare Physician Fee Schedule and its RVU methodology, referenced by most commercial contracts); correct coding edits (NCCI and MUE, adopted by most commercial payers); coverage determination structure (NCDs and LCDs, imitated by commercial medical policy); and the compliance and audit apparatus. **17.** Non-par: \$320.00 × 0.95 = **\$304.00**. Limiting charge: \$304.00 × 1.15 = **\$349.60**. Medicare reimburses the beneficiary 80% of \$304.00 = \$243.20. Beneficiary net out-of-pocket: \$349.60 − \$243.20 = **\$106.40**. (Against \$64.00 if a participating provider had accepted assignment — 20% of \$320.00.) **18.** Consultation codes (Medicare stopped recognizing the 992xx consultation family; many commercial payers still pay it); edits and modifier policy (commercial payers add and relax edits); preventive and screening benefits (different lists, frequencies, and modifiers — PT for Medicare, 33 for commercial). **19.** **Does:** process and pay claims, publish LCDs and billing and coding articles, enroll providers, conduct medical review, handle the first level of appeal, and publish education. **Does not:** set national policy, decide national coverage, or override an NCD. **20.** A crossover claim is a Medicare-adjudicated claim automatically forwarded to a registered secondary payer. **Read the crossover indicator on the remittance advice.** If it crossed, billing the secondary yourself creates a duplicate; if it did not, the claim will sit until you bill it. **21.** Because the patient may be in Original Medicare (claim to the MAC) or in a Medicare Advantage plan (claim to the plan), and both patients accurately describe themselves as having Medicare. Only the eligibility transaction distinguishes them. **22.** In commercial insurance, participation is a *pricing* question (a network contract with an agreed fee schedule) and assignment is a *routing* question (whether the payer pays the provider directly). Medicare links them: a **participating** provider has agreed to accept assignment on **all** claims, is paid the full fee schedule amount, and is paid directly. A non-participating provider decides assignment claim by claim, is paid 95%, and on unassigned claims collects from the beneficiary up to the limiting charge. **23.** Which **contractor/jurisdiction** published it, and whether that is your MAC; the **version and effective date**, since the policy in effect on the date of service governs; whether there is a **companion billing and coding article** carrying the code lists; and whether an **NCD** exists that supersedes or constrains it. **24.** Charge \$367.00 · Allowed \$168.24 · Contractual adjustment \$198.76 · Patient \$33.65 · Medicare \$134.59. Checks: 367.00 − 168.24 = 198.76 ✓ and 168.24 − 33.65 = 134.59 ✓