Billing Regulations: ACO/NCCI/LCD/NCD/ (Pg. 73-76)

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Questions and Answers

What is the primary purpose of establishing a national definition of a global surgical package?

To prevent providers from billing for unnecessary services

To standardize Medicare payments for the same services (correct)

To ensure MACs make inconsistent payments across jurisdictions

To allow for higher reimbursement rates for certain services

What is 'unbundling' in the context of medical billing?

Creating new billing codes for existing procedures

Separately billing services that are usually billed together (correct)

Submitting claims without proper documentation

Billing for bundled procedures at a reduced rate

Which box in the CMS-1500 form is specifically used for reporting diagnosis codes?

Box 1

Box 21 (correct)

Box 33

Box 15

What is included in the CMS-1500 claim form to facilitate accurate billing?

Patient's demographic and insurance policy information Signup and view all the answers

What should a medical office staff member do when a patient arrives for an appointment?

Collect copayments and verify insurance eligibility Signup and view all the answers

When is the UB-04 form primarily used?

For inpatient care provided by institutional healthcare facilities Signup and view all the answers

In the billing process, what is a 'clean claim'?

A claim that contains all required billing and coding elements Signup and view all the answers

What is the electronic equivalent of the CMS-1500 form?

837P Health Care Claim: Professional Signup and view all the answers

What is a common method used by practices to collect overdue accounts?

Sending letters and making phone calls Signup and view all the answers

Who is typically responsible for verifying a patient's eligibility and copayment details?

The medical office staff or medical assistant Signup and view all the answers

What is an adjustment in the context of accounts receivable?

An amount added to or taken away from the balance of an account. Signup and view all the answers

What is a write-off in accounts receivable?

An amount removed from a balance due to uncollectibility. Signup and view all the answers

Which of the following describes the allowed charge?

The amount a payer agrees to reimburse for a procedure. Signup and view all the answers

What does the resource-based fee method consider?

The complexity, overhead costs, and risk related to the procedure. Signup and view all the answers

What does the UCR method stand for?

Usual, Customary, and Reasonable. Signup and view all the answers

Which factor is NOT considered in the resource-based fee structures?

Patient health insurance type. Signup and view all the answers

What does the term 'customary' refer to in the UCR method?

The range of fees charged by similar providers in the area. Signup and view all the answers

Which of the following describes Relative Value Studies (RVS)?

A list of 5-digit procedure codes with assigned unit values. Signup and view all the answers

What could cause variability in a provider's reimbursement schedule from insurance companies?

Differences in individual insurance company policies. Signup and view all the answers

Adjustments are often necessary for which of the following reasons?

To reflect uncollectible amounts and corrections. Signup and view all the answers

What is the purpose of an Accountable Care Organization (ACO)?

To improve the coordination of patient care Signup and view all the answers

How does the National Correct Coding Initiative (NCCI) function?

It controls which CPT code pairs can be reported together Signup and view all the answers

What is the role of a Local Coverage Determination (LCD)?

To determine the coverage of services within a specific region Signup and view all the answers

What does a National Coverage Determination (NCD) signify?

A nationwide decision on whether Medicare will cover a service Signup and view all the answers

What is incident-to billing primarily used for?

Billing for services provided by non-physician practitioners Signup and view all the answers

Which services cannot be assigned to an Accountable Care Organization (ACO)?

Medicare Advantage plans Signup and view all the answers

What is a characteristic of the information-sharing system used by ACOs?

It is protected by federal laws Signup and view all the answers

Who determines whether a service is reasonable and necessary under a Local Coverage Determination?

A Medicare Administrative Contractor Signup and view all the answers

What is a primary goal of using Electronic Health Records (EHRs) in ACOs?

To reduce redundancy in medical testing Signup and view all the answers

Which of the following is NOT a function of Accountable Care Organizations?

Directing which provider a patient must see Signup and view all the answers

Study Notes

Accountable Care Organizations (ACO)

ACOs coordinate patient care, share information securely, and may use EHRs for better communication.
Medicare patients participating in an ACO receive written notice or find information in a poster.
Medicare beneficiaries can be assigned to an ACO, but not Medicare Advantage plans, HMOs, or PPOs.

National Correct Coding Initiative (NCCI)

Developed by CMS for Medicare Part B and Medicaid claims.
An automated system preventing duplicate billing for similar procedures on the same day.

Local Coverage Determination (LCD)

Decision made by a Medicare Administrative Contractor (MAC) regarding whether a service is covered in their region.

National Coverage Determination (NCD)

Nationwide decision on whether Medicare will pay for a specific item or service.
If no NCD exists, coverage depends on local LCDs.

Incident-to Billing

Allows billing for outpatient services provided by non-physician practitioners (NPPs) in certain settings.
Examples of NPPs include nurse practitioners (NPs), physician assistants (PAs), and other non-physician providers.

Global Surgical Packages

Medicare established a national definition to ensure consistent payment for surgical services.
Designed to prevent Medicare payments for services that are bundled with the procedure.

Unbundling

Improper coding practice where bundled procedures are billed separately for higher reimbursement.
EHR software can facilitate unbundling.

CMS-1500

Used for reimbursement of professional services by physicians and suppliers.
Uniform format ensures consistency in claims across providers and insurers.
Electronic version is called X12 837 Health Care Claim: Professional 837P
Contains patient demographics, insurance policy information, and medical coding.

Claim Submission

Photocopy insurance card and check expiration date and eligibility.
Determine if prior authorization is required.
Use CMS-1500 form for submitting claims.
Claims must be signed by the physician and sent to a fiscal intermediary.
Claims submitted after the time limit may be reduced or rejected.

UB-04

Used for reimbursement of medical services provided by institutional healthcare providers.
Examples include hospitals, rehabilitation centers, nursing homes, and home health settings.
Electronic version is called 837I.
Consistent format with CMS-1500 for easier processing.

Payer Payment Policies

Certified staff responsible for collecting copays when patients register.
Verification of patient insurance information and eligibility is crucial.
Patients unable to provide payment require respectful handling.
Patient aging report used for overdue accounts.
Adjustments made to account balances to reflect contract amounts, credits, refunds, discounts, bad debt, and corrections.
Allowed charge is the amount the payer will pay for a procedure.
Reimbursement schedules vary depending on insurance company.

Methods for Determining Provider Payment Rates

Charge-based fees based on providers with similar services.
Resource-based methods consider complexity, overhead, and risk.
Usual, Customary, and Reasonable (UCR):
- Usual: provider's typical fee.
- Customary: fees charged by similar providers in the area.
- Reasonable: fee justifiable based on specific circumstances.
Relative Value Studies (RVS): list with codes and corresponding values for procedures.

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Description

Test your knowledge on the various Medicare regulations including Accountable Care Organizations, coding initiatives, and coverage determinations. This quiz covers essential billing practices and the role of non-physician practitioners in Medicare services.