Apply Medicare Coverage Rules - Certified Professional Coder CPC

1. Which Medicare part covers most preventive services such as screening tests and vaccines when covered criteria are met?

   Medicare Part B. Promotes health maintenance by covering screenings, immunizations, and wellness visits at no or low cost when eligibility criteria are satisfied.

2. What is the Medicare rule that prohibits billing the beneficiary for covered services beyond allowed cost sharing?

   Limiting charge/balance billing restrictions (Medicare assignment rules). Protects beneficiaries by capping charges from non-participating providers at 115% of the fee schedule and prohibiting excess billing on assigned claims.

3. Identify the correct Medicare payment system for hospital outpatient department services under Part B.

   OPPS (APC-based payment). Bundles payments for outpatient services into ambulatory payment classifications, promoting efficiency and cost control in hospital settings.

4. What Medicare part is the Medicare Advantage program administered by private plans?

   Medicare Part C. Offers an alternative to Original Medicare through private insurers, combining Parts A and B benefits, often including prescription drugs.

5. Which Medicare part generally requires a beneficiary to be enrolled in Part A and Part B to join the plan?

   Medicare Part C (Medicare Advantage). Requires enrollment in Original Medicare (Parts A and B) as a prerequisite, allowing access to managed care alternatives with potential extra benefits.

6. Which payer is primary when a beneficiary has Medicare and an active employer group health plan from current employment?

   Employer group health plan is primary; Medicare is secondary. Under MSP rules, the employer plan pays first for active employees with group coverage of 20+ employees, with Medicare covering remaining costs.

7. Identify the correct coverage category for outpatient prescription drugs dispensed through a retail pharmacy.

   Medicare Part D. Offers coverage for self-administered drugs through private plans, with formularies determining included medications and tiered cost-sharing.

8. Identify the correct Medicare payment system for acute inpatient hospital stays under Part A.

   IPPS (MS-DRG-based payment). Reimburses hospitals a predetermined amount per discharge based on diagnosis-related groups adjusted for severity and other factors.

9. Which Medicare setting uses a prospective payment system based on Resource Utilization Groups (RUGs) historically?

   Skilled nursing facility (SNF) PPS (historically RUGs; now PDPM). Classifies residents based on clinical needs for per diem payments, transitioning from RUGs to PDPM for more patient-centered reimbursement.

10. What is the Medicare term for services that are reasonable and necessary for diagnosis or treatment?

    Medical necessity. Ensures services align with accepted standards of practice for diagnosing or treating conditions, forming the basis for Medicare coverage decisions.

11. What Medicare methodology is commonly used to pay physicians for Part B professional services?

    MPFS (Medicare Physician Fee Schedule). Calculates payments using relative value units for work, practice expense, and malpractice, adjusted by geographic factors and a conversion factor.

12. What is the term for a provider's agreement to accept Medicare allowed amount as payment in full?

    Accepting assignment. Providers agree to Medicare's approved amount as full payment, receiving 80% directly from Medicare after beneficiary cost-sharing.

13. Which notice is used for Medicare Advantage (Part C) to inform enrollees of potential noncoverage of services?

    Notice of Medicare Non-Coverage (NOMNC) or plan-specific denial notice. Issued at least two days before ending covered services in certain settings, allowing enrollees to appeal the decision promptly.

14. Which payer is primary when Medicare and no-fault insurance both relate to the same accident or injury?

    No-fault insurance is primary. MSP rules prioritize no-fault insurance for medical expenses from accidents, regardless of fault, before Medicare contributes.

15. What Medicare part provides outpatient prescription drug coverage through private plans?

    Medicare Part D. Delivers voluntary prescription drug benefits via private plans, helping beneficiaries afford medications not covered under Original Medicare.

16. What Medicare part primarily covers physician services and outpatient hospital services?

    Medicare Part B. Provides coverage for outpatient medical services, including doctor visits, preventive care, and durable medical equipment, requiring a monthly premium.

17. Which payer is primary for a beneficiary with Medicare and an employer plan from retiree coverage (not current employment)?

    Medicare is primary; retiree plan is secondary. MSP provisions designate Medicare as primary for retirees, as the plan is not tied to current employment, making the retiree plan supplemental.

18. Which Medicare part generally covers home health services when eligibility criteria are met?

    Medicare Part A or Part B (depends on qualifying context). Provides intermittent skilled care like nursing or therapy at home, under Part A post-hospitalization or Part B for ongoing needs if criteria are met.

19. Which Medicare part generally covers hospice care for terminally ill beneficiaries?

    Medicare Part A. Funds palliative care for terminally ill patients, including pain relief and support services, when curative treatment is no longer pursued.

20. What Medicare part primarily covers inpatient hospital care and skilled nursing facility care?

    Medicare Part A. Covers inpatient hospital stays, skilled nursing facilities, hospice, and some home health services for eligible beneficiaries without a monthly premium for most.

21. Which payer is primary when Medicare and workers' compensation both relate to the same work injury?

    Workers' compensation is primary. MSP rules require workers' compensation to cover work-related injuries first, preventing Medicare from paying primary for such claims.

22. Which Medicare rule determines whether Medicare pays first or second when other insurance exists?

    Medicare Secondary Payer (MSP) rules. Coordinates benefits to ensure Medicare pays only after primary insurers, reducing costs and preventing duplicate payments.

23. Which form must be used to notify a Medicare beneficiary that an item or service may not be covered under Part B?

    Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. Required for potential non-covered services, it informs beneficiaries of financial responsibility and allows them to decide whether to proceed.

24. Which Medicare part generally covers durable medical equipment (DME) when medically necessary?

    Medicare Part B. Includes outpatient benefits for items like wheelchairs and oxygen, provided they meet medical necessity and supplier requirements.

25. Which payer is primary when Medicare and liability insurance both relate to the same accident or injury?

    Liability insurance is primary. MSP guidelines establish liability insurance as primary for injuries from accidents where another party is responsible, with Medicare secondary.

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