- A Medicare beneficiary receives a service that is denied because it is deemed not medically necessary per a National Coverage Determination (NCD). An ABN was not issued prior to the service. Who bears financial responsibility for the denied claim?
Answer: The provider — they cannot bill the patient without a valid prior ABN
When a provider fails to issue a valid ABN before providing a service that Medicare subsequently denies as not medically necessary, the provider cannot bill the patient and must absorb the cost. The ABN is a prerequisite for shifting financial liability to the patient. Providers who routinely waive patient cost-sharing without an ABN may also face compliance issues.
- Medicare Part B covers which of the following categories of services?
Answer: Physician services, outpatient care, and preventive services
Medicare Part B covers medically necessary physician services, outpatient hospital care, durable medical equipment, and certain preventive services. Part A covers inpatient hospital, skilled nursing facility, and hospice care. Part D covers outpatient prescription drugs. Part B requires a monthly premium and typically involves a 20% coinsurance after the annual deductible.
- A provider submits a claim to Medicare using the CMS-1500 form. In which field is the NPI (National Provider Identifier) of the billing provider reported?
Answer: Box 33
On the CMS-1500 claim form, Box 33 contains the billing provider's name, address, phone number, and NPI. Box 24J contains the rendering provider's NPI for each line item. Box 17 contains the referring provider's name and NPI. Box 25 contains the federal tax ID number. Understanding the CMS-1500 field structure is essential for accurate claim submission.
- Medicare covers a colorectal cancer screening colonoscopy for average-risk beneficiaries at age 50 and older once every how many years?
Answer: 10 years
Medicare covers a screening colonoscopy for average-risk Medicare beneficiaries once every 10 years after age 50. For high-risk beneficiaries, the frequency is once every 2 years. If a polyp is found and removed during a screening colonoscopy, changing the procedure from screening to diagnostic does not change the patient's cost-sharing if it began as a screening exam under current Medicare policy.
- Medicare Part C, also known as Medicare Advantage, is administered by which type of organization?
Answer: Private insurance companies approved by Medicare
Medicare Part C (Medicare Advantage) plans are administered by private insurance companies that contract with Medicare to provide Part A and Part B benefits, and often Part D coverage, to enrolled beneficiaries. These plans may offer additional benefits beyond traditional Medicare but must cover all Medicare-required services. Beneficiaries enrolled in Medicare Advantage cannot use traditional Medicare providers unless the plan allows it.
- A non-participating Medicare provider (non-PAR) who accepts assignment on a specific claim may charge the patient up to what percentage of the Medicare fee schedule amount?
Answer: 109.25%
Non-participating providers who accept assignment on a claim are paid 95% of the Medicare fee schedule amount (5% less than PAR providers). When a non-PAR accepts assignment, they cannot charge more than the Medicare-approved amount for that claim. The 115% limiting charge applies only to non-PAR providers who do not accept assignment — they may charge up to 115% of the non-PAR fee schedule, which is 109.25% of the Medicare fee schedule.
- A Medicare patient has Medicare as the secondary payer. Their employer group health plan (EGHP) is primary. The EGHP pays its portion first, and then Medicare is billed. What is this billing process called?
Answer: Coordination of Benefits (COB) under the Medicare Secondary Payer (MSP) rules
The Medicare Secondary Payer (MSP) rules govern situations where Medicare is not the primary payer. Coordination of Benefits (COB) ensures that the primary insurer pays first and Medicare covers only applicable remaining costs. The MSP program protects Medicare from paying primary when another payer has primary responsibility (e.g., employer group health plan, workers' compensation, auto liability insurance).
- A Medicare patient requires durable medical equipment (DME). Which Medicare part covers DME provided in the outpatient/home setting?
Answer: Medicare Part B
Medicare Part B covers durable medical equipment (DME) prescribed for use in the patient's home. Examples include wheelchairs, walkers, hospital beds, and oxygen equipment. The DME must be medically necessary, prescribed by a physician, and meet Medicare's definition of DME (durable, medical in nature, used in the home, and able to withstand repeated use). A Certificate of Medical Necessity (CMN) may be required.
- A non-participating Medicare provider does not accept assignment on a claim. What is the maximum amount the provider may charge the Medicare patient?
Answer: 109.25% of the Medicare fee schedule
When a non-participating provider does not accept assignment, they are subject to the limiting charge — a maximum of 115% of the non-PAR fee schedule. Since non-PAR providers are paid at 95% of the Medicare fee schedule, 115% of 95% equals approximately 109.25% of the standard Medicare fee schedule. Charging above the limiting charge is a Medicare violation.
- A physician who participates in Medicare accepts assignment on all claims. What does accepting assignment mean?
Answer: The physician agrees to accept the Medicare-approved amount as payment in full and cannot balance-bill the patient
A participating Medicare provider (PAR) accepts assignment on all claims, meaning they agree to accept the Medicare-approved amount (the fee schedule amount) as payment in full. Medicare pays 80% of the approved amount after the deductible; the patient is responsible for the 20% coinsurance. PAR providers cannot balance-bill patients beyond the approved amount.
- Medicare Part D provides coverage for which type of service?
Answer: Prescription drugs dispensed through outpatient pharmacies
Medicare Part D is a voluntary prescription drug benefit covering outpatient pharmacy-dispensed medications. It is provided through private plans approved by Medicare. Part D does not cover drugs administered in a hospital inpatient setting (covered under Part A) or drugs administered in the physician office as part of a covered Part B service (such as chemotherapy infusions, covered under Part B).
- A provider opts out of Medicare entirely. What are the billing implications for Medicare beneficiaries who receive services from this provider?
Answer: The provider and patient must enter into a private contract; Medicare will not pay anything for the service
Providers who opt out of Medicare cannot bill Medicare or receive Medicare payment for any services provided to Medicare beneficiaries. Instead, the provider and patient enter into a private contract that details the services and fees. Medicare will not reimburse any portion of services provided under a private contract. This is distinct from non-participating status, where the provider can still bill Medicare.
- A Medicare patient is seen for a routine physical examination (not a wellness visit) that Medicare does not cover. The physician performs the exam and also addresses the patient's hypertension during the same visit. How should the billing be handled?
Answer: Issue an ABN for the physical exam; bill Medicare only for the separately identifiable medical E/M service with modifier -25
Medicare does not cover routine physical examinations. However, if a separately identifiable, medically necessary E/M service is also performed (addressing hypertension), that portion is coverable. An ABN should be issued for the non-covered routine physical. The medical E/M is billed to Medicare with modifier -25 to indicate it is a significant, separately identifiable service. The patient is billed directly for the non-covered physical portion.
- A Local Coverage Determination (LCD) issued by a Medicare Administrative Contractor establishes coverage criteria for a specific service. What is the geographic scope of an LCD?
Answer: Regional — it applies only within the jurisdiction of the MAC that issued it
Local Coverage Determinations (LCDs) are developed and issued by individual Medicare Administrative Contractors (MACs) and apply only within their specific geographic jurisdiction. Different MACs may have different LCDs for the same service. NCDs take precedence over LCDs when both exist for the same service. Providers must follow the LCD applicable to their MAC's jurisdiction.
- Which of the following preventive services is covered by Medicare Part B at no cost to the beneficiary (no deductible or coinsurance) when billed correctly?
Answer: Influenza vaccination and administration
Medicare Part B covers certain preventive services at no cost-sharing to the beneficiary, including influenza, pneumococcal, and hepatitis B vaccinations. The Annual Wellness Visit (AWV) is also covered without cost-sharing. Routine physicals are not covered. Labs ordered at a preventive visit may or may not be covered without cost-sharing depending on whether they are part of the covered preventive benefit.
- A Medicare beneficiary has both Medicare Part B and a Medigap (Medicare supplemental insurance) policy. Medicare processes the claim and pays its portion. Who is billed next?
Answer: The Medigap insurer automatically, through crossover claims processing
When a Medicare beneficiary has a Medigap policy, Medicare crossover claims processing automatically forwards the claim to the Medigap insurer after Medicare processes its payment. The Medigap policy is designed to cover the patient's cost-sharing obligations (deductibles and coinsurance). The provider should not bill the patient for the Medigap-covered portion before the Medigap insurer processes the crossover claim.
- A Medicare patient with end-stage renal disease (ESRD) is enrolled in a Medicare Advantage (Part C) plan. The patient requires dialysis services. Which entity is responsible for the primary payment of dialysis services?
Answer: The Medicare Advantage plan
Medicare beneficiaries enrolled in a Medicare Advantage (Part C) plan receive all their Medicare-covered benefits — including dialysis for ESRD — through the private insurer administering the plan, not through traditional Medicare Part A or B. The Medicare Advantage plan is responsible for the primary payment of covered services, including dialysis. Traditional Medicare does not pay separately when a beneficiary is enrolled in Medicare Advantage.
- A National Coverage Determination (NCD) establishes a Medicare coverage policy. Which entity issues NCDs?
Answer: The Centers for Medicare & Medicaid Services (CMS) at the national level
National Coverage Determinations (NCDs) are issued by CMS at the national level and apply uniformly across all Medicare Administrative Contractors and regions. NCDs establish whether a particular item or service is covered or non-covered under Medicare. Local Coverage Determinations (LCDs), by contrast, are developed by individual MACs and apply only within their geographic jurisdiction.
- The resource-based relative value scale (RBRVS) used by Medicare to determine physician payment consists of three components. Which component accounts for the largest percentage of the total relative value?
Answer: Physician work (52%)
The Medicare RBRVS assigns relative value units (RVUs) to physician services based on three components: physician work (52%), practice expense (44%), and professional liability insurance (PLI) (4%). The physician work component — which reflects time, technical skill, mental effort, and risk to the patient — comprises slightly more than half of the total relative value for any given service.
- Medicare's Annual Wellness Visit (AWV) for an established patient is reported with which HCPCS code?
Answer: G0439
HCPCS code G0439 covers the Annual Wellness Visit (AWV) for subsequent years (established patients). G0438 covers the Initial Preventive Physical Examination (IPPE), also known as the "Welcome to Medicare" exam, for new enrollees. CPT® codes 99387 and 99397 are preventive medicine visit codes used for non-Medicare patients; Medicare does not recognize these CPT® preventive codes and uses G codes instead.
