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CPB > 7&8 > Flashcards

7&8 Flashcards

Medical necessity and claim forms

1
Q

Can the X subset modifiers be used in conjunction with modifier 59?

A

No

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2
Q

FA and F1 - F9 are anatomic modifiers for what?

A

FA is left hand thumb moving in order to F9 right hand fifth digit.

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3
Q

Fields on the electronic CMS-1500 are referred to as what?

A

Loops

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4
Q

Fields on the paper CMS-1500 are referred to as what?

A

Items

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5
Q

How are dates entered on a paper field vs. electronic file?

A

Paper: MMDDCCYY Elec: CCYYMMDD

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6
Q

How are patient names entered on a CMS-1500 form?

A

Last, first, middle initial with any suffix after the last name and before the first.

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7
Q

How are procedural charges listed on a UB-04 form?

A

By revenue code in ascending numerical order.

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8
Q

How do you enter a 9 digit zip code on a CMS-1500?

A

All digits with NO hyphen.

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9
Q

How is a physicians name entered on a CMS-1500 claim form?

A

First, middle, last and credential, no commas or periods. (Michael James Johnson MD)

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10
Q

How many modifiers can be added to codes on a CMS-1500 form?

A

4

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11
Q

How often are NCCI edits updated by CMS?

A

Quarterly

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12
Q

How often is the NCCI policy manual updated?

A

Annually

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13
Q

If a patient has Medicare as a primary insurance, what should be put in the item 4 “name” box?

A

It should be left blank

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14
Q

If a patient has Medicare primary and a secondary insurance, how is the secondary insurance filed?

A

IF the insurance is a cross-over insurance, Medicare will cross the claim over to the secondary after determination. If not, you will have to submit to secondary AFTER you get the EOB back from the primary.

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15
Q

In item 4 of the CMS-1500, what is entered when the patient has an insurance primary to Medicare and the patient is the insured?

A

SAME

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16
Q

On a UB-04 form, if the patients birthdate is unknown, what is entered?

A

Zeros are entered for all 8 digits.

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17
Q

On a UB-04 form, what is entered in FL 50A if the patient has Medicare?

A

Medicare

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18
Q

TA and T1 - T9 are anatomic modifiers for what?

A

TA is great toe of left foot moving in order to T9 fifth digit of right foot.

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19
Q

There are three coding modifiers to determine if code pairs can bypass the NCCI edits, what are they?

A

0 - Not allowed, cannot bypass edits 1 - Allowed, edits can be bypassed 9 - Does not apply to the code pair

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20
Q

What are the 4 HCPCS modifiers to selectively identify subsets of modifier 59 (distinct procedural service)?

A

XE - separate encounter (separate encounter on the same date of service) XS - Separate structure (performed on a separate organ or structure) XP - separate practitioner (performed by a different practitioner) XU - Unusual non-overlapping service

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21
Q

What are the six methodologies of the Medicade NCCI program?

A
  1. A methodology with PTP edits for practitioner and ASC services. 2. A methodology with PTP edits for outpatient hospital services. 3. A methodology with PTP edits for durable medical equipment. 4. A methodology with MUE for practitioner and ASC services. 5. A methodology with MUE for outpatient hospital services. 6. A methodology with MUE for durable medical equipment.
22
Q

What are the three liability options in item 10 on the CMS-1500 form?

A

Employment, Auto Accident, Other Accident

23
Q

What are the two types of claim forms and who uses them?

A
  1. CMS-1500, used by providers and Ambulatory Surgical centers (ASC) 2. UB-04, used to report facility services.
24
Q

What code set is NOT used on the CMS-1500 form?

A

ICD-10-PCS

25
Q

What does ASC stand for?

A

Ambulatory surgical center

26
Q

What does FL stand for on a UB-04 form?

A

Form Locator

27
Q

What does LCD stand for?

A

Local coverage determinations

28
Q

What does MAC stand for?

A

Medicare administrative contractors

29
Q

What does MBI stand for?

A

Medicare beneficiary identifier

30
Q

What does Medicare refer to the insureds ID as?

A

Medicare Beneficiary Identifier (MBI)

31
Q

What does MUE stand for?

A

Medically unlikely edits

32
Q

What does NCCI stand for?

A

National correct coding initiative

33
Q

What does NCD stand for?

A

National coverage determinations

34
Q

What does PTP stand for?

A

Procedure to procedure

35
Q

What entities are given NPIs?

A

Individual practitioners, health care organizations, medical supply organizations. ONLY entities which provide a healthcare service.

36
Q

What is an MUE (medically unlikely edit)?

A

Edits showing the maximum number of times a procedure can be performed for one beneficiary in one date of service.

37
Q

What is another name for the UB-04 form?

A

CMS-1450

38
Q

What punctuation mark cannot be used for names on the CMS-1500?

A

A period

39
Q

What regulation requires claims to be sent electronically unless unusual circumstances are met?

A

Administrative Simplification Compliance Act (ASCA)

40
Q

When is the insurers payment amount determined after member benefits have been applied?

A

Adjucation

41
Q

When must a 8-digit date be used on a CMS-1500?

A

For any date of birth

42
Q

When there is an NCD and an LCD for the same procedure, which takes precedence?

A

NCD

43
Q

Where are LCD mandated guidelines applicable?

A

Only in that specific MACs jurisdiction.

44
Q

Where is the principal diagnosis code entered on the UB-04 form?

A

FL 67 is where the correct ICD-10 code goes. FL 69 is where the reason for admission goes, NOT a diagnosis.

45
Q

Which form is used for outpatient facility billing?

A

UB-04

46
Q

Which item on the CMS-1500 form accepts assignment of benefits if signed?

A

Item 13

47
Q

Which item(s) on the CMS-1500 form contains Medigap information?

A

9, 9a, 9d Medigap is supplemental insurance and so goes in the secondary insurance field.

48
Q

Which modifiers cannot be used to bypass edits? (2)

A

76 and 77

49
Q

Which three modifiers does NCCI policy specifically discuss?

A

25 (separately identifiable procedure), 58 (staged or related procedure), 59 (distinct procedural service)

50
Q

Who determines medical necessity?

A

The payer (insurance, Medicare)

51
Q

Who is responsible for the development and maintenance of the CMS-1500 form?

A

The National Uniform Claim Committee (NUCC)

52
Q

Who were the NCCI edits developed to be used by?

A

Medicare administrative contractors (MAC)

CPB (5 decks)

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