National & Local Coverage Determination

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GretaAnacker
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251848
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National & Local Coverage Determination
Updated:
2013-12-08 22:21:59
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National Local Coverage Determination
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National & Local Coverage Determination
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  1. What action can the healthcare provider take in order to receive reimbursement on a denied laboratory test charge?
    A. Re-submit the claim with the denied charge as a separate claim.
    B. Re-submit the claim with an additional diagnosis from records to support the test.
    C. Re-submit the claim without the denied test code and charge.
    D. Re-submit the claim with a V code for the suspected condition.
    B. Re-submit the claim with an additional diagnosis from records to support the test.
    (this multiple choice question has been scrambled)
  2. A patient is seen in the emergency department for treatment of an open wound of the elbow sustained from a fall from a bicycle. Other diagnoses noted by the physician on the patient's medical record are a history of hypertension and abdominal dissection.The physician orders a serum magnesium laboratory test. Your fiscal intermediary returns the claim with the edit that the serum magnesium laboratory test is not covered. What is the reason for the non-covered exam?
    A. An invalid CPT-4 procedure code is charged for a serum laboratory test.
    B. The serum magnesium laboratory exam is not a covered benefit for this beneficiary.
    C. The diagnoses on the claim do not meet medical necessity.
    D. The beneficiary has exhausted outpatient laboratory benefits.
    C. The diagnoses on the claim do not meet medical necessity.
    (this multiple choice question has been scrambled)
  3. Serum magnesium is a mineral required by the body for the use of adenosine triphosphate (ATP) as a source of energy. It is also necessary for neuromuscular conduction and the process of blood clotting. Magnesium deficiency may also cause weakness, tremors, lethargy, and convulsions. A serum magnesium study is also helpful for the diagnosis and management of pre-eclampsia, and asymptomatic chronic alcoholism.What diagnosis would support medical necessity for this laboratory test?

    A. 291.81
    B. 275.2
    C. 632
    D. 404.11
    A. 291.81

    The lab CPT for serum magnesium is found under the Chemistry sub-header of the Pathology and Laboratory section in CPT-4.
    (this multiple choice question has been scrambled)
  4. The fiscal intermediary (FI) is also defined as
    A. provider.
    B. beneficiary.
    C. F.A.C.
    D. carrier.
    D. carrier.

    An FI is a carrier and carriers are divided by state. They are program contractors that develop and adopt local coverage decisions (LCDs) when there are no national coverage decisions (NCDs) or when there is a need to further define an NCD.
    (this multiple choice question has been scrambled)
  5. The Medicare Coverage Database (MCD) is intended for use by
    A. family members to view eligibility.
    B. beneficiaries to view coverage.
    C. Medicare providers.
    D. government agencies to enroll beneficiaries.
    • C. Medicare providers.
    • The MCD is intended for use by Medicare contractors, providers, and healthcare industry professionals. People with Medicare, and their family members and caregivers, should visit www.Medicare.gov, the official U.S. government Web site.
  6. The Medicare Coverage Database (MCD) offers multiple ways to locate and view data via the Internet to include all the following EXCEPT
    A. reports.
    B. program transmittals.
    C. downloads.
    D. searches.
    B. program transmittals.

    The MCD offers the variety of search capabilities except a search for program transmittals. Program transmittals are located on the Medicare Web site.
    (this multiple choice question has been scrambled)
  7. A patient is seen in an outpatient procedure center for a diagnostic upper gastrointestinal endoscopy (CPT-4 procedure code 43259).Of the following ICD-9-CM diagnoses, what diagnosis would most likely be covered?
    A. 577.0
    B. 530.0
    C. 787.91
    D. 787.03
    B. 530.0

    According to the diagnosis descriptions of the codes in the answer choices, the only clinical indication for the study that is covered is the stricture and stenosis of the esophagus (530.0).
    (this multiple choice question has been scrambled)
  8. To ensure accurate and complete reimbursement on outpatient surgery, emergency department, and procedure and treatment room claims, the healthcare provider should
    A. increase charges for items and services annually for maximum reimbursement.
    B. stay abreast of continuing changes in reimbursement and coverage policies.
    C. bill only charges that are reimbursed by the carrier to reduce denials.
    D. hire additional coding, billing, and collections staff to increase revenue.
    • B. stay abreast of continuing changes in reimbursement and coverage policies.
    • (There are multiple variables that impact revenue from claims submitted by providers. Staying abreast of the local coverage determinations and national coverage decisions is critical. Providing accurate documentation for coding ICD-9-CM diagnoses and submitting clean and accurate claims will ensure complete reimbursement for services rendered.)
  9. A patient is seen in the emergency department with complaints of 3 days of migraine headaches. The physician orders an MRA/head (magnetic resonance angiography of the head).According to the ICD-9-CM diagnoses in the choices provided, what diagnosis would most likely be covered?
    A. 784.2
    B. 432.9
    C. 441.1
    D. 307.81
    • B. 432.9
    • (According to the diagnoses provided, the only clinical indication for the study is the unspecified intracranial hemorrhage (432.9).
  10. According to LCD/NCD, CPT-4 procedures to include elective sterilization, breast reduction, rhinoplasty, and abortion are examples of
    A.covered CPT-4 procedures for a designated age/population set.
    B. statutorily non-covered procedures unless specifically covered conditions support the reason for the procedure.
    C. covered CPT-4 procedures with the provider's preauthorization to treat the injury/illness.
    D. covered CPT-4 procedures based upon the patient's illness (e.g., mental retardation, cerebral palsy).
    • B. statutorily non-covered procedures unless specifically covered conditions support the reason for the procedure.
    • (According to NCD/LCD, treatments to include elective sterilization, breast reduction, rhinoplasty, and abortion are statutorily not covered with few diagnosis exceptions.)
  11. The items and services criteria contained in the Medicare Coverage Database (MCD) are developed by whom?
    A. auditors at the contractors that pay Medicare claims
    B. physicians associated with the American Medical Association (AMA)
    C. board members of the American Medical Association (AMA) and Medicare
    D. clinicians at the contractors that pay Medicare claims
    D. clinicians at the contractors that pay Medicare claims

    Medicare provides coverage for items and services for over 43 million beneficiaries. The vast majority of coverage is provided at the local level and developed by clinicians at the contractors that pay Medicare claims. However, in certain cases, Medicare deems it appropriate to develop a national coverage determination for an item or service to be applied on a national basis for all Medicare beneficiaries who meet the criteria for coverage.
    (this multiple choice question has been scrambled)

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