General Billing - Assesment II

The next possible action when a claim is pending for MD attestation is to wait until the MD attestation is completed. This means that the claim is currently being reviewed and verified by the medical provider, and it is necessary to wait for their confirmation or approval before taking any further action.

The correct answer is 99233. E&M stands for Evaluation and Management, which refers to the codes used for medical services that involve the evaluation and management of a patient's condition. Code 99233 is an E&M code, while the other codes listed (93327, 93970, 93299) are not E&M codes.

The correct answer is 99215. The established patient visit code for 99205 is 99215. This code is used for a comprehensive examination and evaluation of an established patient, where the physician spends a significant amount of time face-to-face with the patient. It involves a detailed history, comprehensive examination, and medical decision-making of high complexity. This code is appropriate for patients with complex medical conditions or multiple chronic illnesses.

Annual examination visit codes (99381 - 99387) & (99391 - 99397) are payable once every 12 months. This means that these codes can only be billed and reimbursed once within a 12-month period. After the initial visit, any subsequent visits with the same codes within the same 12-month period will not be reimbursed. This is to ensure that patients receive an annual check-up and prevent excessive billing for frequent visits.

When a claim is billed for an immunization vaccine performed for a child, both the administration code and the vaccine injection code should be reported as per payer guidelines. This means that the healthcare provider should accurately report both codes on the claim form in order to ensure proper reimbursement. By doing so, the payer can easily identify the specific vaccine administered and the associated administration fee, allowing for accurate billing and payment. Therefore, the statement "True" is correct.

If CPT 88300,26 gets denied as not covered because it is not available in the Medicaid fee schedule, it can be adjusted. This means that the healthcare provider can make changes to the billing or coding information in order to rectify the denial. Adjustments may involve correcting any errors or inaccuracies in the claim, resubmitting the claim with updated information, or providing additional documentation to support the medical necessity of the procedure. By making the necessary adjustments, the provider can potentially resolve the denial and receive payment for the service.

Since the member had Medicare as active insurance, the appropriate action would be to submit the claim to Medicare Part B. Medicare Part B covers outpatient services, including physician charges, even if the member was initially admitted as an inpatient. Therefore, the physician charges for the 3 days of treatment should be submitted to Medicare Part B for reimbursement.

The correct answer is Medicare & Medicare HMO's. This means that the modifier GC can only be used when billing for services provided to patients with Medicare or Medicare HMO insurance. Modifier GC is not acceptable for Medicaid, auto insurance, or any commercial payers.

Based on the information provided, the correct next possible action would be to update the ER (Emergency Room) indicator and resubmit the claim. This is because the member only has coverage for emergency benefits on the date of service, but the physician performed a regular office visit. By updating the ER indicator to reflect the correct type of service, the claim can be resubmitted for consideration and potential reimbursement.

Since the claim was denied by both Medicaid-NY and Senior Whole Health, the next action would be to bill the balance to the member. This means that the member will be responsible for paying the remaining amount of the claim.

The statement "GC modifier is billable only with E&M codes" is true. The GC modifier is used to indicate that a service or procedure is related to a diagnosis or condition that is not covered by Medicare. It is typically used with evaluation and management (E&M) codes to indicate that the service provided is not related to a Medicare-covered diagnosis. The GC modifier helps to ensure accurate billing and reimbursement for non-covered services.

The statement is false because the date of service and the date of injury are not always the same. The date of service refers to the date on which a service or treatment is provided, while the date of injury is the specific date when an injury or incident occurred. These two dates can be different, especially if there is a delay between the injury and seeking medical treatment.

The next action would be to submit a discrepancy request through the Healthfirst portal. This is because there is a discrepancy between the claim denial by Healthfirst stating that the patient is ineligible on the date of service (DOS), and the information shown on Epaces, which indicates that the patient has Healthfirst Medicaid HMO coverage on the DOS. By submitting a discrepancy request, it allows for clarification and resolution of the conflicting information, potentially leading to a reconsideration of the claim denial.

The Medicare secondary qualifier is an indicator that is used to notify why Medicare is secondary. This means that Medicare is not the primary insurance coverage for the individual, and there is another insurance policy that is primary. The qualifier helps to determine the order in which insurance claims are processed and paid.

In this scenario, the patient is homeless and has Medicaid as their only insurance. Since the patient does not have a permanent address, submitting the claim to Medicaid with the Brookdale office address as the member's address is the appropriate course of action. This ensures that the claim is processed correctly and the patient's medical bill is covered by Medicaid.

CPT code 93042 cannot be adjusted per COM if it was denied as non covered.

The correct answer is to resubmit the claim with appropriate modifier. This is because there are 3 records for the same DOS (Date of Service), 1 for another provider and 2 for the provider named Syed Asma. By resubmitting the claim with an appropriate modifier, it indicates that there are multiple services provided on the same DOS by the same provider. This will help to ensure that the claim is processed correctly and that the provider is appropriately reimbursed for the services rendered.

The statement "IF Worker's compensation is Primary then Medicaid is Secondary" is false. In the context of insurance, primary and secondary refer to the order in which insurance providers cover medical expenses. If worker's compensation is primary, it means that it is the first insurance provider responsible for covering the costs. Medicaid, on the other hand, is a government-funded program that provides healthcare coverage to low-income individuals. It is not considered secondary to worker's compensation. Therefore, the correct answer is false.

The correct answer is "Bill the balance to the member". This means that since the medical bill has been denied due to the member exhausting their medical benefits, the remaining balance of the bill should be sent to the member for payment.

The correct answer is to appeal the claim with medical records. This means that you should gather all the necessary medical records related to Mr. John's injury and submit them as evidence to support the claim. By doing so, you are requesting a review of the denial and providing additional information that may help overturn the decision made by Medicare.