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CRHC practice questions

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Question 1Rural Health Clinic Program Requirements and Regulatory Framework

Which federal agency administers the Rural Health Clinic (RHC) certification program and issues the Conditions for Certification that RHCs must meet?

  1. The Food and Drug Administration (FDA)
  2. The Federal Communications Commission (FCC)
  3. The Health Resources and Services Administration (HRSA)
  4. The Centers for Medicare & Medicaid Services (CMS) Correct answer.

Explanation

CMS administers the Medicare program and sets the RHC Conditions for Certification that surveyors use to determine compliance. HRSA supports rural health through grants and the rural health clinic program but does not issue the certification conditions.

Question 2Rural Health Clinic Program Requirements and Regulatory Framework

The Rural Health Clinic program was originally created by federal legislation primarily to address which problem?

  1. Excessive Medicare spending on rural hospitals
  2. A lack of malpractice insurance for rural providers
  3. Inadequate rural pharmacy reimbursement
  4. A shortage of physicians and health services in rural areas Correct answer.

Explanation

The RHC program was established to increase access to primary care in rural communities by allowing mid-level practitioners to deliver services under physician oversight with cost-based reimbursement. It was a response to maldistribution of physicians and limited access, not to hospital spending or pharmacy issues.

Question 3Rural Health Clinic Program Requirements and Regulatory Framework

To qualify for RHC certification, a clinic must be located in an area that is designated as which of the following?

  1. A metropolitan statistical area with a teaching hospital
  2. Any county with a population under one million
  3. A rural area that is a health professional shortage area or medically underserved area Correct answer.
  4. A state-designated enterprise zone

Explanation

RHC location criteria require the clinic to be in a rural area and in a shortage area (HPSA) or medically underserved area (MUA), or be certified by the state as serving such an area. Population size alone or other designations do not satisfy the requirement.

Question 4Rural Health Clinic Program Requirements and Regulatory Framework

Which staffing arrangement is a defining structural requirement of an RHC?

  1. The clinic must be owned by a hospital
  2. A physician must be physically on site at all times the clinic is open
  3. The clinic must employ a nurse practitioner, physician assistant, or certified nurse midwife Correct answer.
  4. The clinic must operate a licensed pharmacy on site

Explanation

A core RHC requirement is that the clinic employ at least one nurse practitioner, physician assistant, or certified nurse midwife to provide services. Physician presence is required on a scheduled basis, not continuously, and hospital ownership or a pharmacy is not required.

Question 5Rural Health Clinic Program Requirements and Regulatory Framework

Under the RHC Conditions for Certification, how frequently must a physician provide oversight and review of the clinic's operations?

  1. At least once every two years
  2. Only after a patient complaint is filed
  3. Only when a new practitioner is hired
  4. On a periodic basis sufficient to ensure quality, typically at least every two weeks Correct answer.

Explanation

The physician must provide periodic oversight of the clinic and review of clinical practice, with the frequency generally expected to be at least every two weeks. This ensures ongoing supervision of mid-level practitioners and quality of care.

Question 6Rural Health Clinic Program Requirements and Regulatory Framework

An RHC is preparing for a certification survey. Which document is most directly used by the surveyor to evaluate compliance?

  1. The state's business licensing statute
  2. The clinic's employee handbook
  3. The clinic's marketing brochure
  4. The Medicare Conditions for Certification for RHCs Correct answer.

Explanation

Surveyors evaluate RHCs against the Medicare Conditions for Certification, which set the standards for patient care, staffing, and operations. Marketing materials, handbooks, and business licensing do not define the survey standards.

Question 7Rural Health Clinic Program Requirements and Regulatory Framework

Which reimbursement methodology is characteristic of the RHC program for Medicare-covered services?

  1. Cost-based reimbursement subject to an all-inclusive rate per visit Correct answer.
  2. Fee-for-service payment at physician fee schedule rates
  3. Prospective payment based on diagnosis-related groups
  4. Capitation paid per enrolled beneficiary per month

Explanation

RHCs are generally reimbursed by Medicare on a cost-related basis using an all-inclusive rate per qualifying visit, subject to upper payment limits. This differs from DRG-based hospital payment and physician fee schedule payment.

Question 8Rural Health Clinic Program Requirements and Regulatory Framework

For an encounter to qualify for RHC reimbursement, which condition must generally be met?

  1. The visit must be with an outside specialist
  2. The visit must occur after normal business hours
  3. The visit must last at least sixty minutes
  4. The visit must involve a face-to-face encounter with a qualifying practitioner Correct answer.

Explanation

A qualifying RHC visit requires a face-to-face encounter with a physician, nurse practitioner, physician assistant, or certified nurse midwife, among other requirements. Duration, time of day, and referral to a specialist are not qualifying criteria.

Question 9Rural Health Clinic Program Requirements and Regulatory Framework

Which service is typically included in the RHC all-inclusive rate rather than billed separately?

  1. Durable medical equipment delivered to the home
  2. A separately billed hospital inpatient stay
  3. Independent laboratory tests ordered by an outside physician
  4. Routine primary care services furnished during a qualifying visit Correct answer.

Explanation

The all-inclusive rate bundles the primary care services furnished during a qualifying RHC visit, including related routine services. Inpatient hospital care, home-delivered equipment, and certain outside services are not part of the bundled visit rate.

Question 10Rural Health Clinic Program Requirements and Regulatory Framework

The upper payment limit applied to RHC Medicare reimbursement is intended to do which of the following?

  1. Set a fixed national payment regardless of location
  2. Cap payments by comparing them to a benchmark such as a percentage of the physician fee schedule Correct answer.
  3. Require clinics to repay all prior year payments
  4. Eliminate cost reporting for RHCs

Explanation

The upper payment limit constrains the RHC all-inclusive rate by benchmarking it against a reference payment amount, such as a percentage of the Medicare physician fee schedule for comparable services. It does not impose uniform national rates or remove cost reporting obligations.

Question 11Rural Health Clinic Program Requirements and Regulatory Framework

Which practitioner type is explicitly recognized as a mid-level practitioner whose services support RHC certification?

  1. A licensed clinical social worker
  2. A registered dietitian
  3. A certified nurse midwife Correct answer.
  4. A physical therapy assistant

Explanation

The RHC statute recognizes nurse practitioners, physician assistants, and certified nurse midwives as the mid-level practitioners whose employment supports certification. Dietitians, social workers, and therapy assistants are not among the recognized categories for this purpose.

Question 12Rural Health Clinic Program Requirements and Regulatory Framework

A clinic wishes to be certified as an RHC. Which entity typically performs the initial certification survey on behalf of CMS?

  1. The clinic's malpractice insurer
  2. The regional Medicare Administrative Contractor alone
  3. The state survey agency Correct answer.
  4. The local chamber of commerce

Explanation

CMS delegates certification surveys to state survey agencies, which evaluate compliance with the Conditions for Certification. Other entities listed do not conduct the RHC certification survey.

Question 13Rural Health Clinic Program Requirements and Regulatory Framework

Which requirement applies to the RHC's arrangement for physician services when the physician is not physically present?

  1. The clinic must close whenever the physician leaves
  2. The clinic must transfer all patients to a hospital
  3. The clinic must hire a second physician
  4. The clinic must have a written agreement for physician oversight and available consultation Correct answer.

Explanation

RHCs must have a documented arrangement ensuring physician oversight, consultation, and referral availability even when the physician is off site. Closing the clinic or transferring all patients is not required.

Question 14Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following best describes the RHC requirement regarding a quality assessment and performance improvement (QAPI) program?

  1. It is optional and only recommended for large clinics
  2. It applies only to hospital-affiliated clinics
  3. It is satisfied by an annual staff picnic
  4. It must be an ongoing, data-driven effort to monitor and improve care Correct answer.

Explanation

RHCs are expected to maintain an ongoing quality assessment and performance improvement program that uses data to monitor and improve care. It is not optional, not limited to hospital-affiliated clinics, and not satisfied by social events.

Question 15Rural Health Clinic Program Requirements and Regulatory Framework

An RHC must maintain a written policy addressing which of the following patient-care areas?

  1. Patient rights, including grievance procedures Correct answer.
  2. The color scheme of the waiting room
  3. The personal vehicle policy for staff
  4. The clinic's social media marketing strategy

Explanation

RHC conditions require policies that protect patient rights and provide a process for grievances and complaints. Decor, marketing, and staff vehicle policies are not patient-care requirements.

Question 16Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following is a required element of the RHC's infection control program?

  1. Mandatory annual closure for fumigation
  2. A requirement that all staff hold a master's degree
  3. A ban on all reusable equipment
  4. A system for identifying, reporting, and investigating infections and communicable disease Correct answer.

Explanation

RHCs must maintain an infection control program that includes surveillance, identification, and investigation of infections and communicable diseases, along with preventive measures. Blanket equipment bans or annual closures are not required.

Question 17Rural Health Clinic Program Requirements and Regulatory Framework

How does the RHC program generally treat services furnished by a nurse practitioner compared with services furnished by a physician for reimbursement purposes?

  1. Nurse practitioner services are never reimbursable
  2. Nurse practitioner services must be billed under the physician's national provider identifier only
  3. Nurse practitioner services are reimbursed at a lower rate set by the state
  4. Qualifying nurse practitioner services are included in the all-inclusive rate Correct answer.

Explanation

Qualifying services furnished by recognized mid-level practitioners during an RHC visit are included in the all-inclusive rate. They are not categorically excluded or required to be billed solely under a physician's identifier.

Question 18Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following describes the relationship between an RHC and a hospital that owns it?

  1. Hospital-owned clinics are exempt from all RHC conditions
  2. Hospital ownership converts the clinic into a skilled nursing facility
  3. A hospital-owned clinic automatically loses RHC status
  4. An RHC may be owned by a hospital and still be certified as an RHC if it meets the conditions Correct answer.

Explanation

Hospitals may own RHCs, and the clinic can retain RHC certification as long as it meets the applicable conditions. Ownership does not automatically strip certification or exempt the clinic from the requirements.

Question 19Rural Health Clinic Program Requirements and Regulatory Framework

Which document must an RHC make available to patients that explains their rights and responsibilities?

  1. A vendor contract
  2. A tax return
  3. A patient rights statement Correct answer.
  4. A stock prospectus

Explanation

RHCs must inform patients of their rights, typically through a written patient rights statement, and provide a grievance process. Financial and corporate documents are not patient-facing rights disclosures.

Question 20Rural Health Clinic Program Requirements and Regulatory Framework

An RHC is reviewing whether it can bill a qualifying visit that was provided entirely by telehealth. Which statement best reflects the general RHC framework?

  1. Telehealth is never permitted in any circumstance
  2. Telehealth coverage and payment rules for RHCs have been shaped by specific federal policies and waivers that must be verified Correct answer.
  3. Telehealth is permitted only for hospital inpatients
  4. Telehealth visits are always reimbursed at double the in-person rate

Explanation

RHC telehealth coverage and payment have evolved through specific federal policies and temporary waivers, so clinics must verify current rules. Blanket prohibitions, double payment, or inpatient-only limits misstate the framework.

Question 21Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following is a purpose of the RHC cost report?

  1. To report allowable costs used to determine Medicare payment Correct answer.
  2. To register the clinic's domain name
  3. To satisfy malpractice insurance underwriting
  4. To apply for a business license

Explanation

RHCs submit cost reports that document allowable costs used in determining Medicare reimbursement and applying payment limits. It is not a licensing, insurance, or internet registration document.

Question 22Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following best describes the RHC requirement for a governing body or responsible person?

  1. The clinic must have a designated individual or body responsible for its operation and compliance Correct answer.
  2. The clinic must have a board of at least fifty members
  3. The clinic may operate without any designated responsible party
  4. The clinic must be governed by a federal employee

Explanation

RHCs must have a clearly designated responsible person or governing body accountable for operations and compliance with the conditions. Federal employees, large board sizes, and the absence of a responsible party are not requirements.

Question 23Rural Health Clinic Program Requirements and Regulatory Framework

A rural clinic is located in a county that is part of a larger metropolitan statistical area but the specific census tract is rural and underserved. What must the clinic generally demonstrate to qualify for RHC certification?

  1. That the clinic serves at least ten thousand patients per year
  2. That the clinic is within five miles of a hospital
  3. That the clinic is open seven days a week
  4. That the clinic is located in a rural area and in a shortage or underserved area, or otherwise meets the location criteria Correct answer.

Explanation

RHC location criteria focus on rural designation combined with shortage or underserved status, using the applicable geographic designations. Proximity to a hospital, patient volume thresholds, and seven-day operation are not location criteria.

Question 24Rural Health Clinic Program Requirements and Regulatory Framework

Which statement about the RHC's obligation to provide services regardless of a patient's ability to pay is most accurate?

  1. RHCs may refuse service to uninsured patients
  2. RHCs must provide all services free of charge
  3. RHCs are expected to serve the community and may not discriminate based on payment source in a way that violates applicable requirements Correct answer.
  4. RHCs may charge different rates based on race

Explanation

RHCs are community-oriented providers expected to serve patients without unlawful discrimination, including on the basis of payment source. They are not required to provide all care free, and discriminatory pricing is prohibited.

Question 25Rural Health Clinic Program Requirements and Regulatory Framework

Which of the following is generally a condition for an RHC to be eligible for Medicare reimbursement of a visit?

  1. The visit must be provided by a specialist
  2. The patient must be enrolled in a Medicare Advantage plan
  3. The clinic must be located on a hospital campus
  4. The clinic must be certified as an RHC and the visit must be a qualifying encounter Correct answer.

Explanation

Medicare reimburses RHC visits when the clinic is certified and the encounter meets the qualifying visit criteria. Enrollment in Medicare Advantage, specialist provision, or hospital campus location is not required.

Question 26Rural Health Clinic Program Requirements and Regulatory Framework

Which federal agency administers the Medicare Rural Health Clinic certification program at the national level?

  1. The Federal Trade Commission
  2. The Department of Labor
  3. The Centers for Medicare & Medicaid Services Correct answer.
  4. The Health Resources and Services Administration

Explanation

CMS administers the Medicare program, including the RHC certification conditions of participation and payment rules. HRSA supports rural health generally but does not run Medicare RHC certification.

Question 27Rural Health Clinic Program Requirements and Regulatory Framework

Under the RHC statute, which location rule must a clinic satisfy to qualify as rural?

  1. It must be at least 50 miles from the nearest hospital
  2. It must be in an area designated as rural by the state governor's office
  3. It must be outside a metropolitan statistical area or in a designated shortage area Correct answer.
  4. It must be located in a non-urbanized area as defined by the Census Bureau

Explanation

The RHC location test requires the clinic to be in a rural area, generally outside an MSA or in a rural census tract, and in a shortage area such as an HPSA or MUA. Distance to a hospital is not the statutory criterion.

Question 28Rural Health Clinic Program Requirements and Regulatory Framework

Which type of practitioner is required to be available for the RHC to meet the physician availability requirement?

  1. A physician who provides medical direction and is available for consultation Correct answer.
  2. A board-certified specialist in every major discipline
  3. A licensed social worker on call
  4. A pharmacist available on site at all times

Explanation

RHCs must have physician services available for medical direction and consultation, with arrangements for physician availability when not on site. Specialty coverage and on-site pharmacy or social work are not the core availability requirement.

Question 29Rural Health Clinic Program Requirements and Regulatory Framework

Which term describes the fixed per-visit payment method used for RHC Medicare services?

  1. All-inclusive rate Correct answer.
  2. Fee schedule
  3. Prospective per-diem
  4. Cost-based interim payment

Explanation

RHCs are paid an all-inclusive rate per qualifying visit that bundles covered RHC services into a single payment. It is not a per-diem and is not based on a physician fee schedule.

Question 30Rural Health Clinic Program Requirements and Regulatory Framework

An RHC's nurse practitioner provides a covered service that a physician could also have furnished. How is that encounter generally treated for payment purposes?

  1. It must be billed under the physician's provider number at the physician rate
  2. It is paid at the same all-inclusive rate as a physician visit Correct answer.
  3. It is not reimbursable unless a physician co-signs the note
  4. It is reimbursed at a reduced percentage of the physician rate

Explanation

For RHC purposes, services furnished by a nurse practitioner or physician assistant are paid at the same all-inclusive rate as physician services. The RHC rate does not vary by practitioner type for covered visits.

Question 31Rural Health Clinic Program Requirements and Regulatory Framework

A clinic is owned by a hospital and certified as a provider-based RHC. Which statement about its relationship to the hospital is most accurate?

  1. It is automatically converted to a freestanding clinic on certification
  2. It must be treated as a department of the hospital and meet provider-based requirements Correct answer.
  3. It may share the hospital's provider number without any additional requirements
  4. It must be separately incorporated and independent of the hospital

Explanation

A provider-based RHC operates as a department of the parent hospital and must satisfy provider-based attestation and integration requirements. Separate incorporation is not required, and certification does not convert it to freestanding status.

Question 32Rural Health Clinic Program Requirements and Regulatory Framework

Which element is central to the RHC's quality assessment and performance improvement program?

  1. Annual external accreditation by a private body
  2. Ongoing measurement and tracking of quality indicators with corrective action Correct answer.
  3. A single annual staff meeting reviewing incidents
  4. Quarterly submission of quality data to CMS

Explanation

A QAPI program requires ongoing, data-driven measurement of quality indicators and follow-up corrective action. It is not satisfied by a one-time meeting or by external accreditation alone.

Question 33Rural Health Clinic Program Requirements and Regulatory Framework

Which patient-care policy area must an RHC maintain in writing as part of its conditions of participation?

  1. Staff parking assignments
  2. Marketing and advertising strategy
  3. Investment portfolio management
  4. Handling of patient grievances Correct answer.

Explanation

RHC conditions require written policies covering patient care and rights, including how patient grievances are received and resolved. Business, marketing, and facility logistics matters are outside the clinical policy requirements.

Question 34Rural Health Clinic Program Requirements and Regulatory Framework

Which activity is a required component of an RHC infection control program?

  1. Maintaining a system for identifying and investigating infections and taking corrective action Correct answer.
  2. Conducting monthly full-facility fumigation
  3. Requiring all staff to hold a national infection control certificate
  4. Publishing infection rates on the clinic website

Explanation

An infection control program must include surveillance to identify infections, investigation, and corrective action, along with related policies. Public reporting, mandatory national certificates, and routine fumigation are not the required core elements.

Question 35Rural Health Clinic Program Requirements and Regulatory Framework

Which document must an RHC provide to patients that describes their rights and responsibilities?

  1. A physician employment contract
  2. A copy of the clinic's tax return
  3. A list of board members
  4. A patient rights statement Correct answer.

Explanation

RHCs must inform patients of their rights and responsibilities, typically through a written patient rights statement. Employment contracts, tax returns, and board lists are not patient-facing rights documents.

Question 36Rural Health Clinic Program Requirements and Regulatory Framework

An RHC wants to bill a Medicare visit furnished entirely through telehealth. Which statement best reflects the general RHC rule?

  1. Telehealth is prohibited for all RHC patients
  2. Any telehealth encounter automatically qualifies as a billable RHC visit
  3. Telehealth-only visits are generally not billable as RHC visits unless specific exceptions apply Correct answer.
  4. Telehealth visits are billed at double the in-person rate

Explanation

Under the general RHC rules, a visit furnished solely via telehealth does not automatically count as a qualifying RHC visit; limited statutory and waiver exceptions may apply. It is not automatically billable, doubled, or universally prohibited.

Question 37Rural Health Clinic Program Requirements and Regulatory Framework

What is a primary purpose of the annual RHC cost report?

  1. To set patient copay amounts
  2. To report employee salaries to the IRS
  3. To document marketing expenses for tax deductions
  4. To establish the all-inclusive rate and reconcile payments with allowable costs Correct answer.

Explanation

The cost report supplies the cost data used to determine the RHC all-inclusive rate and to reconcile Medicare payments against allowable costs, subject to the upper payment limit. It is not an IRS wage report or a copay-setting tool.

Question 38Rural Health Clinic Program Requirements and Regulatory Framework

A rural clinic sits in a county included in an MSA, but the specific census tract is rural and the area is a designated shortage area. How is the location test generally evaluated?

  1. The clinic fails because any MSA county is automatically urban
  2. The clinic must relocate outside the state to qualify
  3. The clinic may qualify because rural census tracts within MSAs can be treated as rural Correct answer.
  4. The clinic qualifies only if it is hospital-owned

Explanation

The RHC location rules recognize that certain rural census tracts within MSAs can be treated as rural, and a shortage designation is also required. MSA inclusion alone does not automatically disqualify a clinic, and ownership type is irrelevant to the location test.

Question 39Rural Health Clinic Program Requirements and Regulatory Framework

Which statement best describes an RHC's obligation regarding a patient's ability to pay?

  1. The clinic may refuse service solely because the patient cannot pay
  2. The clinic must provide free care to all patients
  3. The clinic may charge different rates based on insurance status without policy
  4. The clinic must not deny care based on inability to pay and must have a policy addressing it Correct answer.

Explanation

RHCs are expected to serve patients without denying care based on inability to pay and to maintain policies on sliding fees and collections. This does not mean free care for everyone, and discriminatory rate-setting without policy is not permitted.

Question 40Rural Health Clinic Program Requirements and Regulatory Framework

An RHC visit includes a covered service and a non-covered service on the same day. How does the all-inclusive rate concept generally apply?

  1. The non-covered service voids payment for the entire visit
  2. The rate covers bundled RHC services, and non-covered services are handled separately under applicable rules Correct answer.
  3. The clinic must bill both services at the physician fee schedule
  4. All services on that day are automatically covered by the rate

Explanation

The all-inclusive rate bundles covered RHC services into one payment, while non-covered services are not automatically absorbed and are addressed under separate billing rules. A non-covered service does not void the covered visit, and the fee schedule does not govern RHC visits.

Question 41Medicare and Medicaid Billing, Coding, and Reimbursement

Under the Medicare Physician Fee Schedule, what does the relative value unit (RVU) for a service represent?

  1. The relative resource cost of physician work, practice expense, and malpractice Correct answer.
  2. The number of units billable per calendar year
  3. The geographic cost index applied to a practice's overhead
  4. The maximum allowed charge a beneficiary can be billed

Explanation

The MPFS payment formula multiplies three component RVUs (work, practice expense, and malpractice) by a geographic practice cost index and a conversion factor. The RVUs express relative resource cost, not dollar ceilings or visit limits.

Question 42Medicare and Medicaid Billing, Coding, and Reimbursement

A Medicare participating provider accepts assignment on a service with an approved amount of $100. The applicable coinsurance is 20%. What is the beneficiary's responsibility?

  1. $20 Correct answer.
  2. $80
  3. $0
  4. $100

Explanation

Medicare pays 80% of the approved amount and the beneficiary owes the 20% coinsurance when the provider accepts assignment. The provider cannot collect more than that coinsurance from the patient.

Question 43Medicare and Medicaid Billing, Coding, and Reimbursement

Which claim form is used to bill Medicare Part B professional services?

  1. CMS-588
  2. ADA dental claim form
  3. CMS-1450 (UB-04)
  4. CMS-1500 Correct answer.

Explanation

The CMS-1500 is the standard paper claim for professional services billed to Medicare Part B and most commercial payers. Institutional claims such as hospital outpatient services use the UB-04.

Question 44Medicare and Medicaid Billing, Coding, and Reimbursement

In ICD-10-CM coding, what is the role of the seventh character in many injury codes?

  1. It identifies the payer type
  2. It identifies the encounter type, such as initial or subsequent encounter Correct answer.
  3. It specifies the billing provider's specialty
  4. It indicates the patient's age group

Explanation

Many ICD-10-CM injury, poisoning, and external cause codes require a seventh character to indicate the episode of care, such as initial encounter, subsequent encounter, or sequela. It is part of the diagnosis code itself.

Question 45Medicare and Medicaid Billing, Coding, and Reimbursement

What does the Medicare limiting charge apply to?

  1. Nonparticipating providers who do not accept assignment on unassigned claims Correct answer.
  2. Services covered by Medicaid
  3. Durable medical equipment only
  4. Services furnished by participating providers

Explanation

The limiting charge caps what a nonparticipating provider may collect from a beneficiary on an unassigned claim, set at 115% of the nonparticipating fee schedule amount. Participating providers accept assignment and are bound by the approved amount instead.

Question 46Medicare and Medicaid Billing, Coding, and Reimbursement

What is the purpose of the National Correct Coding Initiative (NCCI) edits?

  1. To calculate the geographic practice cost index
  2. To set the annual conversion factor
  3. To prevent improper payment when services are reported together inappropriately Correct answer.
  4. To determine beneficiary eligibility

Explanation

NCCI procedure-to-procedure edits identify code pairs that generally should not be billed together, preventing unbundling and duplicate payment. The edits are applied during claims processing.

Question 47Medicare and Medicaid Billing, Coding, and Reimbursement

A provider renders a service to a patient enrolled in both Medicare and full Medicaid benefits. Which payer is generally billed first?

  1. Medicaid, because the patient is low income
  2. The payer the patient chooses
  3. Medicare, because it is the primary payer Correct answer.
  4. Both payers simultaneously as coinsurers

Explanation

Medicare is generally the primary payer and Medicaid is the payer of last resort, often covering the Medicare coinsurance and deductible within state limits. Coordination of benefits rules establish this order.

Question 48Medicare and Medicaid Billing, Coding, and Reimbursement

What does the Medicare Administrative Contractor (MAC) do with a clean claim?

  1. Processes it and issues payment according to the fee schedule Correct answer.
  2. Returns it to the provider for coding review
  3. Sends it to the state Medicaid agency
  4. Forwards it to the Social Security Administration

Explanation

MACs process Medicare Part A and B claims, apply coverage and coding edits, and issue payment based on the applicable fee schedule. They are the primary claims processors for their jurisdictions.

Question 49Medicare and Medicaid Billing, Coding, and Reimbursement

A physician performs a procedure with 15 minutes of intraoperative care and the code's global period is 10 days. Which statement about postoperative care is correct?

  1. Only the first postoperative visit is included
  2. The global period applies only to hospital visits
  3. All postoperative visits within 10 days are included in the surgical payment Correct answer.
  4. Postoperative visits are always separately billable

Explanation

A 10-day global period includes the day of surgery plus follow-up care for the stated number of days, and routine postoperative care during that period is bundled into the surgical payment. Separate billing for related visits is not allowed.

Question 50Medicare and Medicaid Billing, Coding, and Reimbursement

A patient presents for a preventive visit and, during the same encounter, a significant, separately identifiable problem is evaluated. How should this be coded?

  1. Both services with modifier 59 on the preventive visit
  2. Preventive visit with modifier 25 appended to the problem-oriented E/M service Correct answer.
  3. Preventive visit only
  4. Problem-oriented E/M only

Explanation

When a significant, separately identifiable E/M service is performed on the same day as a preventive service, modifier 25 is appended to the problem-oriented E/M code to show it is distinct. Both services may then be reported.