ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 9

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ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 9 ANSWERS TO THINKING IT THROUGH Thinking It Through 9.1 page 322 1. Students should recognize a defined benefits program as one that requires medical items or services to fit into a benefit category established by law, and not be otherwise excluded. Thinking It Through 9.2 page 324 1. At time of writing, the Medicare Part B monthly premium is $99.90, and the deductible is $140.00. Students should look up the most recent premium and deductible. Yes, there is a surcharge for a small percentage of Medicare Part B beneficiaries who have high incomes. Thinking It Through 9.3 page 329 1. A. No, the examination is not covered under Medicare Part B because it is preventive care. B. The stress test will probably be covered, since it is being performed for diagnostic purposes, not for routine screening purposes. Thinking It Through 9.4 page 336 1. -GX Thinking It Through 9.5 page 338 1. Participating Provider A. Physician's standard fee $210.00 B. Medicare fee $115.00 C. Medicare pays 80% $92.00 D. Patient/supplemental plan pays 20% $23.00 E. Provider adjustment (write-off) $95.00 2. Nonparticipating Provider (Accepts Assignment) A. Physician's standard fee $210.00 B. Medicare nonpar fee $109.25 C. Medicare pays 80% $87.40 D. Patient/supplemental plan pays 20% $21.85 E. Provider adjustment (write-off) $100.75 3. Nonparticipating Provider (Does Not Accept Assignment) A. Physician's standard fee $210.00 B. Medicare nonpar fee $109.25 C. Limiting charge $125.64

D. Patient billed $125.64 E. Medicare pays patient (80%) $87.40 F. Total provider can collect $125.64 G. Patient out-of-pocket expense $38.24 Thinking It Through 9.6 page 340 1. No, a participating provider in a traditional fee-for-service plan does not always get paid more for a service than a nonparticipating provider who does not accept assignment. In fact, nonpar providers who do not accept assignment receive fees that are 9.25 percent higher than PAR providers. The 115 percent limiting charge of 95 percent (the nonpar fee schedule amount) comes to 109.25 percent, so the fees collected are 9.25 percent above the standard PAR fee schedule. 2. Yes, a patient in a traditional fee-for-service plan always pays higher fees when services are provided by a nonparticipating provider who does not accept assignment. This is because the limiting charge is 115 percent of the nonpar fee schedule, and Medicare pays only 80 percent of the nonpar fee schedule amount, not 80 percent of the limiting charge. Thinking It Through 9.7 page 341 1. In exchange for their increased coverage, such as vision, hearing, dental, and wellness programs, MA CCP plans often require higher out-of-network beneficiary payments or have no coverage for out-ofnetwork visits, referrals for specialists (in the HMO plans), and coinsurance in addition to copayments for visits. Thinking It Through 9.8 page 343 1. State-specific. Thinking It Through 9.9 page 347 1. To identify the CPT code that is Medicare-compliant for billing a new patient office consultation that was formerly reported with E/M 99242, look at 99242 and determine its requirements expanded problem-focused history and examination, plus straightforward medical decision making and match those to the available new patient office visit codes to determine the correct answer, 99202.

ANSWERS TO REVIEW QUESTIONS Matching page 352 1. D 2. H 3. B 4. I 5. C 6. A 7. F 8. J 9. E 10. G Multiple Choice page 353 1. C 2. C 3. D 4. B 5. C 6. D 7. B 8. B 9. A 10. B Completion page 354 1. Excluded services, such as cosmetic surgery, are not covered by Medicare under any circumstances. Not reasonable and necessary services are conditional; whether they are paid depends on such factors as the relation of the charges to the diagnosis, the frequency of the services, and the level of service relative to the severity of the condition. 2. The carrier for Newark, New Jersey. ANSWERS TO APPLYING YOUR KNOWLEDGE pages 354-357 Cases 9.1, 9.2, and 9.3 require claim completion. Students may complete paper CMS-1500 forms by hand or by using the electronic CMS-1500 form. They may also use the simulated Medisoft Connect Plus exercises to create and print the claims. The claim case answer keys provided in this Instructor s Manual are based on completion of paper CMS-1500 claim forms using the electronic form.

Case 9.1

Case 9.2

Case 9.3

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