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ASSIGNMENT 13-1 REVIEW QUESTIONS

Part I Fill in the Blank 1. state governments; federal

2. assistance

3. Medi-Cal

4. a. coverage b. benefits

5. State Children's Health Insurance Program; Maternal and Child Health Program; Covers children younger than 21 years.

6. a. Medicaid Qualified Medicare Beneficiary Program b. Specified Low-Income Medicare Beneficiary Program c. Qualifying Individuals Program

7. a. categorically needy b. medically needy

8. Early and Periodic Screening, Diagnosis, and Treatment; EPSDT.

9. a. date of authorization b. name of the person who provided authorization c. approximate time of day authorization was given d. verbal number given by field office

10. 2 months; 12 or 18 months; State time limit will vary by state.

11. CMS-1500 (08-05) Health Insurance Claim Form

12. a. Bill TRICARE first b. Bill Medicaid second and attach a Remittance Advice, Explanation of Benefits, or check voucher from TRICARE to the billing form

13. a. adjustments b. approvals c. denials d. suspends e. audit/refund transactions

14. a. regional fiscal intermediary or Medicaid bureau b. Department of Social Welfare or Human Services c. appellate court

Part II Multiple Choice 15. c. month of service

16. b. automobile insurance carrier

17. a. Arizona

18. d. all of the above

19. b. obtain prior authorization, preferably written

20. d. all of the above

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Part III True/False 21. T

22. F

23. T

24. T

25. T

Assignment 13–2 CRITICAL THINKING 1. No. Because it is an emergency and prior authorization is not needed.

2. Block 24C and enter an emergency certification statement

3. Block 19 or include an attachment to the claim with this data.

Note: Each state uses different Medicaid guidelines to complete CMS-1500 (08-05) claim forms.

Assignment 13–3 COMPLETE A CLAIM FORM FOR A MEDICAID CASE Rose Clarkson: Generally, Blocks 8 and 11D may be left blank in Medicaid cases unless the regional fiscal intermediary requires that these blocks be completed. For the Medi-Cal program in California, Blocks 24C and 24E are not a requirement for completion.

Diagnostic codes: 428.0 Congestive heart failure, and 424.0 mitral valve prolapse

ICD-10-CM Diagnostic codes: I50.9 Congestive heart failure NOS and I34.1 nonrheumatic mitral (valve) prolapse

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Assignment 13–4 COMPLETE A CLAIM FORM FOR A MEDICAID CASE Stephen M. Drake: Block 14: In some regions, the Medicaid fiscal intermediary may request that this block be completed. If so, enter 040420XX. The strep screen test (87081) is found under “Culture, Bacteria, Screening.” Other tests listed under Streptococcus are divided into group A or B and are more sophisticated and typically done by an outside laboratory. Penicillin injection should be billed with an administration code (90772) and a code for the medication (J0540). The global fee for tonsillectomy and adenoidectomy includes the follow-up visit in the physician’s office; however, the visit the day before surgery should be billed with modifier –57 to indicate that a decision was made for surgery and the visit was not just for preoperative purposes. The tonsillectomy and adenoidectomy code number 42821 is for an individual older than age 12.

ICD-9-CM Diagnostic codes: 463 Acute tonsillitis; 474.02 (chronic tonsillitis and adenoiditis) is included because some Medicaid state guidelines require a chronic diagnostic code indicating that the patient has had this condition and warrants the surgery. Diagnostic code 034.0 may be listed in the third position.

ICD-10-CM Diagnostic codes: J03.90 Acute tonsillitis, unspecified, J35.03 chronic tonsillitis and adenoiditis, and J02.0 streptococcal sore throat.

Additional Coding 1. Symptom ICD-9-CM Code ICD-10-CM Code

a. Sore throat 462 J02.9

b. Enlarged tonsils 474.11 J35.1

c. Fever 780.60 R50.9

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