Summary of Questions

Hospice Most Denials

Hospice claims can be denied for reasons such as incorrect diagnosis coding, lack of medical

necessity, or insufficient documentation. Example: Claims denied for not meeting the eligibility

requirements for hospice care.

Inpatient and Outpatient Definitions

Inpatient care requires an overnight stay in a hospital, while outpatient care does not. Example:

Surgery in a hospital where the patient is admitted overnight is inpatient care, whereas a same-day

procedure is outpatient care.

Condition Code

Condition codes are used in healthcare billing to provide additional details about a patient's

diagnosis or treatment. Example: Condition code 44 indicates that a hospital inpatient claim should

have been billed as outpatient.

72 Hours Rule

The 72-hour rule applies to services provided within 72 hours of a hospital admission, affecting

billing and reimbursements. Example: Emergency services before admission might not be covered if

billed after 72 hours.

Payment Processed

Payment processing involves claims submission, review, and approval by insurers based on medical

necessity and coverage. Example: A provider submits a claim to an insurer who processes the

payment after verification of services provided.

Occurrence codes specify important dates related to claims, such as the onset of a condition or

hospital admission. Example: Occurrence code 42 indicates the date the patient was first admitted

to the hospital.

Revenue Codes

Revenue codes are used to categorize healthcare services for billing and insurance purposes.

Example: Revenue code 0450 is used for outpatient surgery in hospitals.

Minimum Dollar for Hospice Care

Minimum billing thresholds for hospice care are defined by Medicare, ensuring providers meet

minimum service criteria for reimbursement. Example: A hospice provider may not be reimbursed

unless they meet the required service level for a minimum number of days.

MUE Edits

MUE (Medically Unlikely Edits) are used to flag claims with excessive quantities of services,

preventing overutilization. Example: A claim for 10 units of a diagnostic test within one day might be

denied based on MUE limits.

POA Indicator

The POA (Present on Admission) indicator identifies whether a condition was present when the

patient was admitted. Example: A diagnosis of pneumonia present at admission is marked as 'Y'

(Yes), while a post-admission condition is marked 'N' (No).

Supplement Plan

Medicare Supplement Plans (Medigap) cover costs not paid by Original Medicare, like deductibles

and coinsurance. Example: Medigap Plan F covers all gaps, including the Part B deductible and
coinsurance.

Claim Charges

Claim charges refer to the billed amount for services provided by healthcare providers. Example: A

hospital bill for a surgery may include charges for the procedure, anesthesia, and hospital stay.

Inpatient and Outpatient Definitions

Inpatient care involves an overnight hospital stay, while outpatient care does not. Example: A patient

staying overnight for heart surgery is inpatient; a patient receiving same-day treatment is outpatient.

What is Condition Code

Condition codes provide additional information about a claim, such as the patient's treatment or

diagnosis. Example: Code 44 indicates that a claim should have been billed as outpatient, not

inpatient.

What is the 72 hours rule

The 72-hour rule refers to the timeframe for submitting claims for services provided within 72 hours

of admission. Example: Emergency services given within 72 hours of admission may not be covered

if billed after the window.

How is Payment Processed

Payment for medical services is processed after verifying claim details and medical necessity.

Example: After a hospital submits a claim, the insurer reviews and issues payment based on

covered services.

What is Occurrence Code

Occurrence codes identify specific events related to a patient's hospitalization, such as the onset of
illness or injury. Example: Code 42 marks the date of first admission for a particular condition.

What are Revenue Codes

Revenue codes categorize services for billing, determining payment amounts. Example: Revenue

code 0450 is used for outpatient hospital surgery.

What is Minimum Dollar for Hospice Care

The minimum dollar threshold ensures that hospice providers meet criteria for reimbursement.

Example: Providers must offer a certain level of care for at least a set number of days to be eligible

for payment.

MUE Edits

MUE Edits prevent excessive service quantities by flagging claims with high numbers of procedures.

Example: If a provider submits a claim for excessive units of a test, it may be rejected based on

MUE limits.

POA Indicator

POA indicators identify if a condition was present at the time of hospital admission or acquired

during the stay. Example: A condition marked 'Y' indicates it was present on admission; 'N' means it

was acquired later.

Supplement Plan

Medicare Supplement (Medigap) plans help pay for costs not covered by Original Medicare, like

coinsurance. Example: Plan G covers everything except the Part B deductible.