Ch 6 - AC #1
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is a nonparticipating provider with Cirrus Health. Patients frequently receive allergy scratch testing, CPT code 95004, and are charged $470. In addition, Dr. Zook charges $65 for the average established patient office visit, CPT code 99213, and $70 for the average new patient office visit, CPT code 99203.
Harris Theodore is a new patient covered by Medicare. He has met his yearly deductible; his coinsurance is 80-20. Medicare’s allowed charge for 99213 is $52, for 99203 is $55, and for 95004 is $375. He was seen by Dr. Zook for an office visit and allergy scratch testing.
What amount will Dr. Zook be reimbursed by Medicare for each procedure? In total?
What amount, if any, will Dr. Zook write off for each procedure? In total?
What amount, if any, will be billed to Mr. Theodore for each procedure? In total?
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Ch 6 - AC #4
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is a nonparticipating provider with Cirrus Health. Patients frequently receive allergy scratch testing, CPT code 95004, and are charged $470. In addition, Dr. Zook charges $65 for the average established patient office visit, CPT code 99213, and $70 for the average new patient office visit, CPT code 99203.Harris Theodore is a new patient covered by Medicare. He has met his yearly deductible; his coinsurance is...
Ch 6 - AC #2
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is a nonparticipating provider with Cirrus Health. Patients frequently receive allergy scratch testing, CPT code 95004, and are charged $470. In addition, Dr. Zook charges $65 for the average established patient office visit, CPT code 99213, and $70 for the average new patient office visit, CPT code 99203.Parminder Singh is an established patient also seen by Dr. Zook for an office visit and allergy scratch...
Ch 6 - AC #3
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is a nonparticipating provider with Cirrus Health. Patients frequently receive allergy scratch testing, CPT code 95004, and are charged $470. In addition, Dr. Zook charges $65 for the average established patient office visit, CPT code 99213, and $70 for the average new patient office visit, CPT code 99203.Monica Salenski is a new patient covered by Cirrus Health. She was seen by Dr. Zook for an...
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is...
Dr. Ellen Zook, an allergist, is a participating provider with Phoenix Care and Medicare. She is a nonparticipating provider with Cirrus Health. Patients frequently receive allergy scratch testing, CPT code 95004, and are charged $470. In addition, Dr. Zook charges $65 for the average established patient office visit, CPT code 99213, and $70 for the average new patient office visit, CPT code 99203, and $477 for 95004. Nils Hovik is an established patient and is covered by Phoenix Care through...
Depending on the setting that you work in, you may be required to respond to billing...
Depending on the setting that you work in, you may be required to respond to billing questions. Let's assume you are working in an office and a patient called today and asked for you to explain a form that she received from her insurance company. She said the form was called an Explanation of Benefits. Explanation of Benefits Data Provider: Dr. Theodore Simmons Date: 11/11/2017 Type of Service: Office visit Amount submitted: $82.00 Amount allowed: $74.00 Coinsurance: $14.80 Deductible: $300.00...
Ch 6 - AC #5
Dr. Zook also accepts patients with PhoenixPlus, a non-Medicare PPO. New or established patients pay a copay of $15 for office visits. Dr. Zook's contract with PhoenixPlus includes a capitation schedule that sets capitation rates as follows:Age/ Gender Rate0-4 years, Female $17.570-4 years, Male $17.575-15 years, Female $14.535-15...
Dr. Melissa Rose is trying to decide whether to be a Medicare-participating physician for the upcoming...
Dr. Melissa Rose is trying to decide whether to be a Medicare-participating physician for the upcoming year. (Assume that her entire practice consists of Medicare patients. Her Medicare patients do not displace non-Medicare patients.) Assume that her average charge is $120 (before Medicare’s limiting charge is applied), for which the average Medicare-approved amount is $100. If she decides to be a non-participating physician, she expects to accept assignment 80% of the time. For the unassigned patients assume that she would...
The Resource Based Relative Value Scale (RBRVS) is a prospective payment system established in 1992 by...
The Resource Based Relative Value Scale (RBRVS) is a
prospective payment system established in 1992 by the Centers for
Medicare and Medicaid Services (CMS) designed to improve and
stabilize the payments made to health care providers.
Application Assignment Instructions
Provide a response to the following questions:
1. What are the three types of RVU's?
2. Explain how CMS determines the national conversion factor
for the RBRVS system?
Using the following grid, respond to questions 3-5
below:
3. What is the...
Ch 16 Case Studies #1
The Medicare HMO plan sent the practice an RA as shown in Figure 16.1.Locate the claim for Wendy Walker in the remittance advice (RA). Notice that the claim has been denied. 1. What reason is given for the rejected claim? What procedure has been billed in the claim? 2. Refer back to the encounter form for Wendy Walker in Claim Case Study 15.1. Does the encounter form contain the same procedure code that is listed in the RA? 3. Refer next to the patient...
Outpatient Insurance Coding - Applying Concepts Ch 1
1. The patient's health insurance plan has a $750 deductible for hospital visits, and then it covers 100 percent of hospital visit charges. The patient's first hospital visit this year had charges of $612. The patient was subsequently admitted to the hospital a second time this year, and the charges totaled $358. How much will the patient be billed for each visit? How much will the health insurance plan reimburse for each visit?2 A patient insured under an indemnity plan...
The Resource Based Relative Value Scale (RBRVS) is a
prospective payment system established in 1992 by the Centers for
Medicare and Medicaid Services (CMS) designed to improve and
stabilize the payments made to health care providers.
Application Assignment Instructions
Provide a response to the following questions:
1. What are the three types of RVU's?
2. Explain how CMS determines the national conversion factor
for the RBRVS system?
Using the following grid, respond to questions 3-5
below:
3. What is the...
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