Coding Corner Question: An Insurance Billing Quiz

1. A 55-year-old male patient diagnosed with generalized osteoarthritis and diagnosed with end stage renal failure (ESRD) 20 months previously presents to the office to see the rheumatologist. The patient has a commercial insurance plan and Medicare. Which carrier is primary for this visit?
   1. Commercial insurance carrier
   2. Medicare
   3. You do not know because it is not clear if he is still working
   4. None of the above
2. A new patient, a 66-year-old woman, is in the office to see the rheumatologist for her diagnosis of age-related osteoporosis. She has Medicare, but is also covered under her husband’s insurance plan. Which carrier is primary for her visit?
   1. You don’t know unless you ask if she is disabled
   2. Medicare
   3. Commercial insurance carrier
   4. You need to know which carrier became effective first
3. A 76-year-old male patient with joint pain in his knees and elbows is seeing the rheumatologist for the first time. He has both Medicare and Medicaid, but the practice does not accept Medicaid. Can the rheumatologist balance bill the patient for the allowable amount not paid by Medicare?
   1. No
   2. Yes
   3. Only if the patient was notified the practice does not accept Medicaid and agrees to pay out of pocket for balance due.
   4. None of the above
4. A 10-year-old child with joint pain is seen in the rheumatologist’s office for his symptoms. Both parents work for the same company and have commercial insurance coverage. Which parent’s coverage should be billed as primary?
   1. Father then mother
   2. Hire date of parents
   3. Birthday of parents
   4. B or C

Editor’s note: Case vignettes presented in the Coding Corner are created to illustrate questions about coding. They are not intended to represent the full medical record of a case.

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