AAPC Billing Documentation & Compliance 3 — Questions and Answers
Question 1: Which of the following best describes 'upcoding' in medical billing?
- Billing a lower-level service than what was performed
- Billing for a higher-level or more expensive service than what was documented (Correct answer)
- Submitting the same claim to multiple payers simultaneously
- Adding modifier -25 to every E/M service
Correct answer: Billing for a higher-level or more expensive service than what was documented
Upcoding means billing a CPT or revenue code that reflects a higher level of service than what was actually documented and performed.
Question 2: A Coordination of Benefits (COB) error occurs when:
- A claim is filed after the timely filing deadline
- The primary and secondary payers are billed in the wrong order (Correct answer)
- A patient's deductible has not been met
- A referring provider's NPI is missing from the claim
Correct answer: The primary and secondary payers are billed in the wrong order
COB errors occur when claims are not filed in the correct order of insurance responsibility, potentially resulting in incorrect payment or denial.
Question 3: The purpose of an Advance Beneficiary Notice (ABN) in Medicare billing is to:
- Authorize the physician to perform surgery
- Inform the beneficiary that Medicare may not pay and the patient may be responsible (Correct answer)
- Waive the patient's right to appeal a Medicare denial
- Confirm the patient's Medicare eligibility at the time of service
Correct answer: Inform the beneficiary that Medicare may not pay and the patient may be responsible
An ABN notifies a Medicare beneficiary that a service may not be covered and allows the provider to bill the patient if Medicare denies the claim.
Question 4: Which form is used to bill Medicare Part B for professional (physician) services?
- UB-04 (CMS-1450)
- CMS-1500 (Correct answer)
- CMS-485
- CMS-2567
Correct answer: CMS-1500
The CMS-1500 is the standard claim form used by non-institutional providers, including physicians, to bill Medicare Part B.
Question 5: A provider who performs medically unnecessary services and bills for them may be liable under:
- EMTALA only
- The False Claims Act (Correct answer)
- COBRA regulations
- The Balanced Budget Act
Correct answer: The False Claims Act
Billing for services that are not medically necessary constitutes a false claim and can result in FCA liability, including treble damages and penalties.
Question 6: The term 'medical necessity' in billing is primarily determined by:
- The biller based on the CPT code chosen
- The payer's coverage policies and clinical guidelines (Correct answer)
- The patient's request for services
- The number of diagnoses listed on the claim
Correct answer: The payer's coverage policies and clinical guidelines
Medical necessity is determined by whether the services are consistent with the patient's diagnosis, the payer's coverage policies, and established clinical guidelines.
Question 7: Documentation that is 'cloned' or copied and pasted without individualization across patient encounters is problematic because:
- It violates CPT copyright rules
- It may not accurately reflect each patient's unique condition, compromising billing integrity (Correct answer)
- It causes EHR software to malfunction
- It is prohibited only in inpatient settings
Correct answer: It may not accurately reflect each patient's unique condition, compromising billing integrity
Copy-pasting without modification means documentation may not reflect actual services rendered, making associated claims potentially fraudulent.
AAPC Billing Documentation & Compliance 3
Which of the following best describes 'upcoding' in medical billing?