AHIMA Revenue Cycle Management 2 — Questions and Answers
Question 1: Which claim form is required for professional/physician billing to Medicare?
- UB-04
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
- HIPAA 837I
Correct answer: CMS-1500
The CMS-1500 is the standard claim form used by non-institutional providers, including physicians, for professional billing to Medicare.
Question 2: What is the primary purpose of a Remittance Advice (RA)?
- To pre-authorize services before treatment
- To notify patients of their outstanding balance
- To explain payments and adjustments made by the payer (Correct answer)
- To document medical necessity for a claim
Correct answer: To explain payments and adjustments made by the payer
A Remittance Advice details how a payer processed and paid (or denied) a claim, including adjustment reason codes and payment amounts.
Question 3: A denial with CARC code CO-4 typically indicates:
- The service is not covered under the patient's plan
- The procedure code is inconsistent with the modifier used (Correct answer)
- The claim was submitted after the timely filing limit
- The patient was not eligible on the date of service
Correct answer: The procedure code is inconsistent with the modifier used
CO-4 means the procedure code is inconsistent with the modifier used, or a required modifier is absent.
Question 4: What is the Medicare timely filing limit for initial claim submission?
- 90 days from date of service
- 6 months from date of service
- 12 months (1 year) from date of service (Correct answer)
- 24 months from date of service
Correct answer: 12 months (1 year) from date of service
Medicare requires claims to be filed within one calendar year (12 months) from the date of service.
Question 5: In denial management, what does it mean to 'work' a denial?
- Writing off the denied amount as a contractual adjustment
- Investigating the denial reason and taking corrective action to resolve it (Correct answer)
- Resubmitting the original claim without any changes
- Transferring the remaining balance to the patient
Correct answer: Investigating the denial reason and taking corrective action to resolve it
Working a denial involves analyzing the reason code, gathering supporting documentation, and submitting a corrected claim or formal appeal.
Question 6: Which KPI measures the average number of days to collect payment after service delivery?
- Days in Accounts Receivable (AR) (Correct answer)
- Net Collection Rate
- Denial Rate
- Clean Claim Rate
Correct answer: Days in Accounts Receivable (AR)
Days in AR measures the average elapsed time between service delivery and receipt of payment, indicating collection efficiency.
Question 7: Which HIPAA transaction set is used to transmit an electronic remittance advice (ERA)?
- HIPAA 835 (Correct answer)
- HIPAA 837P
- HIPAA 270/271
- HIPAA 276/277
Correct answer: HIPAA 835
The HIPAA 835 transaction is the electronic remittance advice used by payers to communicate payment details and adjustments to providers.
AHIMA Revenue Cycle Management 2
Which claim form is required for professional/physician billing to Medicare?