CBCS - Certified Billing and Coding Specialist Payment Adjudication Questions and Answers

Question 1

A billing specialist receives a remittance advice (RA) that shows a claim for a complex patient visit, billed with CPT code 99215, was reimbursed at the lower rate for CPT code 99213.
The payer did not deny the claim but adjusted the payment.
This action by the payer is known as:

Accepted Answer

Downcoding

Answer

Rejection

Answer

Unbundling

Answer

Upcoding

Question 2

During the adjudication process, a payer's automated system flags a claim because the diagnosis code submitted does not align with the procedure code as a medically necessary reason for the service. Which of the following is the MOST likely reason for this initial claim denial?

Accepted Answer

Lack of Medical Necessity

Answer

Timely Filing Limit Exceeded

Answer

Incorrect Patient Information

Answer

Service Not a Covered Benefit

Question 3

A Certified Billing and Coding Specialist is reviewing an Electronic Remittance Advice (ERA) to post payments. Which of the following pieces of information is essential for reconciling the account and determining the next steps?

Accepted Answer

Claim Adjustment Reason Codes (CARCs)

Answer

Patient's preferred pharmacy

Answer

Provider's National Provider Identifier (NPI)

Answer

The date the claim was created

Question 4

A claim is submitted to a commercial payer. During adjudication, the claim is found to have a transposed digit in the patient's insurance ID number. What is the most probable initial outcome for this claim?

Accepted Answer

The claim will be denied or rejected.

Answer

The claim will be paid in full.

Answer

The claim will be partially paid with an adjustment.

Answer

The claim will be forwarded to a secondary payer.

Question 5

After a claim is denied, the billing office prepares and submits additional documentation, including a letter from the physician explaining why the service was medically necessary, to the insurance company for a second review. This process is called:

Accepted Answer

An appeal

Answer

Re-adjudication

Answer

A query

Answer

Payment posting

Question 6

Which of the following best describes the primary purpose of the payment adjudication phase in the revenue cycle?

Accepted Answer

For the payer to evaluate a submitted claim and determine their payment responsibility.

Answer

To verify the patient's insurance eligibility and benefits before a service is rendered.

Answer

To convert physician documentation into standardized medical codes for billing.

Answer

To generate and send a statement to the patient for their outstanding balance.

A billing specialist receives a remittance advice (RA) that shows a claim for a complex patient visit, billed with CPT code 99215, was reimbursed at the lower rate for CPT code 99213.The payer did not deny the claim but adjusted the payment.This action by the payer is known as:

A billing specialist receives a remittance advice (RA) that shows a claim for a complex patient visit, billed with CPT code 99215, was reimbursed at the lower rate for CPT code 99213.
The payer did not deny the claim but adjusted the payment.
This action by the payer is known as: