Billing and Claims Submission Flashcards
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Read the first 6 Billing and Claims Submission flashcards as text
What modifier is used to indicate that a procedure was performed on both sides of the body (bilateral)?
Answer: -50
Modifier -50 is appended to a CPT code to indicate that a procedure was performed bilaterally (on both sides) during the same operative session.
What does the 837P electronic transaction format represent?
Answer: Electronic claim transaction for professional (physician) services submitted to payers
The 837P (Professional) is the HIPAA-standard electronic transaction for submitting professional claims (CMS-1500 equivalent). 837I is for institutional claims (UB-04 equivalent).
What is a clearinghouse in medical billing?
Answer: An intermediary company that receives electronic claims from providers, checks them for errors, reformats them to payer specifications, and transmits them to payers
A clearinghouse acts as an intermediary between healthcare providers and payers, receiving electronic claims, scrubbing them for errors, and transmitting them in the correct format to each payer.
When a claim is rejected vs. denied, what is the key difference?
Answer: Rejected claims were never processed due to errors (missing data, invalid codes); denied claims were processed but not paid for a coverage or policy reason
A rejection occurs before processing — the claim has errors and was never entered into the payer's system. A denial occurs after processing — the payer adjudicated the claim and decided not to pay.
What is an electronic data interchange (EDI) in healthcare billing?
Answer: The computer-to-computer exchange of standard business documents (claims, eligibility, remittance) between trading partners in a standard format
EDI is the electronic exchange of structured business data between organizations (e.g., provider and payer) using standardized formats. HIPAA mandated specific EDI transaction standards for healthcare.
What is the purpose of using Modifier -25 on a claim?
Answer: To indicate that a significant and separately identifiable E/M service was performed on the same day as a procedure
Modifier -25 is appended to the E/M service code to indicate that a significant, separately identifiable evaluation and management service was performed by the same physician on the same day as a procedure or other service.