CCMA Medical Billing and Coding Basics 4 — Questions and Answers
Question 1: A claim is rejected because the patient's insurance ID number does not match the payer's records. What is the correct next step?
- Resubmit the claim with the same information
- Verify the ID with the patient and correct the claim before resubmitting (Correct answer)
- Write off the balance as uncollectible
- Submit the claim to secondary insurance instead
Correct answer: Verify the ID with the patient and correct the claim before resubmitting
Rejected claims contain errors that must be corrected before resubmission, so the ID should be verified with the patient first.
Question 2: Which ICD-10-CM code category is used to report external causes of morbidity, such as a patient injured in a car accident?
- Z codes
- V, W, X, Y codes (Correct answer)
- E codes
- T codes
Correct answer: V, W, X, Y codes
In ICD-10-CM, V, W, X, and Y codes classify external causes of injury and morbidity.
Question 3: What does the term 'crossover claim' refer to in medical billing?
- A claim submitted to both the patient and the payer simultaneously
- A claim automatically forwarded from Medicare to Medicaid for dual-eligible patients (Correct answer)
- A claim that spans two calendar years
- A claim submitted to two different commercial insurers
Correct answer: A claim automatically forwarded from Medicare to Medicaid for dual-eligible patients
A crossover claim is automatically sent from Medicare (primary) to Medicaid (secondary) for patients eligible for both programs.
Question 4: A coder assigns CPT code 99213 for an established patient office visit. Which factor is NOT used to determine the level of E/M service?
- Medical decision making
- Total time spent on the date of the encounter
- The physician's years of experience (Correct answer)
- History and physical examination (for pre-2021 guidelines)
Correct answer: The physician's years of experience
E/M level selection is based on medical decision making and time (or key components), not the provider's years of experience.
Question 5: What is the purpose of a Superbill (encounter form) in the medical office?
- To record the patient's vital signs during the visit
- To document diagnosis and procedure codes used to generate an insurance claim (Correct answer)
- To notify the patient of their outstanding balance
- To authorize a referral to a specialist
Correct answer: To document diagnosis and procedure codes used to generate an insurance claim
A superbill captures diagnosis and procedure codes along with fees, serving as the source document for claim generation.
Question 6: Under HIPAA, which standard transaction set is used for electronic submission of professional healthcare claims?
- ASC X12 837P (Correct answer)
- ASC X12 835
- ASC X12 270/271
- ASC X12 276/277
Correct answer: ASC X12 837P
The HIPAA 837P transaction is the electronic standard for submitting professional (physician) claims.
Question 7: A patient has both Medicare Part B and a Medigap policy. Which payer is billed first?
- Medigap, because it is the supplemental policy
- Medicare Part B, as it is the primary payer (Correct answer)
- Either payer, depending on the patient's preference
- The payer with the highest reimbursement rate
Correct answer: Medicare Part B, as it is the primary payer
Medicare Part B is always the primary payer for Medicare beneficiaries; Medigap pays after Medicare processes the claim.
CCMA Medical Billing and Coding Basics 4
A claim is rejected because the patient's insurance ID number does not match the payer's records.
What is the correct next step?