CCMA Medical Billing and Coding Basics 5 — Questions and Answers
Question 1: Which modifier is appended to a CPT code to indicate that a procedure was performed on the left side of the body?
- -RT
- -LT (Correct answer)
- -51
- -59
Correct answer: -LT
Modifier -LT (Left Side) is used to identify procedures performed on the left side of the body.
Question 2: What is a 'clean claim' in medical billing?
- A claim that has been paid in full by the patient
- A claim submitted without errors that can be processed and paid without additional information (Correct answer)
- A claim from which personal health information has been removed
- A claim resubmitted after a denial
Correct answer: A claim submitted without errors that can be processed and paid without additional information
A clean claim contains all required information and no errors, allowing the payer to adjudicate it without requesting additional data.
Question 3: The Relative Value Unit (RVU) system used in Medicare's RBRVS fee schedule consists of which three components?
- Diagnosis, procedure, and time
- Work, practice expense, and malpractice (Correct answer)
- CPT code, ICD code, and HCPCS code
- Facility, professional, and ancillary
Correct answer: Work, practice expense, and malpractice
RVUs are composed of physician work, practice expense, and malpractice expense components, each adjusted by a geographic factor.
Question 4: When a provider does not have a contract with a patient's insurance plan, the provider is considered:
- Participating
- Credentialed
- Non-participating (out-of-network) (Correct answer)
- Fee-for-service
Correct answer: Non-participating (out-of-network)
A non-participating or out-of-network provider has no contractual agreement with the payer, often resulting in lower reimbursement and higher patient cost-sharing.
Question 5: Which of the following best describes 'upcoding' in medical billing?
- Assigning a lower-level code than the service provided to reduce patient costs
- Assigning a higher-level code than the service documented to increase reimbursement (Correct answer)
- Correcting a previously submitted code to the accurate level
- Coding a service that was never performed
Correct answer: Assigning a higher-level code than the service documented to increase reimbursement
Upcoding is the fraudulent practice of billing for a higher-level service than was actually provided or documented.
Question 6: A patient is seen for an office visit and also receives an injection during the same encounter. The provider bills both services. What modifier may be needed on the injection code?
- -25 on the E/M code
- -59 on the injection code (Correct answer)
- -51 on the E/M code
- -22 on the injection code
Correct answer: -59 on the injection code
Modifier -59 (Distinct Procedural Service) on the injection code indicates it is a separate and distinct service from the E/M visit.
Question 7: What is the function of the National Provider Identifier (NPI) in medical billing?
- It identifies the patient's insurance plan
- It is a unique 10-digit number assigned to healthcare providers for use in standard transactions (Correct answer)
- It tracks the patient's medical record number across facilities
- It classifies the type of diagnosis being billed
Correct answer: It is a unique 10-digit number assigned to healthcare providers for use in standard transactions
The NPI is a unique HIPAA-mandated 10-digit identifier assigned to each healthcare provider for use in electronic billing and administrative transactions.
CCMA Medical Billing and Coding Basics 5
Which modifier is appended to a CPT code to indicate that a procedure was performed on the left side of the body?