CEHRS Revenue Cycle and Billing 5

Question 1

A payer denies a claim stating the service is 'not covered under the patient's plan.' The best next step is to:

Accepted Answer

File an appeal with clinical documentation supporting the service

Answer

Non-covered service denials can sometimes be overturned on appeal with supporting clinical documentation demonstrating medical necessity or plan coverage.

Question 2

Which type of health plan requires patients to select a primary care physician (PCP) and obtain referrals to see specialists?

Accepted Answer

Health Maintenance Organization (HMO)

Answer

HMOs require members to choose a PCP who coordinates their care and provides referrals to in-network specialists.

Question 3

Under the CMS-1500 claim form, Box 21 is used to report:

Accepted Answer

ICD diagnosis codes

Answer

Box 21 of the CMS-1500 requires the ICD-10-CM diagnosis codes that support the medical necessity of the billed services.

Question 4

A Medicare patient sees a non-participating provider who does not accept assignment. The provider's charge is $300 but Medicare's allowed amount is $200. The maximum the provider can bill the patient above the Medicare allowed amount is limited by:

Accepted Answer

The limiting charge regulation

Answer

The Medicare limiting charge caps the amount a non-participating provider may bill a Medicare beneficiary at 115% of the non-participating fee schedule amount.

Question 5

Which of the following is an example of 'unbundling' in medical billing?

Accepted Answer

Billing each component of a surgical package separately instead of using the global code

Answer

Unbundling is the improper practice of billing multiple procedure codes for components that should be reported under a single comprehensive code.

(CEHRS) Certified Electronic Health Records Specialist Practice Test

(CEHRS) Certified Electronic Health Records Specialist Practice Test

CEHRS Revenue Cycle and Billing 5