CMA Medical Billing and Coding 5 — Questions and Answers
Question 1: What does the National Provider Identifier (NPI) represent?
- A unique 10-digit identification number assigned to healthcare providers (Correct answer)
- A code identifying the type of insurance plan
- A patient identification number used for billing
- A code assigned to medical procedures
Correct answer: A unique 10-digit identification number assigned to healthcare providers
The NPI is a unique 10-digit number assigned by CMS to identify healthcare providers in standard electronic transactions.
Question 2: Which diagnosis coding guideline applies when a patient presents with signs and symptoms but no definitive diagnosis has been established?
- Code the suspected diagnosis as if confirmed
- Code the signs and symptoms themselves (Correct answer)
- Leave the diagnosis field blank on the claim
- Code 'unspecified' for the body system involved
Correct answer: Code the signs and symptoms themselves
For outpatient encounters, ICD-10-CM guidelines require coding the signs and symptoms when no confirmed diagnosis exists, rather than coding an uncertain condition.
Question 3: A physician performs a procedure and wants to indicate the service was greater than usually required. Which modifier should be used?
- -22 (Correct answer)
- -52
- -53
- -24
Correct answer: -22
Modifier -22 (Increased Procedural Services) is used when the work required is substantially greater than typically required, and supporting documentation must accompany the claim.
Question 4: What is the timely filing limit, and what happens if a claim is submitted after this deadline?
- The payer can reduce the payment by 10%
- The payer will deny the claim and the provider generally cannot bill the patient for the balance (Correct answer)
- The claim is automatically resubmitted the following month
- The claim is sent to a secondary insurer automatically
Correct answer: The payer will deny the claim and the provider generally cannot bill the patient for the balance
Timely filing limits define the window to submit claims; late submission results in denial, and the provider typically cannot collect from the patient for a billing error.
Question 5: Which type of audit reviews a sample of claims AFTER payment to identify potential overpayments or compliance issues?
- Prospective audit
- Concurrent audit
- Retrospective audit (Correct answer)
- Credentialing audit
Correct answer: Retrospective audit
A retrospective audit reviews claims and documentation after services have been rendered and payment made, identifying billing errors or fraud.
Question 6: In CPT, what is the correct way to report a service that is not represented by any existing code?
- Use the closest matching code without notation
- Use an unlisted procedure code and submit with a special report (Correct answer)
- Use a deleted code from a prior year's manual
- Leave the procedure field blank on the claim
Correct answer: Use an unlisted procedure code and submit with a special report
Unlisted procedure codes (e.g., 99499, 27899) are used for services with no specific CPT code, and a special report describing the service must accompany the claim.
Question 7: What is the difference between a co-pay and a co-insurance?
- A co-pay is a percentage; co-insurance is a fixed dollar amount
- A co-pay is a fixed dollar amount due at the time of service; co-insurance is a percentage of the allowed amount (Correct answer)
- Co-pay applies only to hospitalizations; co-insurance applies to outpatient visits
- They are interchangeable terms for the same patient cost-sharing concept
Correct answer: A co-pay is a fixed dollar amount due at the time of service; co-insurance is a percentage of the allowed amount
A co-pay is a set dollar amount (e.g., $25) collected at the visit, while co-insurance is a percentage (e.g., 20%) of the allowed amount the patient owes after the deductible.
CMA Medical Billing and Coding 5
What does the National Provider Identifier (NPI) represent?