Medical Billing & Coding Flashcards

Which of the following is an example of upcoding?

Answer: Billing a 99215 when only a 99212 was performed

Upcoding means billing a higher-level code than the service actually performed to receive a larger reimbursement, which is fraudulent.

What is the purpose of a Coordination of Benefits (COB) agreement between insurers?

Answer: To prevent duplicate payments when a patient has multiple insurance plans

COB rules establish which plan pays first (primary) and which pays second (secondary) to ensure total reimbursement does not exceed 100% of the allowed amount.

A crossover claim is:

Answer: A Medicare claim automatically forwarded to Medicaid for secondary billing

A crossover claim is one that Medicare automatically forwards to Medicaid after adjudication for dual-eligible beneficiaries.

Which modifier indicates that a procedure was performed by two surgeons, each performing a distinct part?

Answer: Modifier -62

Modifier -62 is used when two surgeons work together as primary surgeons performing distinct portions of a single reportable procedure.

A patient's insurance plan requires them to pay $30 for every office visit regardless of the billed amount. This is called a:

Answer: Co-payment

A co-payment (copay) is a fixed dollar amount the patient pays at the time of service for a covered healthcare visit or service.

Which of the following best describes the 'birthday rule' in insurance coordination of benefits?

Answer: The plan of the parent whose birthday falls earlier in the calendar year is primary for dependent children

The birthday rule states that for dependent children covered by both parents' plans, the plan of the parent with the earlier birthday in the calendar year is primary.

What does place of service (POS) code 11 indicate on a CMS-1500 claim?

Answer: Office

POS code 11 represents the Office setting, indicating services were rendered in a physician's or other provider's office.