COC Revenue Cycle and Compliance 2 — Questions and Answers
Question 1: What is 'coordination of benefits' (COB) in healthcare billing?
- The process of determining which payer pays first when a patient has multiple insurances (Correct answer)
- The negotiation of contracted rates between providers and payers
- The assignment of patient responsibility for copayments
- The process of verifying insurance eligibility
Correct answer: The process of determining which payer pays first when a patient has multiple insurances
Coordination of benefits establishes the order in which multiple insurance plans pay when a patient has more than one coverage, preventing overpayment.
Question 2: Under HIPAA, the standard electronic transaction format for claim submission is:
- 837P (professional) or 837I (institutional) (Correct answer)
- UB-04 paper form
- CMS-1500 paper form
- X12 999
Correct answer: 837P (professional) or 837I (institutional)
HIPAA mandates the ASC X12 837P transaction for professional claims and 837I for institutional (facility) claims submitted electronically.
Question 3: The 'Birthday Rule' is a COB rule that states:
- The parent whose birthday falls earlier in the calendar year has the primary plan for dependent children (Correct answer)
- The older parent's plan is always primary
- The employer's plan always pays before the spouse's plan
- The plan held longest is always primary
Correct answer: The parent whose birthday falls earlier in the calendar year has the primary plan for dependent children
The Birthday Rule determines primary coverage for dependent children when both parents have coverage: the parent with the earliest birthday (month/day) in the year has the primary plan.
Question 4: Which of the following best describes 'medical necessity' in coding compliance?
- Services must be appropriate to the diagnosis, evidence-based, and not excessive (Correct answer)
- Any service ordered by a licensed physician
- Services covered under the patient's insurance plan
- Services provided in an emergency situation
Correct answer: Services must be appropriate to the diagnosis, evidence-based, and not excessive
Medical necessity requires that services are clinically appropriate for the diagnosis, consistent with evidence-based standards, and not excessive relative to the patient's condition.
Question 5: What is the purpose of a healthcare organization's compliance program?
- Prevent, detect, and correct improper billing and coding practices (Correct answer)
- Increase reimbursement by maximizing code complexity
- Satisfy HIPAA requirements for patient privacy
- Manage hospital credentialing for physicians
Correct answer: Prevent, detect, and correct improper billing and coding practices
A compliance program is designed to prevent fraudulent billing, detect errors and abusive practices, and correct deficiencies to ensure legal, ethical claim submission.
Question 6: Under the OIG Work Plan, which of the following would be a common audit target for outpatient coding?
- High-frequency E/M code levels (e.g., predominantly billing 99215) (Correct answer)
- Use of Z-codes as additional diagnoses
- Non-covered preventive service billing
- Billing for approved clinical trials
Correct answer: High-frequency E/M code levels (e.g., predominantly billing 99215)
The OIG routinely targets providers who bill a disproportionately high frequency of the highest-level E/M codes, which may indicate upcoding.
COC Revenue Cycle and Compliance 2
What is 'coordination of benefits' (COB) in healthcare billing?