COC Revenue Cycle and Compliance 2

Question 1

What is 'coordination of benefits' (COB) in healthcare billing?

Accepted Answer

The process of determining which payer pays first when a patient has multiple insurances

Answer

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:

Accepted Answer

837P (professional) or 837I (institutional)

Answer

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:

Accepted Answer

The parent whose birthday falls earlier in the calendar year has the primary plan for dependent children

Answer

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?

Accepted Answer

Services must be appropriate to the diagnosis, evidence-based, and not excessive

Answer

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?

Accepted Answer

Prevent, detect, and correct improper billing and coding practices

Answer

A compliance program is designed to prevent fraudulent billing, detect errors and abusive practices, and correct deficiencies to ensure legal, ethical claim submission.

COC - Certified Outpatient Coder Practice Test

COC - Certified Outpatient Coder Practice Test

COC Revenue Cycle and Compliance 2