Code Validation & Billing Procedures Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Code Validation & Billing Procedures flashcards as text
Which of the following best describes the concept of 'medical necessity' as it applies to coding and billing?
Answer: Services must be reasonable and necessary for the diagnosis or treatment of illness or injury
Medicare and most payers define medically necessary services as those that are reasonable and necessary for diagnosing or treating a patient's condition.
A payer audits a claim and requests medical records to verify a billed service. The provider fails to respond to the records request. What is the typical outcome?
Answer: The claim payment may be recouped or the claim denied for lack of supporting documentation
Failure to respond to a payer's request for medical records typically results in claim denial or recoupment of any payment already made.
What is the correct way to report a procedure that was discontinued after the patient was prepared and taken to the procedure room but before the procedure began?
Answer: Report the procedure code with modifier -73
Modifier -73 is used when a procedure is discontinued after the patient has been prepped and brought to the procedure room but before anesthesia is administered or the procedure starts.
Which HCPCS Level II code range is used for drugs administered other than oral method?
Answer: J codes (J0000-J9999)
HCPCS J codes (J0000-J9999) are used to report injectable drugs, chemotherapy agents, and other drugs administered other than orally.
A provider bills for a service that is never covered by Medicare under any circumstance. This is known as a:
Answer: Statutory exclusion
A statutory exclusion is a service explicitly excluded from Medicare coverage by law, such as cosmetic surgery or routine dental care.
When a physician provides care to a Medicare patient in a skilled nursing facility (SNF), which place of service code is used on the claim?
Answer: 31
Place of service code 31 designates a skilled nursing facility, and using the correct POS code affects both claim processing and reimbursement rates.
An EOB lists reason code CO-45 with a balance of $0 after the adjustment. What does CO-45 indicate?
Answer: Charges exceed the payer's fee schedule or maximum allowable amount
CARC CO-45 indicates that the charge exceeds the payer's fee schedule or maximum allowable amount, and the difference is a contractual write-off.