Code Validation & Billing Procedures Flashcards

A claim is returned because the ICD-10-CM diagnosis code does not support medical necessity for the CPT procedure billed. What is the coder's first action?

Answer: Review the clinical documentation to find a more specific or additional supporting diagnosis

The coder should review documentation for a diagnosis that accurately reflects and supports the medical necessity of the procedure performed.

Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?

Answer: -RT

Modifier -RT (Right side) is used when a procedure is performed on the right side of a paired organ or body part.

An Explanation of Benefits (EOB) shows a claim was denied for 'duplicate billing.' The coder confirms the service was only billed once. What should the coder do?

Answer: File an appeal with documentation proving the service was rendered only once

When a payer incorrectly denies a claim as duplicate, the provider should appeal with supporting documentation demonstrating the claim is not a duplicate.

What does the term 'bundling' refer to in the context of claim validation?

Answer: The payer's practice of combining payment for related procedures into a single allowable

Bundling occurs when a payer packages multiple related services together and pays them as a single unit, often following the National Correct Coding Initiative (NCCI) edits.

A coder notices the claim form lists the rendering provider's NPI in Box 24J but the billing provider's NPI is missing from Box 33a on the CMS-1500. What is the likely outcome?

Answer: The claim will be rejected for missing required billing provider information

Box 33a requires the billing provider's NPI, and its absence is a common reason for claim rejection before adjudication.

Which of the following best describes a 'clean claim'?

Answer: A claim that contains all required data elements and passes all payer edits upon first submission

A clean claim is one that is accepted by the payer on first submission without any missing, invalid, or inconsistent information.

When a procedure is performed during the global surgical period of a prior procedure, and the new service is unrelated, which modifier should be used?

Answer: -79

Modifier -79 is used for an unrelated procedure or service by the same physician during the postoperative period.