Code Validation & Billing Procedures Flashcards

A payer's remittance advice shows claim adjustment reason code (CARC) 4. What does this typically indicate?

Answer: Service denied because the patient is not eligible for coverage on the date of service

CARC 4 indicates the service was denied because the patient was not eligible for the plan on the date the service was rendered.

Which claim filing deadline rule is most important for a coder to know when billing Medicare?

Answer: Claims must be filed within 1 year (12 months) from the date of service

Medicare requires that claims be filed within 1 calendar year (12 months) from the date of service for timely filing compliance.

What is the purpose of the National Correct Coding Initiative (NCCI) in claim validation?

Answer: To prevent improper payment of procedures that should not be billed together

NCCI edits are CMS-developed code pairs that identify procedures which should not be billed together because one is considered a component of the other.

A physician bills CPT 99213 with modifier -25 and also bills a minor procedure on the same day. What does the modifier -25 signify?

Answer: The E/M was a significant, separately identifiable service above and beyond the usual pre/post-procedure work

Modifier -25 indicates that on the day of a procedure, a significant and separately identifiable evaluation and management service was also performed.

What is an Advance Beneficiary Notice (ABN) and when is it required?

Answer: A written notice given to a Medicare patient when the provider expects Medicare may deny the service as not medically necessary

An ABN must be given to a Medicare patient before rendering a service the provider believes Medicare will deny, giving the patient the option to accept financial responsibility.

A coder is validating a claim where the place of service code is listed as '11' but the procedure was performed in a hospital outpatient department. What is the correct place of service code?

Answer: 22

Place of service code 22 designates an on-campus outpatient hospital setting, whereas code 11 is for an office setting.

Which of the following is an example of upcoding?

Answer: Billing a comprehensive office visit when documentation only supports a brief visit

Upcoding is the fraudulent practice of billing a higher-level or more complex service than what was actually documented or performed.