CPC Code Validation & Billing Procedures 2

Question 1

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?

Accepted Answer

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

Answer

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

Question 2

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

Accepted Answer

-RT

Answer

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

Question 3

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?

Accepted Answer

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

Answer

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

Question 4

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

Accepted Answer

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

Answer

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.

Question 5

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?

Accepted Answer

The claim will be rejected for missing required billing provider information

Answer

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

(CPC) Certified Procedural Coder Practice Test

(CPC) Certified Procedural Coder Practice Test

CPC Code Validation & Billing Procedures 2