CPC Code Validation & Billing Procedures 3

Question 1

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

Accepted Answer

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

Answer

Service not covered by plan

Answer

The procedure code is inconsistent with the modifier

Answer

The service is not covered unless submitted via a referral

Question 2

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

Accepted Answer

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

Answer

Claims must be filed within 90 days of service

Answer

Claims must be filed within 6 months of service

Answer

Claims must be filed within 2 years of service

Question 3

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

Accepted Answer

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

Answer

To establish fee schedules for all CPT codes

Answer

To assign diagnosis codes to inpatient stays

Answer

To certify medical coders at the national level

Question 4

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

Accepted Answer

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

Answer

The E/M service was performed by a different physician

Answer

The procedure was staged

Answer

The patient had multiple diagnoses

Question 5

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

Accepted Answer

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

Answer

A notice given to all Medicare patients before any service

Answer

A billing statement provided after claim adjudication

Answer

A prior authorization form required for specialist referrals

Question 6

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?

Accepted Answer

22

Answer

21

Answer

11

Answer

19

Question 7

Which of the following is an example of upcoding?

Accepted Answer

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

Answer

Reporting a lower-level E/M than documented to avoid audit risk

Answer

Using modifier -52 to indicate a reduced service

Answer

Unbundling a global surgical package