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

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

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

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

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

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.

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

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

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

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.

(CPC) Certified Procedural Coder Practice Test

(CPC) Certified Procedural Coder Practice Test

CPC Code Validation & Billing Procedures 3