CPC Code Validation & Billing Procedures 5

Question 1

Which of the following best describes the concept of 'medical necessity' as it applies to coding and billing?

Accepted Answer

Services must be reasonable and necessary for the diagnosis or treatment of illness or injury

Answer

Medicare and most payers define medically necessary services as those that are reasonable and necessary for diagnosing or treating a patient's condition.

Question 2

A payer audits a claim and requests medical records to verify a billed service. The provider fails to respond to the records request. What is the typical outcome?

Accepted Answer

The claim payment may be recouped or the claim denied for lack of supporting documentation

Answer

Failure to respond to a payer's request for medical records typically results in claim denial or recoupment of any payment already made.

Question 3

What is the correct way to report a procedure that was discontinued after the patient was prepared and taken to the procedure room but before the procedure began?

Accepted Answer

Report the procedure code with modifier -73

Answer

Modifier -73 is used when a procedure is discontinued after the patient has been prepped and brought to the procedure room but before anesthesia is administered or the procedure starts.

Question 4

Which HCPCS Level II code range is used for drugs administered other than oral method?

Accepted Answer

J codes (J0000-J9999)

Answer

HCPCS J codes (J0000-J9999) are used to report injectable drugs, chemotherapy agents, and other drugs administered other than orally.

Question 5

A provider bills for a service that is never covered by Medicare under any circumstance. This is known as a:

Accepted Answer

Statutory exclusion

Answer

A statutory exclusion is a service explicitly excluded from Medicare coverage by law, such as cosmetic surgery or routine dental care.

(CPC) Certified Procedural Coder Practice Test

(CPC) Certified Procedural Coder Practice Test

CPC Code Validation & Billing Procedures 5