CPCA CPCA Reimbursement and Payer Policies 2

Question 1

What form is used to submit professional claims to Medicare and most commercial payers?

Accepted Answer

CMS-1500

Answer

The CMS-1500 is the standard paper claim form used by physicians and other non-institutional providers.

Question 2

A patient has both Medicare Part B and a Medigap policy. Which payer receives the claim first?

Accepted Answer

Medicare Part B

Answer

Medicare Part B is always the primary payer, and the Medigap policy is billed as secondary for the remaining balance.

Question 3

What does the term 'coordination of benefits' (COB) refer to in medical billing?

Accepted Answer

Determining which payer is primary when a patient has multiple coverages

Answer

COB is the process used to prevent duplicate payment when a patient has more than one health insurance plan.

Question 4

Which modifier is appended to a CPT code to indicate that a service was reduced or eliminated at the physician's discretion?

Accepted Answer

Modifier 52

Answer

Modifier 52 is used when a service or procedure is partially reduced, signaling to the payer that full reimbursement is not expected.

Question 5

A practice receives a denial code CO-4. What does this typically indicate?

Accepted Answer

Modifier is inconsistent with the procedure code

Answer

CO-4 indicates the service code is inconsistent with the modifier, requiring the biller to review the modifier-procedure pairing.

CPCA Exam Practice Test