Claims Processing and Billing Flashcards
7 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Processing and Billing flashcards as text
A claim is returned to the provider as 'unprocessable' by Medicare. What is the most likely reason?
Answer: Required data elements are missing or invalid
Unprocessable claims are returned because they lack required data elements or contain invalid information that prevents adjudication.
Which modifier is appended to a procedure code to indicate a service was performed bilaterally?
Answer: Modifier 50
Modifier 50 is used to report bilateral procedures performed during the same operative session.
A hospital bills an inpatient claim using a DRG. What does DRG stand for?
Answer: Diagnosis-Related Group
DRG stands for Diagnosis-Related Group, a patient classification system used for prospective inpatient hospital payment.
Under the National Correct Coding Initiative (NCCI), what are 'column one/column two' code pairs?
Answer: Code combinations where one code is bundled into the other and cannot be billed separately
NCCI column one/column two edits identify code pairs where the column two code is a component of the column one code and cannot be billed separately.
A payer denies a claim stating the procedure is 'not medically necessary.' What documentation is most critical to support an appeal?
Answer: Clinical documentation and physician notes supporting medical necessity
Clinical documentation and physician notes demonstrating the medical necessity of the service are essential for appealing a medical necessity denial.
What is the purpose of a 'crossover claim' in Medicare billing?
Answer: A claim automatically forwarded from Medicare to a secondary payer after Medicare adjudicates it
A crossover claim is automatically forwarded by Medicare to a secondary payer, such as Medicaid or a Medigap plan, after Medicare processes the claim.
Which claim form is used by institutional providers such as hospitals for Medicare billing?
Answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard claim form used by institutional providers, including hospitals, for billing Medicare and most payers.