Claims Processing and Reimbursement 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 Reimbursement flashcards as text
A claim edit flags a procedure code as requiring an assistant surgeon modifier, but none was billed. What type of edit is this?
Answer: Assistant-at-surgery edit
Assistant-at-surgery edits identify procedures where Medicare's policy allows or requires an assistant surgeon and verify the appropriate modifier is present.
What does the term 'accounts receivable (A/R) days' measure in revenue cycle management?
Answer: The average number of days it takes to collect payment after a service is rendered
A/R days is a key performance metric that measures how efficiently a provider collects revenue after services are delivered.
A provider receives a Remittance Advice (RA) showing claim adjustment reason code (CARC) 97. What does this indicate?
Answer: The benefit for this service is included in the payment/allowance for another service
CARC 97 means the payment for one service is bundled into the payment for another service, indicating a bundling or inclusive adjustment.
Which of the following is an example of an advance beneficiary notice (ABN) situation?
Answer: A provider believes Medicare may deny a routine colonoscopy as not medically necessary
An ABN must be given to Medicare beneficiaries before providing a service that Medicare may deny, allowing the patient to decide whether to proceed and accept financial responsibility.
What is the significance of the 'clean claim' definition in payer contracts?
Answer: It establishes the timeframe within which a payer must adjudicate the claim once received
Most state prompt-pay laws and payer contracts tie adjudication timelines to receipt of a clean claim, making the definition critical for collections and appeals.
A physician bills CPT code 99214 and 99213 on the same day for the same patient. The payer denies 99213. Which edit most likely caused this denial?
Answer: Evaluation and management (E&M) same-day duplicate edit
Payers generally allow only one E&M service per provider per patient per day, so billing two E&M codes on the same day triggers a duplicate/same-day edit.
Under Medicare's Outpatient Prospective Payment System (OPPS), what is the 'three-day payment window' rule?
Answer: Outpatient diagnostic services provided within three days before inpatient admission are bundled into the DRG payment
The three-day (72-hour) payment window requires that outpatient services delivered by a hospital within three days before an inpatient admission be included in the inpatient DRG payment.