CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 2 — Questions and Answers
Question 1: What is the standard electronic claim format used for professional physician billing to Medicare?
- UB-04 transmitted as 837I
- CMS-1500 transmitted as 837P (Correct answer)
- ADA Dental Claim Form
- ANSI X12 271
Correct answer: CMS-1500 transmitted as 837P
The CMS-1500 paper form and its electronic equivalent the 837P transaction are used for professional billing.
Professional billing including physician services uses the CMS-1500 paper claim form and its electronic equivalent the ANSI X12 837P transaction set. Institutional billing for hospitals uses the UB-04 paper form and the 837I transaction. The 271 is used for eligibility response, not claims.
Question 2: What information is captured in the place of service code on a CMS-1500 claim?
- The patient's home address
- The setting where the service was rendered such as office or outpatient hospital (Correct answer)
- The billing provider's tax ID
- The type of insurance plan the patient has
Correct answer: The setting where the service was rendered such as office or outpatient hospital
Place of service codes indicate where a service was provided, which affects payment rates for many payers.
Place of service codes are two-digit codes on CMS-1500 claims that identify the setting where a service was delivered. Common codes include 11 for office, 22 for outpatient hospital, and 21 for inpatient hospital. These codes affect reimbursement because Medicare pays differently for the same service in a physician office versus a hospital outpatient setting.
Question 3: Which position on a claim form identifies the diagnosis primarily responsible for the patient visit?
- Field 24E diagnosis pointer
- The principal diagnosis code in the first position (Correct answer)
- Field 11 insured policy number
- The admitting diagnosis code
Correct answer: The principal diagnosis code in the first position
The first-listed or principal diagnosis code identifies the primary reason for the encounter and drives medical necessity determination.
The principal diagnosis for inpatient or first-listed diagnosis for outpatient identifies the condition chiefly responsible for the visit or admission. It is placed in the primary diagnosis position on the claim and is used by payers to determine medical necessity and DRG or APC assignment.
Question 4: What is the purpose of a clean claim standard in healthcare billing?
- To ensure all claims are submitted on paper forms
- To define the minimum data elements required for a claim to be processed without additional information (Correct answer)
- To mandate that claims be submitted within 24 hours of service
- To require that all claims include a patient signature
Correct answer: To define the minimum data elements required for a claim to be processed without additional information
A clean claim contains all required information for the payer to process it without requesting additional data, which speeds up payment.
A clean claim is one that contains all required data elements including patient demographics, provider identifiers, diagnosis and procedure codes, and service dates needed for the payer to adjudicate it without additional information requests. Under most payer contracts, payers must process clean claims within defined timeframes. Submitting clean claims reduces denials and accelerates cash flow.
Question 5: A claim is submitted electronically and the practice receives a 277CA transaction. What does this indicate?
- The claim has been paid
- The claim acknowledgment status showing whether it was accepted or rejected by the payer (Correct answer)
- The patient's eligibility has been confirmed
- A request for additional clinical documentation
Correct answer: The claim acknowledgment status showing whether it was accepted or rejected by the payer
The 277CA is the Claims Acknowledgment transaction that tells the submitter whether the payer accepted or rejected the claim at the front end.
The ANSI X12 277CA Claims Acknowledgment transaction is sent by payers or clearinghouses to confirm receipt of a claim submission and indicate whether each claim was accepted for processing or rejected due to front-end edits. It does not indicate payment. The 835 remittance advice confirms payment.
Question 6: What is coordination of benefits in claims processing?
- The process of confirming a patient's primary care physician
- The process of determining the order in which multiple insurance plans pay on a claim (Correct answer)
- Verifying that the rendering provider is in-network
- Calculating the patient's deductible balance
Correct answer: The process of determining the order in which multiple insurance plans pay on a claim
COB rules determine which payer is primary and which is secondary when a patient has more than one insurance plan.
Coordination of benefits is the process used to determine payment responsibilities when a patient has coverage under more than one health insurance plan. COB rules governed by state law and payer contracts establish which plan pays first (primary) and which pays second (secondary). The secondary plan may pay part or all of the patient's remaining cost-sharing after the primary has paid.
CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 2
What is the standard electronic claim format used for professional physician billing to Medicare?