CRCR Claims Processing and Billing 2 — Questions and Answers
Question 1: A claim is returned to the provider as 'unprocessable' by Medicare. What is the most likely reason?
- The patient has secondary insurance
- Required data elements are missing or invalid (Correct answer)
- The claim was submitted more than 30 days after service
- The provider's NPI is not enrolled in Medicare
Correct 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.
Question 2: Which modifier is appended to a procedure code to indicate a service was performed bilaterally?
- Modifier 50 (Correct answer)
- Modifier 51
- Modifier 59
- Modifier 76
Correct answer: Modifier 50
Modifier 50 is used to report bilateral procedures performed during the same operative session.
Question 3: A hospital bills an inpatient claim using a DRG. What does DRG stand for?
- Diagnosis-Related Group (Correct answer)
- Direct Reimbursement Guide
- Department Revenue Guidelines
- Diagnostic Reimbursement Grade
Correct answer: Diagnosis-Related Group
DRG stands for Diagnosis-Related Group, a patient classification system used for prospective inpatient hospital payment.
Question 4: Under the National Correct Coding Initiative (NCCI), what are 'column one/column two' code pairs?
- Codes that must always be billed together
- Code combinations where one code is bundled into the other and cannot be billed separately (Correct answer)
- Diagnosis codes paired with procedure codes
- Modifiers paired with evaluation and management codes
Correct 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.
Question 5: A payer denies a claim stating the procedure is 'not medically necessary.' What documentation is most critical to support an appeal?
- The patient's insurance card
- Clinical documentation and physician notes supporting medical necessity (Correct answer)
- The facility's charge master
- The explanation of benefits from a previous claim
Correct 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.
Question 6: What is the purpose of a 'crossover claim' in Medicare billing?
- A claim submitted to both Medicare and Medicaid simultaneously by the provider
- A claim automatically forwarded from Medicare to a secondary payer after Medicare adjudicates it (Correct answer)
- A claim submitted to the wrong payer that must be redirected
- A claim that crosses fiscal year boundaries
Correct 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.
Question 7: Which claim form is used by institutional providers such as hospitals for Medicare billing?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA Dental Claim Form
- HCFA-1450 (legacy only)
Correct 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.
CRCR Claims Processing and Billing 2
A claim is returned to the provider as 'unprocessable' by Medicare.
What is the most likely reason?