CRCR Claims Processing and Billing 2

Question 1

A claim is returned to the provider as 'unprocessable' by Medicare. What is the most likely reason?

Accepted Answer

Required data elements are missing or invalid

Answer

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?

Accepted Answer

Modifier 50

Answer

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?

Accepted Answer

Diagnosis-Related Group

Answer

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?

Accepted Answer

Code combinations where one code is bundled into the other and cannot be billed separately

Answer

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?

Accepted Answer

Clinical documentation and physician notes supporting medical necessity

Answer

Clinical documentation and physician notes demonstrating the medical necessity of the service are essential for appealing a medical necessity denial.

CRCR - Certified Revenue Cycle Representative Program Practice Test