CRCR Claims Processing and Billing 3 — Questions and Answers
Question 1: A provider submits a claim with a diagnosis code that is not specific enough (missing required characters). How will most payers respond?
- Pay the claim at a reduced rate
- Deny or reject the claim for invalid diagnosis code (Correct answer)
- Accept the code and assign a more specific code automatically
- Hold the claim for 30 days pending clarification
Correct answer: Deny or reject the claim for invalid diagnosis code
Payers will deny or reject claims with incomplete ICD-10-CM codes because codes must be reported to the highest level of specificity available.
Question 2: What is the significance of the 'place of service' (POS) code on a CMS-1500 claim form?
- It identifies the patient's home address
- It indicates the setting where the service was rendered and affects reimbursement rates (Correct answer)
- It specifies the ordering physician's specialty
- It determines the filing deadline for the claim
Correct answer: It indicates the setting where the service was rendered and affects reimbursement rates
The POS code identifies the setting where the service was performed, and payers use it to determine the appropriate reimbursement rate.
Question 3: A claim is denied for 'timely filing.' The provider has documentation that the claim was submitted within the timely filing period. What should the provider do?
- Write off the balance as uncollectible
- Appeal the denial with proof of timely submission such as a clearinghouse confirmation (Correct answer)
- Rebill the claim immediately without any additional documentation
- Contact the patient to collect the balance
Correct answer: Appeal the denial with proof of timely submission such as a clearinghouse confirmation
The provider should appeal with documented proof of timely submission, such as a clearinghouse batch confirmation report with a timestamp.
Question 4: Which type of edit checks for duplicate claim submissions within a payer's system?
- Medical necessity edit
- Duplicate claim edit (Correct answer)
- NCCI bundling edit
- Frequency edit
Correct answer: Duplicate claim edit
Duplicate claim edits identify when an identical or substantially similar claim has already been submitted and paid for the same patient, service, and date.
Question 5: When billing Medicare for an outpatient hospital service, what payment system is used?
- Diagnosis-Related Groups (DRG)
- Ambulatory Payment Classifications (APC) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Per Diem prospective payment
Correct answer: Ambulatory Payment Classifications (APC)
Medicare uses Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS) for outpatient hospital services.
Question 6: A payer requests additional information to process a claim, sending a 'development letter.' What is the provider's best course of action?
- Ignore the letter since the claim was already submitted correctly
- Respond with the requested documentation within the payer's specified timeframe (Correct answer)
- Resubmit the original claim without the requested information
- Immediately appeal the request as an inappropriate delay
Correct answer: Respond with the requested documentation within the payer's specified timeframe
The provider must respond promptly with the requested documentation within the payer's timeframe or risk denial of the claim.
Question 7: What does the term 'fee schedule' mean in healthcare billing?
- A list of all services a provider is not allowed to bill
- A predetermined list of maximum allowable amounts a payer will reimburse for specific services (Correct answer)
- The total charges listed on a provider's superbill
- The schedule of patient copayments by plan type
Correct answer: A predetermined list of maximum allowable amounts a payer will reimburse for specific services
A fee schedule is a payer's predetermined list of maximum allowable reimbursement amounts for specific procedures and services.
CRCR Claims Processing and Billing 3
A provider submits a claim with a diagnosis code that is not specific enough (missing required characters).
How will most payers respond?