CRCR Claims Processing and Billing 4 — Questions and Answers
Question 1: A provider bills a new patient office visit (CPT 99203) but the documentation only supports an established patient level of service. What is this an example of?
- Upcoding (Correct answer)
- Downcoding
- Unbundling
- Fragmentation
Correct answer: Upcoding
Upcoding occurs when a provider bills a higher level of service than what is documented, which is considered fraud.
Question 2: Which of the following best describes an Advance Beneficiary Notice (ABN) in Medicare billing?
- A form authorizing the provider to bill Medicare directly
- A written notice given to a Medicare beneficiary before a service that Medicare may not cover, allowing the patient to decide whether to receive and pay for the service (Correct answer)
- A notice from Medicare stating the claim has been approved
- A form used to appeal a Medicare denial
Correct answer: A written notice given to a Medicare beneficiary before a service that Medicare may not cover, allowing the patient to decide whether to receive and pay for the service
An ABN is required to be given to Medicare beneficiaries before rendering services that Medicare may deny as not medically necessary, giving patients the choice to receive the service and accept financial responsibility.
Question 3: What is the role of a clearinghouse in the claims submission process?
- To adjudicate claims on behalf of the payer
- To translate and transmit claims from providers to payers electronically, performing edits to catch errors (Correct answer)
- To collect patient copayments on the provider's behalf
- To negotiate contracts between providers and insurance companies
Correct answer: To translate and transmit claims from providers to payers electronically, performing edits to catch errors
A clearinghouse acts as an intermediary that reformats, edits, and transmits electronic claims from providers to payers, reducing errors before submission.
Question 4: A claim includes CPT code 45378 (colonoscopy) and 45380 (colonoscopy with biopsy) for the same date. A payer denies the 45378. Why?
- The patient is not eligible for a colonoscopy
- CPT 45378 is bundled into 45380 since 45380 includes the diagnostic colonoscopy (Correct answer)
- The provider did not obtain prior authorization
- The colonoscopy exceeds the allowed frequency for the year
Correct answer: CPT 45378 is bundled into 45380 since 45380 includes the diagnostic colonoscopy
CPT 45380 includes a colonoscopy with biopsy, which inherently includes the diagnostic colonoscopy (45378), so billing both is considered unbundling.
Question 5: In the context of claims processing, what is a 'clean claim'?
- A claim that has been paid in full without adjustments
- A claim that contains all required information and passes all edits, allowing the payer to adjudicate it without additional information (Correct answer)
- A claim with no patient balance remaining after payment
- A claim submitted on paper rather than electronically
Correct answer: A claim that contains all required information and passes all edits, allowing the payer to adjudicate it without additional information
A clean claim contains all required data elements, has no errors, and can be processed by the payer without requesting additional information.
Question 6: What is the purpose of the Medicare Secondary Payer (MSP) questionnaire?
- To determine if the patient qualifies for Medicare Advantage
- To identify whether another payer should be billed before Medicare, ensuring Medicare pays only as a secondary payer when appropriate (Correct answer)
- To establish the patient's Medicare deductible status
- To verify the patient's Medicare Part D drug coverage
Correct answer: To identify whether another payer should be billed before Medicare, ensuring Medicare pays only as a secondary payer when appropriate
The MSP questionnaire identifies situations where another insurer, such as a group health plan or workers' compensation, is the primary payer before Medicare.
Question 7: A provider wants to appeal a denied claim. Under ERISA plans, what is the maximum number of internal appeals typically allowed before accessing external review?
- One internal appeal only (Correct answer)
- Two internal appeals
- Three internal appeals
- No limit on internal appeals
Correct answer: One internal appeal only
Under ERISA and ACA regulations, plans must allow at least one internal appeal before requiring access to external independent review.
CRCR Claims Processing and Billing 4
A provider bills a new patient office visit (CPT 99203) but the documentation only supports an established patient level of service.
What is this an example of?