CRCR Claims Processing and Billing 4

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?

Accepted Answer

Upcoding

Answer

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?

Accepted 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

Answer

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?

Accepted Answer

To translate and transmit claims from providers to payers electronically, performing edits to catch errors

Answer

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?

Accepted Answer

CPT 45378 is bundled into 45380 since 45380 includes the diagnostic colonoscopy

Answer

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'?

Accepted Answer

A claim that contains all required information and passes all edits, allowing the payer to adjudicate it without additional information

Answer

A clean claim contains all required data elements, has no errors, and can be processed by the payer without requesting additional information.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Claims Processing and Billing 4