CRCR Claims Processing and Reimbursement 5 — Questions and Answers
Question 1: A claim edit flags a procedure code as requiring an assistant surgeon modifier, but none was billed. What type of edit is this?
- Medically unlikely edit (MUE)
- Correct Coding Initiative (CCI) edit
- Assistant-at-surgery edit (Correct answer)
- Frequency limitation edit
Correct answer: Assistant-at-surgery edit
Assistant-at-surgery edits identify procedures where Medicare's policy allows or requires an assistant surgeon and verify the appropriate modifier is present.
Question 2: What does the term 'accounts receivable (A/R) days' measure in revenue cycle management?
- The number of days a patient has to pay their bill
- The average number of days it takes to collect payment after a service is rendered (Correct answer)
- The total dollar amount owed to the provider
- The number of days between claim submission and denial
Correct answer: The average number of days it takes to collect payment after a service is rendered
A/R days is a key performance metric that measures how efficiently a provider collects revenue after services are delivered.
Question 3: A provider receives a Remittance Advice (RA) showing claim adjustment reason code (CARC) 97. What does this indicate?
- The claim was paid in full
- The claim was submitted past the timely filing limit
- The benefit for this service is included in the payment/allowance for another service (Correct answer)
- The patient was not eligible on the date of service
Correct answer: The benefit for this service is included in the payment/allowance for another service
CARC 97 means the payment for one service is bundled into the payment for another service, indicating a bundling or inclusive adjustment.
Question 4: Which of the following is an example of an advance beneficiary notice (ABN) situation?
- A physician performs an emergency appendectomy covered by Medicare
- A provider believes Medicare may deny a routine colonoscopy as not medically necessary (Correct answer)
- A hospital bills a Medicare Advantage plan for an inpatient stay
- A SNF bills Medicare for the first 20 days of a covered stay
Correct answer: A provider believes Medicare may deny a routine colonoscopy as not medically necessary
An ABN must be given to Medicare beneficiaries before providing a service that Medicare may deny, allowing the patient to decide whether to proceed and accept financial responsibility.
Question 5: What is the significance of the 'clean claim' definition in payer contracts?
- It defines how providers must store medical records
- It establishes the timeframe within which a payer must adjudicate the claim once received (Correct answer)
- It specifies which ICD-10 codes are covered under the contract
- It determines the patient's cost-sharing responsibility
Correct answer: It establishes the timeframe within which a payer must adjudicate the claim once received
Most state prompt-pay laws and payer contracts tie adjudication timelines to receipt of a clean claim, making the definition critical for collections and appeals.
Question 6: A physician bills CPT code 99214 and 99213 on the same day for the same patient. The payer denies 99213. Which edit most likely caused this denial?
- Medically unlikely edit (MUE)
- Evaluation and management (E&M) same-day duplicate edit (Correct answer)
- Global surgery edit
- Place of service edit
Correct answer: Evaluation and management (E&M) same-day duplicate edit
Payers generally allow only one E&M service per provider per patient per day, so billing two E&M codes on the same day triggers a duplicate/same-day edit.
Question 7: Under Medicare's Outpatient Prospective Payment System (OPPS), what is the 'three-day payment window' rule?
- Medicare requires claims to be filed within three days of service
- Outpatient diagnostic services provided within three days before inpatient admission are bundled into the DRG payment (Correct answer)
- Payers must remit payment within three days of receiving a clean claim
- Patients have three days to dispute their Explanation of Benefits
Correct answer: Outpatient diagnostic services provided within three days before inpatient admission are bundled into the DRG payment
The three-day (72-hour) payment window requires that outpatient services delivered by a hospital within three days before an inpatient admission be included in the inpatient DRG payment.
CRCR Claims Processing and Reimbursement 5
A claim edit flags a procedure code as requiring an assistant surgeon modifier, but none was billed.
What type of edit is this?