CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 3 — Questions and Answers
Question 1: Which condition code is used on an institutional claim to indicate that the patient is receiving care under a Medicaid-waiver program?
- Condition code 07 (Correct answer)
- Condition code 04
- Condition code 37
- Condition code 21
Correct answer: Condition code 07
Condition code 07 is used on UB-04 claims to indicate that the claim is being submitted under a state Medicaid home and community-based waiver.
Question 2: A claim is submitted with an incorrect NPI for the rendering provider. What is the most likely denial reason code returned by the payer?
- CO-16: Claim/service lacks information needed for adjudication (Correct answer)
- CO-4: Service/procedure inconsistent with modifier
- PR-96: Non-covered charge
- CO-29: Time limit for filing expired
Correct answer: CO-16: Claim/service lacks information needed for adjudication
CO-16 is assigned when required billing information is missing or invalid, which includes an unrecognized or incorrect NPI number.
Question 3: On the CMS-1500 form, Box 21 is used to report which of the following?
- Diagnosis codes in ICD format (Correct answer)
- CPT procedure codes
- Date of service
- Prior authorization number
Correct answer: Diagnosis codes in ICD format
Box 21 on the CMS-1500 is designated for up to 12 ICD-10-CM diagnosis codes that support medical necessity for the services billed.
Question 4: What does the term 'clean claim' mean in the context of revenue cycle billing?
- A claim that contains all required information and can be processed without additional information requests (Correct answer)
- A claim with no diagnosis codes
- A claim submitted electronically without paper attachments
- A claim that has been fully paid by the payer
Correct answer: A claim that contains all required information and can be processed without additional information requests
A clean claim is one that has all required fields properly completed, allowing the payer to adjudicate it without requesting additional information.
Question 5: Which national standard transaction set is used for electronic submission of professional healthcare claims?
- ASC X12 837P (Correct answer)
- ASC X12 835
- ASC X12 270/271
- ASC X12 276/277
Correct answer: ASC X12 837P
The ASC X12 837P (Professional) transaction is the HIPAA-mandated standard for electronic submission of professional claims.
Question 6: A patient has Medicare Part A as primary and Medicaid as secondary. What billing practice must the provider follow?
- Submit to Medicare first and then cross-over to Medicaid for any remaining balance (Correct answer)
- Submit to Medicaid first since it is a state program
- Bill the patient directly for any Medicare deductible
- Submit separate claims to both payers simultaneously
Correct answer: Submit to Medicare first and then cross-over to Medicaid for any remaining balance
Under the Medicare as Secondary Payer (MSP) rules, Medicare pays first and remaining balances automatically cross over to Medicaid as the payer of last resort.
Question 7: Which edit type on an institutional claim checks whether the billed procedure code is appropriate for the patient's age and sex?
- Demographic edit (Correct answer)
- Medical necessity edit
- Coding consistency edit
- Coordination of benefits edit
Correct answer: Demographic edit
Demographic edits validate that procedures and diagnoses are clinically consistent with the patient's age and gender documented on the claim.
CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 3
Which condition code is used on an institutional claim to indicate that the patient is receiving care under a Medicaid-waiver program?