CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 3

Question 1

Which condition code is used on an institutional claim to indicate that the patient is receiving care under a Medicaid-waiver program?

Accepted Answer

Condition code 07

Answer

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?

Accepted Answer

CO-16: Claim/service lacks information needed for adjudication

Answer

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?

Accepted Answer

Diagnosis codes in ICD format

Answer

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?

Accepted Answer

A claim that contains all required information and can be processed without additional information requests

Answer

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?

Accepted Answer

ASC X12 837P

Answer

The ASC X12 837P (Professional) transaction is the HIPAA-mandated standard for electronic submission of professional claims.

CRCR - Certified Revenue Cycle Representative Program Practice Test