CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 5 — Questions and Answers
Question 1: What is the function of modifier 59 when appended to a CPT procedure code?
- It indicates a distinct procedural service performed on the same day, separate from other services billed (Correct answer)
- It identifies a service performed by a teaching physician
- It denotes a bilateral procedure
- It signals that the service was performed in an emergency setting
Correct answer: It indicates a distinct procedural service performed on the same day, separate from other services billed
Modifier 59 is used to show that a procedure or service was distinct or independent from other services performed on the same day, often to bypass bundling edits.
Question 2: Which of the following best describes a 'crossover claim' in Medicare/Medicaid billing?
- A claim that Medicare automatically forwards to a secondary payer such as Medicaid after adjudication (Correct answer)
- A claim submitted simultaneously to two payers
- A claim transferred to a different Medicare Administrative Contractor
- A corrected claim replacing an original submission
Correct answer: A claim that Medicare automatically forwards to a secondary payer such as Medicaid after adjudication
After Medicare adjudicates a claim for a dual-eligible beneficiary, it automatically sends a crossover claim to the state Medicaid program for secondary payment.
Question 3: A claim is denied with reason code CO-97. What does this indicate?
- The benefit for this service is included in the payment or allowance for another service already adjudicated (Correct answer)
- The claim was submitted after the timely filing deadline
- The provider is not enrolled with the payer
- The patient's coverage was terminated on the date of service
Correct answer: The benefit for this service is included in the payment or allowance for another service already adjudicated
CO-97 means the service was bundled into another procedure already paid, indicating the billed code cannot be separately reimbursed.
Question 4: What is the purpose of the National Correct Coding Initiative (NCCI) edits maintained by CMS?
- To prevent improper payment of CPT codes that should not be billed together (Correct answer)
- To establish fee schedules for all Medicare services
- To set timely filing deadlines for Medicare claims
- To define covered diagnoses for outpatient procedures
Correct answer: To prevent improper payment of CPT codes that should not be billed together
NCCI edits are CMS-developed code pair tables that identify procedure code combinations that are not payable together because one is considered part of the other.
Question 5: When a provider performs the same procedure bilaterally on the same operative session, which modifier is typically appended?
- Modifier 50 (Correct answer)
- Modifier 52
- Modifier 53
- Modifier 58
Correct answer: Modifier 50
Modifier 50 is appended to a CPT code to indicate that an identical procedure was performed on both sides of the body during the same session.
Question 6: Under the Affordable Care Act, what is the maximum period a commercial payer has to pay or deny a clean electronic claim?
- 30 calendar days (Correct answer)
- 14 calendar days
- 45 calendar days
- 90 calendar days
Correct answer: 30 calendar days
Most state laws and ACA regulations require commercial payers to adjudicate clean electronic claims within 30 calendar days of receipt.
Question 7: Which of the following describes the 'coordination of benefits' (COB) order when a child is covered under both parents' plans?
- The plan of the parent whose birthday falls earlier in the calendar year is primary (Birthday Rule) (Correct answer)
- The plan with the lower deductible is always primary
- The mother's plan is always primary
- The plan with the larger network is primary
Correct answer: The plan of the parent whose birthday falls earlier in the calendar year is primary (Birthday Rule)
The Birthday Rule determines primary coverage for dependents by making the plan of the parent with the earlier birthday (month and day, not year) in the calendar year primary.
CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 5
What is the function of modifier 59 when appended to a CPT procedure code?