Medical Billing Software Case Studies & Practical Application 4 — Questions and Answers
Question 1: A billing coordinator is setting up a new payer contract in the software. The contract has different allowed amounts for different place-of-service codes. How should this be configured?
- Enter a single blended rate for all services
- Create place-of-service-specific fee schedule entries within the payer contract (Correct answer)
- Bill all services at the standard fee schedule and adjust manually
- Ignore place-of-service differences until denials occur
Correct answer: Create place-of-service-specific fee schedule entries within the payer contract
Most billing software supports place-of-service modifiers within payer fee schedules, ensuring correct expected reimbursement is applied during payment posting.
Question 2: A billing team is handling a patient who has Medicare as primary and Medicaid as secondary. After Medicare posts, the claim should cross over automatically. If it does not, what is the FIRST thing to check in the software?
- Whether the crossover payer ID is correctly configured for Medicaid in the software (Correct answer)
- Whether the patient owes a copay
- Whether the Medicare explanation of benefits matches the fee schedule
- Whether the claim was sent via paper instead of electronically
Correct answer: Whether the crossover payer ID is correctly configured for Medicaid in the software
Automatic Medicare-to-Medicaid crossover requires the correct Medicaid crossover payer ID to be configured in the billing software's payer setup.
Question 3: A radiology group bills globally (professional + technical component together). A hospital wants to bill only the professional component. Which code modifier must be correctly configured in the billing software?
- Modifier 25
- Modifier TC and Modifier 26 (Correct answer)
- Modifier 59
- Modifier GT
Correct answer: Modifier TC and Modifier 26
Modifier TC (technical component) and Modifier 26 (professional component) split global services; the hospital bills TC and the radiologist bills 26.
Question 4: A billing office implements a new patient payment portal integrated with the billing software. Staff notice that some online payments are not reflecting in the patient account. What is the MOST likely integration issue?
- The payment portal's webhook or API connection to the billing software is failing to post transactions (Correct answer)
- Patients are entering wrong payment amounts
- The software does not support online payments
- Credit card processing fees are being deducted before posting
Correct answer: The payment portal's webhook or API connection to the billing software is failing to post transactions
Payment portal integration relies on webhooks or API calls to post transactions; a broken connection causes payments to process but not appear in patient accounts.
Question 5: A cardiology practice wants to ensure that high-cost implantable device costs are captured on claims. Which billing software feature supports this?
- Device/implant tracking with HCPCS code and NDC/UDI capture linked to the procedure charge (Correct answer)
- Automated prior authorization for all cardiology codes
- Patient balance write-off automation
- Batch eligibility verification
Correct answer: Device/implant tracking with HCPCS code and NDC/UDI capture linked to the procedure charge
Implant tracking modules capture device HCPCS codes, NDC or UDI identifiers, and costs, attaching them to the related procedure charge on the claim.
Question 6: After migrating billing software, a practice finds that accounts receivable days jumped from 32 to 58. Which report would BEST pinpoint where the bottleneck occurred post-migration?
- A claim submission lag report comparing submission date to date of service across payers post-migration (Correct answer)
- A patient demographics completeness report
- A staff scheduling report
- A diagnosis code frequency report
Correct answer: A claim submission lag report comparing submission date to date of service across payers post-migration
A claim submission lag report identifies delays between service dates and actual submission dates, revealing whether the migration caused submission workflow bottlenecks.
Question 7: A federally qualified health center (FQHC) needs to bill using the Prospective Payment System (PPS) encounter rate. How should the billing software be configured differently from standard fee-for-service billing?
- Configure a PPS rate fee schedule by visit type and map encounters to UB-04 revenue codes 0521/0522 (Correct answer)
- Bill each service line separately with individual CPT codes and standard rates
- Use the Medicare physician fee schedule for all FQHC claims
- Submit all FQHC claims on CMS-1500 forms without modification
Correct answer: Configure a PPS rate fee schedule by visit type and map encounters to UB-04 revenue codes 0521/0522
FQHCs bill an all-inclusive PPS encounter rate using UB-04 revenue codes 0521 (medical visit) or 0522 (mental health visit) rather than itemized fee-for-service CPT billing.
Medical Billing Software Case Studies & Practical Application 4
A billing coordinator is setting up a new payer contract in the software.
The contract has different allowed amounts for different place-of-service codes.
How should this be configured?