Medical Billing Software Medical Billing General 2 — Questions and Answers
Question 1: What does the ERA (Electronic Remittance Advice) document communicate to a provider?
- Patient appointment schedules
- Payment details and claim adjudication results from a payer (Correct answer)
- Prior authorization approvals
- Prescription refill statuses
Correct answer: Payment details and claim adjudication results from a payer
An ERA is an electronic transaction from the payer that explains how a claim was adjudicated and details the payment made to the provider.
Question 2: Which modifier should be appended to a CPT code when a procedure is performed bilaterally?
- -25
- -51
- -50 (Correct answer)
- -59
Correct answer: -50
Modifier -50 indicates a procedure was performed bilaterally on both sides of the body during the same operative session.
Question 3: A claim is denied with reason code CO-4. What does this typically indicate?
- The service is not covered under the patient's plan
- The procedure code is inconsistent with the modifier (Correct answer)
- The claim was filed after the timely filing deadline
- The patient's insurance has lapsed
Correct answer: The procedure code is inconsistent with the modifier
CO-4 indicates the procedure code is inconsistent with the modifier billed, requiring correction before resubmission.
Question 4: What is the primary purpose of a charge master (chargemaster) in a hospital billing system?
- To track patient appointment history
- To list all services, supplies, and their standard charges used for billing (Correct answer)
- To manage insurance credentialing for providers
- To calculate patient copayments automatically
Correct answer: To list all services, supplies, and their standard charges used for billing
The chargemaster is a comprehensive list of every billable item a hospital offers along with its standard price, forming the basis of all claims.
Question 5: Under HIPAA, which transaction set is used for electronic health care claim submission?
- X12 837 (Correct answer)
- X12 835
- X12 270
- X12 276
Correct answer: X12 837
The X12 837 transaction is the HIPAA-mandated standard for submitting electronic health care claims to payers.
Question 6: What does 'coordination of benefits' (COB) determine in medical billing?
- Which provider is the patient's primary care physician
- The order in which multiple insurance plans pay on a claim (Correct answer)
- How to split a deductible between family members
- Whether a procedure requires prior authorization
Correct answer: The order in which multiple insurance plans pay on a claim
COB rules establish which insurance plan pays first (primary) and which pays second (secondary) when a patient has multiple coverages.
Question 7: A medical biller receives a claim with CARC 97. What action should be taken?
- Appeal the claim as a medical necessity denial
- Rebill with the correct procedure code because the service is included in the allowance of another service (Correct answer)
- Resubmit the claim to the secondary payer
- Contact the patient for updated insurance information
Correct answer: Rebill with the correct procedure code because the service is included in the allowance of another service
CARC 97 means the service is included in the payment or allowance for another service/procedure, so the bundled code should be removed or an unbundling appeal prepared.
Medical Billing Software Medical Billing General 2
What does the ERA (Electronic Remittance Advice) document communicate to a provider?