Medical Billing Software Medical Insurance Billing 4 — Questions and Answers
Question 1: What is 'balance billing' and when is it typically prohibited?
- Billing a patient for a second time after insurance pays; always allowed
- Charging a patient the difference between the billed amount and the allowed amount; prohibited for in-network providers under most contracts (Correct answer)
- Adding interest charges to overdue patient balances; prohibited by HIPAA
- Billing two insurers simultaneously; prohibited by COB rules
Correct answer: Charging a patient the difference between the billed amount and the allowed amount; prohibited for in-network providers under most contracts
Balance billing occurs when a provider bills a patient for the difference between their charge and the insurer's allowed amount, which is generally prohibited for in-network providers by their contracts.
Question 2: Which National Drug Code (NDC) format is required when billing for drugs administered in a physician's office?
- 5-4-2 format
- 11-digit format (Correct answer)
- 10-digit format only
- 8-digit format
Correct answer: 11-digit format
When billing for physician-administered drugs, the NDC must be submitted in the 11-digit format (with leading zeros if necessary) as required by most payers.
Question 3: What does 'place of service' (POS) code 11 indicate on a CMS-1500 claim?
- Inpatient hospital
- Office (Correct answer)
- Emergency room
- Urgent care facility
Correct answer: Office
POS code 11 indicates that the service was provided in a physician's office setting, which affects the reimbursement rate applied by many payers.
Question 4: Under HIPAA, which transaction standard is used for electronic claims submission from providers to payers?
- ANSI X12 837 (Correct answer)
- ANSI X12 835
- ANSI X12 270
- ANSI X12 820
Correct answer: ANSI X12 837
The ANSI X12 837 transaction set is the HIPAA-mandated standard electronic format for submitting healthcare claims from providers to insurance payers.
Question 5: What is a 'global period' in the context of surgical billing?
- The total time allotted to bill for a procedure before timely filing expires
- A defined postoperative timeframe during which related follow-up services are included in the surgical payment (Correct answer)
- The period during which a patient's global insurance coverage is active
- The time between surgery scheduling and procedure date
Correct answer: A defined postoperative timeframe during which related follow-up services are included in the surgical payment
A global period is the postoperative timeframe (typically 0, 10, or 90 days) during which routine follow-up care is bundled into the surgical fee and cannot be billed separately.
Question 6: Which modifier indicates that a procedure was performed by a resident under the supervision of a teaching physician?
- -GC (Correct answer)
- -GE
- -GW
- -GX
Correct answer: -GC
Modifier -GC indicates that the service was performed in part by a resident under the direction of a teaching physician, as required for Medicare billing in teaching settings.
Question 7: What is the primary purpose of the National Provider Identifier (NPI)?
- To track a provider's malpractice history
- To uniquely identify healthcare providers in standard HIPAA transactions (Correct answer)
- To assign billing privileges in Medicare
- To classify providers by specialty for fee schedule purposes
Correct answer: To uniquely identify healthcare providers in standard HIPAA transactions
The NPI is a 10-digit unique identification number assigned to healthcare providers by CMS, required on all standard HIPAA electronic transactions.
Medical Billing Software Medical Insurance Billing 4
What is 'balance billing' and when is it typically prohibited?