Billing & Reimbursement Pop Quiz Flashcards
A billing and coding specialist is preparing a claim with two types of third-party payer coverage. Which of the following is a process that determines the order of third-party payers for the claim? A. Coordination of benefits B. Insurance claim cycle C. Electronic data interchange D. Explanation of benefits
A. Coordination of benefits
A billing and coding specialist has received numerous denials from a third-party payer for a reauthorized service. Which of the following actions should the specialist take to resolve the denied claim?
A. Request that the third-party payer review for reconsideration.
B. Bill the patient for the denied services.
C. Have the charges adjusted off the patient’s account.
D. Submit a new claim.
A. Request that the third-party payer review for reconsideration.
A billing and coding specialist is posting charges from an encounter. Which of the following scenarios indicate a correct charge capture?
A. Codes 96372 and J3301 x4 are reported for an encounter with injection of 4 units of Kenalog medication.
B. Code 99213 is billed for an established patient that was last seen 3.5 years ago.
C. Codes 99214, 90868, and 90460 are reported for a sick call, and an immunization is provided during the same encounter.
D. Code 4004F is used to bill for smoking cessation counseling services lasting 6 min.
A. Codes 96372 and J3301 x4 are reported for an encounter with injection of 4 units of Kenalog medication.
Which of the following information is needed to accurately review, evaluate, and resolve denied claims?
A. An aging report breakdown of a patient’s account
B. A remittance advice with reason codes
C. Registration notes
D. SOAP notes
B. A remittance advice with reason codes
Which of the following documents is used to review claim reimbursements and denials? A. CMS-1500 B. Remittance advice C. Authorization D. Concurrent review
B. Remittance advice
A billing and coding specialist is reviewing a partially paid claim that was submitted without modifier 22 for increased procedural services. Which of the following actions should the specialist take to obtain accurate reimbursement?
A. Resubmit the claim with copies of the medical record documentation.
B. Submit an appeal with copies of the medical record documentation.
C. Contact the patient for additional reimbursement.
D. Post the payment and write off the difference.
B. Submit an appeal with copies of the medical record documentation.
A billing and coding specialist is reviewing a remittance advice from a third-party payer that indicates $250 out of the $500 charge is a contractual adjustment. Which of the following actions should the specialist take?
A. Bill the patient for the difference.
B. Resubmit the claim for additional review.
C. Change the cost for the services on future claims.
D. Post the adjustment.
D. Post the adjustment.
A patient has Medicare and Tricare insurance plans. Which of the following should be collected as patient financial responsibility after a procedure?
A. 20% of the total charge of the procedure
B. 20% of the allowable amount for the procedure
C. $0.00
D. $1,000.00
C. $0.00
A billing and coding specialist is reviewing claim denials for a surgical procedure. After reviewing the original claim, it is determined that services should have been paid. Which of the following scenarios eliminates the need for prior authorization?
A. The patient had already been admitted to the hospital.
B. The patient required an emergency procedure.
C. The patient received an elective procedure.
D. The patient is a Medicare beneficiary.
B. The patient required an emergency procedure.
Which of the following resources is used to understand Medicare coverage circumstances such as indications and coding guidance? A. NCD articles B. NCCI edits C. Mutually exclusive edits (MUE) D. Alternative payment model (APM)
A. NCD articles
A billing and coding specialist is coding a surgical procedure. The documentation indicates an open appendectomy and a cholecystectomy with exploration of the common duct. Which of the following codes should the specialist use for proper reimbursement? A. 44955, 47610 B. 47562, 44970 C. 47610, 44955 D. 47562, 44970-51
C. 47610, 44955
A billing and coding specialist is completing a claim form for a Medicare Beneficiary for a wellness visit with their primary care provider who is a PAR provider. Which of the following information is required on the form?
A. Medicare identification number, date of birth, and date of injury
B. Medicare identification number, date of birth, and date of discharge
C. Medicare identification number, date of birth, and referring physician’s national provider identifier (NPI)
D. Medicare identification number, date of birth, and accept assignment
D. Medicare identification number, date of birth, and accept assignment
A billing and coding specialist is reviewing a remittance advice(RA). The specialist should identify that which of the following provides the reason for a claim denial?
A. Patient statements
B. Payer website
C. Claim adjustment reason code (CARC)
D. Electronic health record (EHR) scrubbing toolA.
C. Claim adjustment reason code (CARC)
After a claim is processed by a third-party payer, which of the following actions should a billing and coding specialist take to collect the remaining allowed amount?
A. Write off the remaining balance.
B. Submit an adjustment for additional reimbursement.
C. Call the third-party payer to negotiate a higher rate of reimbursement.
D. Prepare and send a patient statement.
D. Prepare and send a patient statement.
After running a report, a billing and coding specialist discovers several claims are being denied for coding errors. To prevent future errors, which of the following actions should the specialist take?
A. Educate the third-party payer on researching coding issues
B. Implement external audit processes
C. Retrain staff on proper documentation and coding guidelines
D. Write off the claims that were incorrectly submitted
C. Retrain staff on proper documentation and coding guidelines
