Ch8- Claim Forms

Question 1

Where can the guidelines for proper completion of claim forms be found?
a. The back of the paper claim form
b. Private payer website and policy manual
c. Medicare Claims Processing Manual
d. Both b and c

Answer 1

d. Both b and c
Response Feedback:
Guidelines for completion of claim forms can be found in private payers’ policy manuals and online instructions. For Medicare claims, the Medicare Claims Processing Manual should be referenced.

Question 2

When a provider “accepts assignment”, what happens to the difference between the charged amount and the allowed amount?
a. It is billed to the patient
b. It can be submitted again for reconsideration
c. It is written off as patient hardship
d. It is considered a contractual write off

Answer 2

d. It is considered a contractual write off
Response Feedback:
Accepting assignment means that the provider agrees to accept the payer’s contracted amount. The provider must write off the difference between the charged amount and the contracted amount as a contractual write off.

Question 3

What is the type of bill code that is reported for a free standing clinic?
a. 073X
b. 074X
c. 085X
d. 075X

Answer 3

a. 073X
Response Feedback:
A free-standing outpatient clinic would report services with type of bill code 073X.

Question 4

What revisions does the CMS-1500 claim form undergo?
a. one NUCC review prior to approval
b. one CMS review prior to approval
c. one HHS and one CMS review and approval
d. Multiple reviews prior to approval and implementation

Answer 4

d. Multiple reviews prior to approval and implementation
Response Feedback:
The approval process for CMS-1500 claim form revisions includes multiple reviews and approvals. Once the updates have been approved by NUCC, the form is submitted to CMS for approval and then awaits public comment through CMS and OMB (Office of Management and Budget) before receiving final approval and implementation.

Question 5

When two or more diagnoses codes reported in item 21 support a procedure, how many diagnosis codes should the provider report in item 24E for Medicare claims?
a. 1
b. 2
c. 3
d. Report all diagnosis codes applicable to the procedure

Answer 5

a. 1
Response Feedback:
According to the Medicare Claim Processing Manual - Item 24E – This is a required field. Enter the diagnosis code reference number or letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number/letter per line item. CMS states that when multiple services are performed, enter the primary reference number/letter for each service only.

Question 6

Which transaction is NOT specified in the 5010 transaction standards?
a. Claims Institutional, Professional and Dental
b. Eligibility Requests and Responses
c. Acknowledgment for Healthcare Insurance
d. Acknowledgement for Patient Payments

Answer 6

d. Acknowledgement for patient payments
Response Feedback:
The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).

Question 7

What is the appropriate POS code to report services rendered in an urgent care facility?
a. 23
b. 17
c. 24
d. 20

Answer 7

d. 20
Response Feedback:
Rationale: POS code 20 is reported when services are provided in an Urgent Care Facility. POS code 23 for services provided in an Emergency Room of a Hospital, POS code 24 for Ambulatory Surgical Center services, and POS code 17 for services rendered in Walk-in Retail Health Clinic. Place of Service codes can be found in the front of the CPT® codebook.

Question 8

Facility charges are reported on which claim form?
a. UB-05 claim form
b. CMS-1500 claim form
c. UB-04 claim form
d. Either CMS-1500 or UB-04 claim form

Answer 8

c. UB-04 claim form
Response Feedback:
The UB-04 claim form is used to report facility charges to the payer for reimbursement.

Question 9

A patient is admitted to the hospital with pneumonia. Which FL would be used to report the patient’s admitting diagnosis?
a. FL 68
b. FL 70
c. FL65
d. FL 69

Answer 9

d. FL 69
Response Feedback:
The diagnosis code reporting the admitting diagnosis must be reported in FL 69. This is required for inpatient claims.

Question 10

Item 14 Qualifier is used to indicate what information?
a. Onset of Current Symptoms or Illness
b. Location of Injury
c. LMP
d. both a and c

Answer 10

d. both a and c
Response Feedback:
In Item 14, enter either an 8-digit (MM|DD|CCYY) or 6-digit (MM|DD|YY) date of current illness, injury, or pregnancy (LMP). Enter the applicable qualifier to the right of the vertical dotted line to identify which date is being reported. Qualifiers include: 431 to report Onset of Current Symptoms or Illness or 484 if reporting Last Menstrual Period

Question 11

National provider identifier (NPI) numbers are issued to individual practitioners as well as other entities. Which of the following is not issued an NPI?
a. Healthcare organizations
b. Facilities
c. DME suppliers
d. Health insurance companies

Answer 11

d. Health insurance companies
Response Feedback:
Rationale: Insurance companies do not require an NPI as they are not providers of service.

Question 12

When filing professional fee (provider) claims, which code set is NOT reported on the CMS-1500 claim form?
a. HCPCS Level II codes
b. ICD-10-PCS codes
c. ICD-10-CM codes
d. CPT codes

Answer 12

b. ICD-10PCS codes
Response Feedback:
Rationale: ICD-10-PCS codes are only reported on the UB-04 claim form for facility inpatient services.

Question 13

Which statement is TRUE regarding diagnosis codes on the UB-04 claim form?
a. The UB-04 claim form is only submitted for inpatient hospitals.
b. Report as many necessary diagnosis codes for the patient during the hospital encounter/stay.
c. Only one ICD-10-CM code can be reported on the UB-004 claim form.
d. Medicare requires the use of ICD-10-CM codes only on the UB-04 claim form and not the CMS-1500 claim form.

Answer 13

b. Report as many necessary diagnosis codes for the patient during the hospital encounter/stay.
Response Feedback:
Rationale: The UB-04 claim form is submitted for inpatient and outpatient hospital, CAHs, and CORFs. Medicare requires ICD-10-CM codes be reported on UB-04 claims and CMS-1500 claims. Do not enter ICD-9-CM and ICD-10-CM codes on the same claim form. FLs 67A-67Q are reported for other additional diagnosis codes. Report as many diagnosis codes as necessary to report the diagnoses of the patient.

Question 14

Which Item on the CMS-1500 claim form contains information regarding Medigap?
a. Medigap is not identified on the claim form
b. Item 1
c. Items 9, 9a, 9d
d. Items 11, 11a, 11b, 11c

Answer 14

c. Items 9, 9a, 9d
Response Feedback:
Rationale: Item 9—Enter SAME if the patient is the Medigap policyholder. If not, enter the policyholder’s last name, first name, and middle initial separated by commas. Item 9a—Enter the policy and/or group number of the secondary insurance (e.g., Medigap ID preceded by MEDIGAP, MG, or MGAP). Item 9d—Enter the 9-digit PAYERID number of the Medigap insurer. The PAYERID can be obtained from the insurance carrier. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

Question 15

For patients who have Medicare primary and a secondary insurance, how is the secondary insurance filed?
a. The claim is always automatically crossed over to the secondary insurance from Medicare.
b. If it is a cross-over insurance, Medicare will cross the claim over to the secondary payer.
c. Insurance carriers do not pay secondary to Medicare so a claim is not filed.
d. The secondary insurance is always printed to paper and sent with the Medicare EOB.

Answer 15

b. If it is a cross-over insurance, Medicare will cross the claim over to the secondary payer.
Response Feedback:
Rationale: If the patient has a primary and secondary insurance, the secondary insurer will not pay the claim until the primary insurance has made a determination. For Medicare, if the patient has a secondary insurance on file, Medicare will cross the claim over to the secondary payer once Medicare has made a payment determination (paid or denied). For payers that do not cross claims over, once the EOB is received from the primary insurance, apply the payment or denial and submit a claim and copy of the primary insurance EOB to the secondary payer for consideration.

Question 16

Which statement is TRUE regarding Item 5 on the CMS-1500 claim form?
a. The provider’s NPI is entered.
b. The physical address where the patient was seen is entered.
c. The provider’s alternate location is entered.
d. The patient’s home address is entered.

Answer 16

d. The patient’s home address is entered.
Response Feedback:
Rationale: Item 5: Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number. This information is provided by the patient and confirmed with the photo ID.

Question 17

What is the correct format to enter the date of birth on a paper CMS-1500 claim form?
a. YY/MM/DD
b. DD/MM/CCYY
c. MM/DD/YY
d. MM/DD/CCYY

Answer 17

d. MM/DD/CCYY
Response Feedback:
Rationale: According to the National Uniform Claim Committee, the correct format for date of birth (DOB) is MM/DD/CCYY on paper claims. The date in the electronic file is transmitted as CCYYMMDD (century, year, month, date).

Question 18

On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent?
a. The procedure or service.
b. The type of facility.
c. The type of care.
d. The frequency of care.

Answer 18

b. The type of facility.
Response Feedback:
Rationale: FL 4 is used for the type of bill and it’s a four-digit numerical code. The second digit identifies the type of facility.

Question 19

If a patient has insurance primary to Medicare, which Items must be completed in addition to Item 11?
a. Items 5, and 11a-11c
b. Items 9a-9d
c. Items 4, 6, 7, and 11a-11c
d. Items 4, 6, and 8

Answer 19

c. Items 4, 6, 7, and 11a-11c
Response Feedback:
Rationale: If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a–11c. This is determined by having the patient complete the Medicare Secondary Payer (MSP) questionnaire. Items 4, 6, and 7 must also be completed.

Question 20

Which statement is TRUE regarding condition codes for the UB-04 claim form?
a. Condition codes are listed in the order of occurrence instead of numerical order.
b. Condition codes are reported only on the CMS-1500 claim form.
c. A condition code is used to indicate an inpatient service is reported on an outpatient claim.
d. A condition code identifies the department for the revenue of the procedure.

Answer 20

c. A condition code is used to indicate an inpatient service is reported on an outpatient claim.
Response Feedback:
Rationale: The provider enters the corresponding code (in numerical order) to describe any conditions or events that apply to the billing period. For example, condition code 44 is reported when the physician orders inpatient services, but upon internal utilization review performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria. In this case, the claim is submitted as outpatient.

Question 21

On the UB-04 claim form, FL 10 is used to record the patient’s birthdate. If the birthdate is unknown, what information is entered?
a. Enter zero for all six digits
b. Enter zero for all eight digits
c. Enter X for all eight digits
d. Leave blank

Answer 21

b. Enter zero for all eight digits
Response Feedback:
Rationale: When the birthdate is not available, zero is to be used for all eight digits – MM/DD/CCYY.

Question 22

Which statement is TRUE regarding Item 7 on the CMS-1500 claim form?
a. This Item is only completed when Item 4 is completed.
b. This Item is always completed with the patient’s information.
c. This Item is left blank when the patient has a secondary insurance.
d. This Item is always completed with the patient’s spouse’s information.

Answer 22

a. This Item is only completed when Item 4 is completed.
Response Feedback:
Rationale: Enter the insured’s address and telephone number (the telephone number is only completed when required by the payer). Complete this Item only when Item 4 is completed.

Question 23

Determination of the insurer’s payment amount after the member’s insurance benefits have been applied in a(n)?
a. Claim Summary
b. Adjudication
c. Remittance
d. Explanation of Benefits

Answer 23

b. Adjudication
Response Feedback:
Rationale: Adjudication is the process of applying the member’s insurance benefits to determine the insurer’s payment responsibility to a medical claim.

Question 24

On the UB-04 claim form, what is entered in FL 50A when Medicare is determined to be the primary payer?
a. Medicare
b. None
c. SAME
d. Other

Answer 24

a. Medicare
Response Feedback:
Rationale: FL 50A-C—Payer Identification. If Medicare is the primary payer, the provider must enter “Medicare” on line A. Entering Medicare indicates that the provider has determined that Medicare is the primary payer.

Question 25

When completing the CMS-1500 claim form, date(s) of service are found in Item 24; a series of identical services were performed, and the claim was denied. Which of the following is the reason for the denial?
a. “From” and “To” dates of service and the number of units do not match.
b. A six-digit date of service is not correct.
c. A six-digit date of service is not correct.
d. “From” and “To” dates of service are not completed.

Answer 25

a. “From” and “To” dates of service and the number of units do not match.
Response Feedback:
Rationale: The “From” and “To” dates should reflect the same dates as dates the services were performed.

Question 26

When reporting line item services on multiple page CMS-1500 claims, which statement is TRUE?
a. The listed diagnosis can change from page to page.
b. Services related to the additional diagnoses can be on the same claim.
c. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.
d. More than 12 diagnoses can be reported on a two-page claim.

Answer 26

c. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.
Response Feedback:
Rationale: Multiple page claims allow only for reporting of diagnoses from the first page and if more than 12 diagnoses are required separate claims are to be reported.

Question 27

What are MEDIGAP, MG, and MGAP abbreviations for?
a. Primary coverage
b. Medicare supplemental insurance
c. Employer provided coverage
d. Medicare questionnaire

Answer 27

b. Medicare supplemental insurance
Response Feedback:
Rationale: MEDIGAP is used to indicate a Medicare patient has supplemental insurance coverage.

Question 28

Item 24D on the CMS-1500 claim form is used to report procedures, services, or supplies. How many modifiers can be added to Item 24D?
a. 2
b. 3
c. 1
d. 4

Answer 28

d. 4
Response Feedback:
Rationale: Four modifiers are allowed in Item 24D.

Question 29

Line 24B is for place of service. Where can the place of service codes be found?
a. Front of the CPT® codebook
b. In the ICD-10-CM codebook
c. In the CPT® Assistant
d. On the AMA website

Answer 29

a. Front of the CPT® codebook
Response Feedback:
Rationale: Item 24B—Enter the appropriate place of service code(s). Place of service codes can be found in the front of the CPT® codebook. Place of service codes are necessary to support validity of services. For example, if an E/M code 99285 (Level 5 emergency department visit) is billed with POS 11 (Office), this might trigger an edit. Emergency Department E/M codes can only be reported with POS 23 (Emergency Room-Hospital).

Question 30

What type of code reports the event(s) related to the billing period on the UB-04 claim form?
a. Occurrence codes
b. Type of Bill
c. CPT codes
d. Revenue codes

Answer 30

a. Occurrence codes
Response Feedback:
Rationale: UB-04 claim form (FLs 31, 32, 33 and 34) - occurrence codes and dates. The provider enters code(s) and associated date(s) defining specific event(s) relating to this billing period. Event codes are two alpha-numeric digits, and dates are six numeric digits (MMDDYY). When occurrence codes 01-04 and 24 are entered, the provider must make sure the entry includes the appropriate value code in FLs 39-41, if there is another payer involved.
An example of an occurrence code is 04 Accident employment related. This is an indication it is a workers’ compensation claim.

Question 31

When an item is checked yes in boxes 10a through 10c, what does this mean?
a. The patient has a primary and a secondary insurance.
b. The patient only has one insurance.
c. The patient does not have insurance.
d. The claim may be covered by workers’ compensation, auto insurance, or liability insurance.

Answer 31

d. The claim may be covered by workers’ compensation, auto insurance, or liability insurance.
Response Feedback:
Rationale: Any item checked “YES” indicates there may be other insurance primary to the patient’s health insurance. For example, if the encounter was to treat a patient’s injury while at work, workers’ compensation is the primary payer not the patient’s health insurance.

Question 32

What does accepting assignment by a provider mean?
a. The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.
b. The provider can bill whatever he determines to be his fee schedule.
c. The patient is not responsible for any charges.
d. The provider can bill 115% of the allowed amount.

Answer 32

a. The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.
Response Feedback:
Rationale: Accepting assignment indicates the provider is contracted and has agreed to a fee schedule that will require a write-off between the charged amount and the allowed amount.

Question 33

When entering an address which of the following is correct?
a. 123 No. Main St.
b. 123 N, Main Street
c. 101 N. Main Street
d. 123 North Main Street

Answer 33

d. 123 North Main Street
Response Feedback:
Rationale: According to the National Uniform Claim Committee, the correct method states no periods, no commas, or other symbols such as # are to be included or input.

Question 34

FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?
a. For all services
b. Only for outpatient services
c. Only for inpatient services
d. Only for ED visits

Answer 34

c. Only for inpatient services
Response Feedback:
Rationale: FL 35 and FL 36 are used only for inpatient services and should not be completed on outpatient claims.