CBCS Billing and Coding Basics 2 — Questions and Answers
Question 1: Which code set is used to report physician and outpatient services on a CMS-1500 claim form?
- ICD-10-CM
- CPT (Correct answer)
- UB-04
- HCPCS Level III
Correct answer: CPT
CPT (Current Procedural Terminology) codes are used to report physician services, outpatient procedures, and other medical services on the CMS-1500 claim form.
CPT codes, maintained by the American Medical Association, are used to describe medical, surgical, and diagnostic services. They appear on the CMS-1500 claim form (Box 24D) and are the primary code set for billing professional services. ICD-10-CM codes report diagnoses, not procedures.
Question 2: What does the acronym HCPCS stand for?
- Health Care Procedural Coding System
- Healthcare Common Procedure Coding System (Correct answer)
- Health Claims Processing and Coding Standards
- Hospital Coding and Payment Classification System
Correct answer: Healthcare Common Procedure Coding System
HCPCS stands for Healthcare Common Procedure Coding System, which includes Level I (CPT codes) and Level II (alphanumeric codes for supplies, equipment, and services not in CPT).
HCPCS (pronounced 'hick-picks') is a standardized coding system used primarily for Medicare and Medicaid claims. Level I consists of CPT codes. Level II consists of alphanumeric codes (e.g., A0428 for ambulance transport) covering drugs, supplies, durable medical equipment, and services not adequately described by CPT codes.
Question 3: What is the purpose of a National Provider Identifier (NPI)?
- To identify a patient's insurance plan
- To uniquely identify healthcare providers in standard transactions (Correct answer)
- To classify diagnoses for billing purposes
- To authorize prior approval for services
Correct answer: To uniquely identify healthcare providers in standard transactions
The NPI is a unique 10-digit identification number assigned to healthcare providers for use in standard electronic transactions under HIPAA.
The National Provider Identifier (NPI) is a HIPAA Administrative Simplification Standard. It is a unique 10-digit number assigned by CMS to healthcare providers. Providers use their NPI in administrative and financial transactions such as claims, eligibility inquiries, and remittance advice. There are two types: Type 1 (individual providers) and Type 2 (organizations).
Question 4: Which section of ICD-10-CM is used to code a patient's chief complaint when no definitive diagnosis has been established?
- Chapter 1: Certain infectious and parasitic diseases
- Chapter 21: Factors influencing health status (Z codes)
- Chapter 18: Symptoms, signs, and abnormal clinical findings (R codes) (Correct answer)
- Chapter 19: Injury, poisoning, and external causes
Correct answer: Chapter 18: Symptoms, signs, and abnormal clinical findings (R codes)
Chapter 18 (R codes) covers symptoms, signs, and abnormal clinical and laboratory findings. These codes are used when a definitive diagnosis cannot be established during the encounter.
When a provider cannot make a definitive diagnosis during an outpatient encounter, the coder should report the highest-degree of certainty — which may be a sign or symptom code from Chapter 18. ICD-10-CM guidelines specify that 'uncertain' diagnoses (possible, probable, suspected) should NOT be coded for outpatient settings; instead, symptoms and signs are coded. Z codes (Chapter 21) are used for factors influencing health status, not active symptoms.
Question 5: What is the main difference between a charge and a payment in the revenue cycle?
- A charge is the amount collected; a payment is the amount billed
- A charge is the amount billed by the provider; a payment is the amount received from the payer or patient (Correct answer)
- A charge is the Medicare fee schedule amount; a payment is the negotiated rate
- A charge is the copay; a payment is the deductible
Correct answer: A charge is the amount billed by the provider; a payment is the amount received from the payer or patient
A charge is the amount a provider bills for a service, while a payment is the amount actually received. The difference may result in adjustments, write-offs, or patient balances.
In medical billing, a charge (or charge capture) represents the fee the provider sets for a service. The payer (insurance) then adjudicates the claim and makes a payment, which is often less than the charge due to contractual adjustments, deductibles, or non-covered services. Understanding the difference is critical for accounts receivable management and identifying underpayments.
Question 6: Which form is used to submit inpatient hospital claims to Medicare?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA Dental Claim Form
- HCFA-1450
Correct answer: UB-04 (CMS-1450)
The UB-04 (also known as CMS-1450) is the standard claim form used by institutional providers such as hospitals, skilled nursing facilities, and home health agencies for inpatient and outpatient billing.
The UB-04 (Uniform Billing 04), formally CMS-1450, is required for institutional claims including inpatient hospital stays, outpatient hospital services, skilled nursing facility care, and home health services. The CMS-1500 is used by physicians, non-institutional providers, and suppliers. The UB-04 contains form locators (FLs) instead of numbered boxes, and uses revenue codes along with CPT/HCPCS codes.
CBCS Billing and Coding Basics 2
Which code set is used to report physician and outpatient services on a CMS-1500 claim form?