CCS Billing, Reimbursement, & Insurance Policies 2 — Questions and Answers
Question 1: Which Medicare claim form is used to submit outpatient hospital facility claims?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA Dental Claim Form
- TRICARE Standard Form
Correct answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard claim form used by hospitals and other institutional providers to bill Medicare and most payers for outpatient and inpatient services.
The UB-04 (also called CMS-1450) is the institutional claim form required by Medicare, Medicaid, and most private insurers for hospital outpatient, inpatient, and other facility claims. The CMS-1500 is used by physicians and non-institutional providers. The distinction is critical because hospital coders submit UB-04 forms, while physician office coders use CMS-1500 forms.
Question 2: Under the Outpatient Prospective Payment System (OPPS), payment is based on which grouping unit?
- Diagnosis Related Group (DRG)
- Ambulatory Payment Classification (APC) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Per Diem Rate
Correct answer: Ambulatory Payment Classification (APC)
OPPS uses Ambulatory Payment Classifications (APCs) to bundle similar outpatient services into a single payment rate for Medicare hospital outpatient claims.
Ambulatory Payment Classifications (APCs) are the payment groupings under OPPS. Each procedure or service is assigned to an APC based on clinical similarity and resource use. Multiple APCs can be paid on one claim. This differs from inpatient DRGs, which group the entire inpatient stay into a single payment. CCS candidates must understand both OPPS/APC and IPPS/DRG systems.
Question 3: A claim is denied due to a 'coordination of benefits' issue. What does this mean?
- The patient has exceeded their annual deductible
- The patient has more than one insurance plan and payer order is disputed (Correct answer)
- The provider is not in the payer's network
- The diagnosis code does not support medical necessity
Correct answer: The patient has more than one insurance plan and payer order is disputed
Coordination of benefits (COB) determines which payer is primary and which is secondary when a patient has multiple insurance plans.
When a patient has coverage under more than one insurance plan, coordination of benefits (COB) rules determine the order of payment. The primary payer pays first up to its allowed amount; the secondary payer may cover remaining costs. Disputes about primary vs. secondary status result in COB denials. The 'birthday rule' and employment status commonly determine COB order.
Question 4: What is the purpose of a Remittance Advice (RA)?
- To authorize a procedure before it is performed
- To explain how a claim was processed and what was paid or denied (Correct answer)
- To notify a patient of their financial responsibility
- To request additional clinical documentation from the provider
Correct answer: To explain how a claim was processed and what was paid or denied
A Remittance Advice (RA) is sent by the payer to the provider detailing claim adjudication: amounts paid, contractual adjustments, and reason codes for denials.
The Remittance Advice (RA), also called Explanation of Benefits (EOB) when sent to patients, details how each service line on a claim was adjudicated. It includes payment amounts, contractual adjustments, denial reason codes (CARC), and remark codes (RARC). Coders and billing staff analyze RAs to identify patterns in denials and to file appeals when appropriate.
Question 5: Which federal law prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of federal health care program business?
- HIPAA
- Anti-Kickback Statute (AKS) (Correct answer)
- False Claims Act
- Stark Law
Correct answer: Anti-Kickback Statute (AKS)
The Anti-Kickback Statute (AKS) makes it a criminal offense to knowingly offer remuneration to induce referrals for services covered by federal health programs.
The Anti-Kickback Statute (42 U.S.C. 1320a-7b(b)) prohibits exchanging anything of value to encourage referrals of Medicare or Medicaid patients. Violations can result in criminal penalties, civil money penalties, and exclusion from federal programs. It differs from the Stark Law, which is a civil statute that prohibits physician self-referrals for designated health services without meeting a specific exception.
Question 6: A patient's claim is returned as 'unprocessable.' What is the most likely reason?
- The claim was filed after the timely filing deadline
- Required fields such as subscriber ID or NPI are missing or invalid (Correct answer)
- The procedure is not covered under the patient's plan
- The patient owes a prior balance
Correct answer: Required fields such as subscriber ID or NPI are missing or invalid
Unprocessable claims are returned (not denied) because they lack required data elements like a valid NPI, subscriber ID, or date of service, preventing the payer from adjudicating them.
A claim returned as 'unprocessable' (also called 'rejected' by clearinghouses) differs from a denial. Denials mean the payer received and evaluated the claim but decided not to pay. Unprocessable/rejected claims have missing or invalid required elements such as no NPI, invalid diagnosis code format, or missing subscriber information and must be corrected and resubmitted as new claims, not appeals.
CCS Billing, Reimbursement, & Insurance Policies 2
Which Medicare claim form is used to submit outpatient hospital facility claims?