CMAA Billing, Coding, and Claims 5 — Questions and Answers
Question 1: A physician performs a laceration repair and also removes a skin tag during the same visit. How should the skin tag removal be billed?
- Bundle it into the laceration repair code
- Bill separately with modifier -51 appended to the secondary procedure (Correct answer)
- Bill separately with modifier -59 appended to the primary procedure
- Do not bill for the skin tag removal
Correct answer: Bill separately with modifier -51 appended to the secondary procedure
When multiple procedures are performed at the same session, modifier -51 (Multiple Procedures) is appended to the secondary/lower-value procedure.
Question 2: Which federal law mandates standard electronic transaction code sets and establishes privacy protections for health information?
- FICA
- HIPAA (Correct answer)
- ACA
- ERISA
Correct answer: HIPAA
HIPAA (Health Insurance Portability and Accountability Act) established national standards for electronic health care transactions and protected health information.
Question 3: A claim is denied because the service requires a referral authorization that was not obtained. This is an example of which type of denial?
- Technical denial
- Clinical denial
- Administrative denial (Correct answer)
- Coordination of benefits denial
Correct answer: Administrative denial
An administrative denial occurs due to procedural or policy issues such as missing authorizations, eligibility problems, or incomplete information.
Question 4: On the CMS-1500 form, Box 21 requires diagnosis codes. How many diagnosis codes can be listed in Box 21?
- Up to 4
- Up to 8
- Up to 12 (Correct answer)
- Up to 16
Correct answer: Up to 12
The current version of the CMS-1500 (02/12) allows up to 12 diagnosis codes to be listed in Box 21.
Question 5: Which code set is used to report supplies, durable medical equipment, and services not covered by CPT codes for Medicare billing?
- ICD-10-PCS
- HCPCS Level II (Correct answer)
- CDT codes
- Revenue codes
Correct answer: HCPCS Level II
HCPCS Level II codes (alphanumeric, starting with A–V) are used to bill Medicare and Medicaid for supplies, DME, injections, and other services not in CPT.
Question 6: A patient receives services from both an in-network and an out-of-network provider during a single hospital stay. What billing term describes this situation?
- Dual coverage
- Balance billing exposure (Correct answer)
- Split billing
- Mixed-network encounter
Correct answer: Balance billing exposure
Balance billing exposure occurs when an out-of-network provider bills the patient for the difference between their charge and the insurer's allowed amount.
Question 7: What does the term 'clean claim' mean in medical billing?
- A claim with no outstanding balance
- A claim submitted without errors that can be processed without additional information (Correct answer)
- A claim that has been audited and approved
- A claim where the patient's deductible has been met
Correct answer: A claim submitted without errors that can be processed without additional information
A clean claim is one that is complete, accurate, and contains all required information so the payer can process it without requesting additional data.
CMAA Billing, Coding, and Claims 5
A physician performs a laceration repair and also removes a skin tag during the same visit.
How should the skin tag removal be billed?