CPC Code Validation & Billing Procedures 2 — Questions and Answers
Question 1: A claim is returned because the ICD-10-CM diagnosis code does not support medical necessity for the CPT procedure billed. What is the coder's first action?
- Submit an appeal immediately
- Review the clinical documentation to find a more specific or additional supporting diagnosis (Correct answer)
- Change the procedure code to match the diagnosis
- Write off the claim as a denial
Correct answer: Review the clinical documentation to find a more specific or additional supporting diagnosis
The coder should review documentation for a diagnosis that accurately reflects and supports the medical necessity of the procedure performed.
Question 2: Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?
- -LT
- -RT (Correct answer)
- -50
- -51
Correct answer: -RT
Modifier -RT (Right side) is used when a procedure is performed on the right side of a paired organ or body part.
Question 3: An Explanation of Benefits (EOB) shows a claim was denied for 'duplicate billing.' The coder confirms the service was only billed once. What should the coder do?
- Accept the denial and write off the balance
- Re-submit the claim without changes
- File an appeal with documentation proving the service was rendered only once (Correct answer)
- Bill the patient for the full amount
Correct answer: File an appeal with documentation proving the service was rendered only once
When a payer incorrectly denies a claim as duplicate, the provider should appeal with supporting documentation demonstrating the claim is not a duplicate.
Question 4: What does the term 'bundling' refer to in the context of claim validation?
- Submitting multiple claims for the same patient on the same date
- The payer's practice of combining payment for related procedures into a single allowable (Correct answer)
- Grouping multiple patients on one claim form
- Attaching supporting documentation to a claim
Correct answer: The payer's practice of combining payment for related procedures into a single allowable
Bundling occurs when a payer packages multiple related services together and pays them as a single unit, often following the National Correct Coding Initiative (NCCI) edits.
Question 5: A coder notices the claim form lists the rendering provider's NPI in Box 24J but the billing provider's NPI is missing from Box 33a on the CMS-1500. What is the likely outcome?
- The claim will process normally
- The claim will be rejected for missing required billing provider information (Correct answer)
- The payer will auto-populate the billing NPI
- The claim will be denied for medical necessity
Correct answer: The claim will be rejected for missing required billing provider information
Box 33a requires the billing provider's NPI, and its absence is a common reason for claim rejection before adjudication.
Question 6: Which of the following best describes a 'clean claim'?
- A claim with no outstanding patient balance
- A claim that contains all required data elements and passes all payer edits upon first submission (Correct answer)
- A claim submitted on paper rather than electronically
- A claim that has been resubmitted after a denial
Correct answer: A claim that contains all required data elements and passes all payer edits upon first submission
A clean claim is one that is accepted by the payer on first submission without any missing, invalid, or inconsistent information.
Question 7: When a procedure is performed during the global surgical period of a prior procedure, and the new service is unrelated, which modifier should be used?
- -78
- -79 (Correct answer)
- -24
- -58
Correct answer: -79
Modifier -79 is used for an unrelated procedure or service by the same physician during the postoperative period.
CPC Code Validation & Billing Procedures 2
A claim is returned because the ICD-10-CM diagnosis code does not support medical necessity for the CPT procedure billed.
What is the coder's first action?