CPC Code Validation & Billing Procedures 3 — Questions and Answers
Question 1: A payer's remittance advice shows claim adjustment reason code (CARC) 4. What does this typically indicate?
- Service not covered by plan
- The procedure code is inconsistent with the modifier
- The service is not covered unless submitted via a referral
- Service denied because the patient is not eligible for coverage on the date of service (Correct answer)
Correct answer: Service denied because the patient is not eligible for coverage on the date of service
CARC 4 indicates the service was denied because the patient was not eligible for the plan on the date the service was rendered.
Question 2: Which claim filing deadline rule is most important for a coder to know when billing Medicare?
- Claims must be filed within 90 days of service
- Claims must be filed within 1 year (12 months) from the date of service (Correct answer)
- Claims must be filed within 6 months of service
- Claims must be filed within 2 years of service
Correct answer: Claims must be filed within 1 year (12 months) from the date of service
Medicare requires that claims be filed within 1 calendar year (12 months) from the date of service for timely filing compliance.
Question 3: What is the purpose of the National Correct Coding Initiative (NCCI) in claim validation?
- To establish fee schedules for all CPT codes
- To prevent improper payment of procedures that should not be billed together (Correct answer)
- To assign diagnosis codes to inpatient stays
- To certify medical coders at the national level
Correct answer: To prevent improper payment of procedures that should not be billed together
NCCI edits are CMS-developed code pairs that identify procedures which should not be billed together because one is considered a component of the other.
Question 4: A physician bills CPT 99213 with modifier -25 and also bills a minor procedure on the same day. What does the modifier -25 signify?
- The E/M service was performed by a different physician
- The E/M was a significant, separately identifiable service above and beyond the usual pre/post-procedure work (Correct answer)
- The procedure was staged
- The patient had multiple diagnoses
Correct answer: The E/M was a significant, separately identifiable service above and beyond the usual pre/post-procedure work
Modifier -25 indicates that on the day of a procedure, a significant and separately identifiable evaluation and management service was also performed.
Question 5: What is an Advance Beneficiary Notice (ABN) and when is it required?
- A notice given to all Medicare patients before any service
- A written notice given to a Medicare patient when the provider expects Medicare may deny the service as not medically necessary (Correct answer)
- A billing statement provided after claim adjudication
- A prior authorization form required for specialist referrals
Correct answer: A written notice given to a Medicare patient when the provider expects Medicare may deny the service as not medically necessary
An ABN must be given to a Medicare patient before rendering a service the provider believes Medicare will deny, giving the patient the option to accept financial responsibility.
Question 6: A coder is validating a claim where the place of service code is listed as '11' but the procedure was performed in a hospital outpatient department. What is the correct place of service code?
- 21
- 22 (Correct answer)
- 11
- 19
Correct answer: 22
Place of service code 22 designates an on-campus outpatient hospital setting, whereas code 11 is for an office setting.
Question 7: Which of the following is an example of upcoding?
- Reporting a lower-level E/M than documented to avoid audit risk
- Billing a comprehensive office visit when documentation only supports a brief visit (Correct answer)
- Using modifier -52 to indicate a reduced service
- Unbundling a global surgical package
Correct answer: Billing a comprehensive office visit when documentation only supports a brief visit
Upcoding is the fraudulent practice of billing a higher-level or more complex service than what was actually documented or performed.
CPC Code Validation & Billing Procedures 3
A payer's remittance advice shows claim adjustment reason code (CARC) 4.
What does this typically indicate?