Case Analysis & Practical Application Flashcards

A patient with Medicare Part B is also covered by a large employer group plan. Which plan is the primary payer?

Answer: The employer group plan is primary because the employer has 20 or more employees

When a Medicare patient is covered by an employer group plan with 20+ employees, the group plan is primary per Medicare Secondary Payer (MSP) rules.

A claim is denied with remark code CO-4 (the procedure code is inconsistent with the modifier). Which corrective action is appropriate?

Answer: Review the procedure code and modifier pairing, correct the inconsistency, and resubmit a corrected claim

CO-4 indicates a coding error; the claim must be corrected before resubmission to resolve the denial.

During patient check-in, you discover the patient's address and phone number on file are two years old. What is the best practice?

Answer: Verify and update demographic information at every visit to ensure accurate billing and communication

Updating demographics at each visit reduces claim rejections from incorrect information and ensures proper patient contact.

A patient's surgery is scheduled for next week but their insurance authorization covers only office visits. What should be done immediately?

Answer: Contact the insurance company to obtain a separate prior authorization specifically for the surgical procedure

Surgical procedures typically require specific prior authorization separate from office visit coverage.

A patient requests copies of their medical records and you notice a psychotherapy note in the file. Under HIPAA, how are psychotherapy notes treated?

Answer: Psychotherapy notes have special protections and generally require separate, specific authorization to release

HIPAA grants psychotherapy notes extra protection beyond standard PHI, requiring specific patient authorization for most disclosures.

An insurance company's EFT payment is $200 less than expected for a batch of claims. What is the most efficient first step to investigate?

Answer: Reconcile the ERA/remittance advice against each claim in the batch to identify which specific claim(s) were adjusted

The ERA contains line-by-line adjustment reason codes that pinpoint exactly which claim and why payment differed.

A patient who was seen for a workers' compensation injury returns for an unrelated condition. How should this visit be billed?

Answer: Bill the patient's regular health insurance for the new condition, keeping it separate from the WC claim

Workers' compensation covers only work-related injuries; unrelated conditions must be billed to the appropriate health insurer.