Code Validation & Billing Procedures Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Code Validation & Billing Procedures flashcards as text
A payer's remittance advice shows claim adjustment reason code (CARC) 4. What does this typically indicate?
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.
Which claim filing deadline rule is most important for a coder to know when billing Medicare?
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.
What is the purpose of the National Correct Coding Initiative (NCCI) in claim validation?
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.
A physician bills CPT 99213 with modifier -25 and also bills a minor procedure on the same day. What does the modifier -25 signify?
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.
What is an Advance Beneficiary Notice (ABN) and when is it required?
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.
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?
Answer: 22
Place of service code 22 designates an on-campus outpatient hospital setting, whereas code 11 is for an office setting.
Which of the following is an example of upcoding?
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.