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
Which section of the CMS-1500 (02-12) claim form is used to report the patient's diagnosis codes?
Answer: Box 21
Box 21 on the CMS-1500 is designated for listing up to 12 ICD-10-CM diagnosis codes that support the services billed.
A claim edit flags a CPT code as requiring prior authorization that was not obtained. The authorization was actually obtained but not listed on the claim. What is the appropriate correction?
Answer: Add the authorization number to the appropriate field and resubmit the claim
When a prior authorization exists but was omitted from the claim, adding the authorization number in the correct field and resubmitting resolves this edit.
What is the key difference between a claim 'rejection' and a claim 'denial'?
Answer: A rejection occurs before adjudication due to technical errors; a denial occurs after adjudication on clinical or coverage grounds
Rejections are returned before the payer processes the claim due to missing or invalid data, while denials are issued after review when the payer decides not to pay.
A procedure has an asterisk (*) next to it in the CPT manual. What does this historically indicate?
Answer: A surgical package does not apply and the procedure is billed as separate components
In older CPT editions, an asterisk indicated a starred procedure, meaning the surgical package rules did not apply and components were billed separately; this concept informs current coding practices.
Which of the following is NOT included in the global surgical package?
Answer: Treatment of unrelated conditions during the post-operative period
Treatment of conditions unrelated to the surgery is NOT bundled in the global surgical package and may be billed separately with modifier -79.
When validating an outpatient hospital claim, which code set is used for reporting diagnoses?
Answer: ICD-10-CM
ICD-10-CM is used to report diagnoses on all outpatient claims, including hospital outpatient, physician office, and ambulatory surgery center claims.
A coder discovers that a claim was submitted with the wrong date of service. The claim has already been paid. What is the correct action?
Answer: Submit a corrected claim with the accurate date of service
When a paid claim contains an error in the date of service, a corrected claim (using the appropriate claim frequency type code) should be submitted to reflect the accurate information.