Medical Billing and Coding Flashcards

What is the timely filing limit's purpose for insurance claims?

Answer: It sets a deadline by which a claim must be submitted to be paid

Timely filing limits require claims to be submitted within a set period or they are denied.

The fourth and later characters of an ICD-10-CM code generally provide:

Answer: Greater specificity such as site, severity, or laterality

Additional characters in ICD-10-CM add detail like anatomical site, severity, and laterality.

What does 'medical necessity' mean for claim approval?

Answer: The service is appropriate and reasonable for the diagnosis

Medical necessity means the service is justified by the patient's diagnosis and standard of care.

A write-off in billing typically represents:

Answer: The difference between the charge and the contracted allowed amount

A contractual write-off is the portion of the charge a provider agrees not to collect per contract.

Which code describes why a claim line was adjusted or denied on a remittance advice?

Answer: Claim Adjustment Reason Code (CARC)

CARCs explain the reason an amount was adjusted, reduced, or denied on the RA.

The Place of Service (POS) code on a claim indicates:

Answer: Where the service was provided, such as office or hospital

POS codes specify the setting in which a service was rendered, like office (11) or ER (23).

When a primary payer denies a claim, the appropriate next step is usually to:

Answer: Review the denial reason and file an appeal or correct and resubmit

Denials should be analyzed and either appealed or corrected and resubmitted based on the reason given.