AAPC CPB - Chapter 8 Review

Which statement is TRUE regarding condition codes for the UB-04 claim form?

Selected Answer: d.

a. A condition code identified the department for the revenue of the procedure.

b. Condition codes are listed in the order of occurrence instead of numerical order.

c. Condition codes are reported only on the CMS-1500 claim form.

d. A condition code is used to indicate an inpatient service is reported on an outpatient claim.

d. A condition code is used to indicate an inpatient service is reported on an outpatient claim.

Accepting assignment by a provider means:

a. The patient is not responsible for any charges.

b. The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.

c. The provider can bill whatever he determines to be his fee schedule.

d. The provider can bill 115% of the allowed amount.

b. The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.

On the UB-04 claim form, what is entered in FL 50A when Medicare is determined to be the primary payer?

a. None

b. SAME

c. Medicare

d. Other

c. Medicare

In Item 4 of the CMS-1500 claim form, what is entered on a Medicare claim when the patient has an insurance primary to Medicare and the patient is the insured?

a. Nothing, leave it blank

b. SAME

c. The patient's name

d. The name of the insurance company

b. SAME

What is the purpose of the standard CMS-1500 claim form?

a. Bill services for hospitals

b. Bill services to the patient

c. Bill professional services for physicians

d. Used to file electronic claims

c. Bill professional services for physicians

On the UB-04 claim form, FL 10 is used to record the patient's birthdate. If the birthdate is unknown, what information is entered?

a. Leave blank

b. Enter zero for all eight digits

c. Enter zero for all six digits

d. Enter X for all eight digits

b. Enter zero for all eight digits

How are the procedural charges on a UB-04 claim form sequenced?

a. They are not sequenced in any particular order.

b. They are sequenced based on RVU with the highest weighted procedure reported first.

c. They are sequenced based on RVU with the lowest weighted procedure reported first.

d. They are sequenced by revenue code in ascending numerical order.

d. They are sequenced by revenue code in ascending numerical order.

The assignment of benefits is confirmed if a patient signs which Item?

a. Item 13

b. Item 17

c. Item 24

d. Item 27

a. Item 13

When billing incident-to a physician, which Item do you enter for the ordering physician's NPI?

a. Item 17

b. Item 17b

c. Block 24I

d. Item 31

b. Item 17b

On the CMS-1500 form, which item number identifies the prior authorization or referral number?

a. 11

b. 23

c. 17

d. 22

b. 23

Which Item on the CMS-1500 claim form contain information regarding Medigap?

a. Item 1

b. Items 9, 9a, 9d

c. Items 11, 11a, 11b, 11c

d. Medigap is not identified on the claim form.

b. Items 9, 9a, 9d

When sequencing diagnosis codes, which of the following statements is true?

a. Sequencing doesn't matter, the pointers are important.

b. The primary diagnosis should be listed first.

c. Secondary diagnoses can be listed in any order.

d. List the most complex diagnosis first.

b. The primary diagnosis should be listed first.

When entering the patient's name on the CMS-1500 claim form, what punctuation should be used?

a. Period

b. Comma

c. Space

d. Parentheses

b. Comma

Determination of the insurer's payment amount after the member's insurance benefits have been applied is a(n)?

a. Remittance

b. Claim Summary

c. Explanation of Benefits

d. Adjudication

d. Adjudication

Which statement is TRUE regarding Item 7 on the CMS-1500 claim form?

a. This Item is left blank when the patient has a secondary insurance.

b. This Item is only completed when Item 4 is completed.

c. This Item is always completed with the patient's information.

d. This Item is always completed with the patient's spouse's information.

b. This Item is only completed when Item 4 is completed.

When reporting line item services on multiple page CMS-1500 claims, which statement is TRUE?

a. The listed diagnosis can change from page to page.

b. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.

c. More than 12 diagnoses can be reported on a two-page claim.

d. Services related to the additional diagnoses can be on the same claim.

b. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.

Identify the correct format to enter the date of birth on a paper CMS-1500 claim form.

a. YY/MM/DD

b. MM/DD/YY

c. MM/DD/CCYY

d. DD/MM/CCYY

c. MM/DD/CCYY

Which statement is TRUE regarding revenue codes?

a. To limit the number of line items on each bill, it should sum revenue codes at the "zero" level to the extent possible.

b. To provide the most detail, all revenue codes should be reported to the most specific level, even within the same category.

c. Revenue codes are not reported on the UB-04 claim form.

d. Revenue codes identify the reason for a procedure.

a. To limit the number of line items on each bill, it should sum revenue codes at the "zero" level to the extent possible.

On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent?

a. The frequency of care.

b. The type of care.

c. The type of facility.

d. The procedure or service.

c. The type of facility.

Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found?

a. Medicare Secondary Payer (MSP) Manual

b. Medigap Policy

c. CMS Claims Processing Manual

d. CMS Program Integrity Manual

a. Medicare Secondary Payer (MSP) Manual

The UB-04 claim form is also called:

a. CMS-1500

b. CMS-1540

c. CMS-1450

d. CMS-5010

c. CMS-1450

Response Feedback: UB-04 is also called a CMS-1450 and is used to report hospital services.

Determination of the insurer's payment amount after the member's insurance benefits have been applied is a(n)?

a. Remittance

b. Claim Summary

c. Explanation of Benefits

d. Adjudication

d. Adjudication

Response Feedback: Adjudication is the process of applying the member's insurance benefits to determine the insurer's payment responsibility to a medical claim.

Case 2: Matt Smith 0124XX

What should be done to correct this claim from what is listed below?

I. Correct the diagnosis pointer

II. Correct the modifier

III. Correct the place of service codes

IV. Correct the patient's insurance information on the claim

V. Change the number of units for the visits

a. IV

b. III and V

c. I and V

d. I and II

b. III and V

Response Feedback: The place of service should be corrected to 11 and the units should be corrected to one.

When completing the CMS-1500 claim form, date(s) of service are found in Item 24. A series of identical services were performed, and the claim was denied. Which of the following is the reason for the denial?

a. "From" and "To" dates of service are not completed.

b. "From" and "To" dates of service and the number of units do not match.

c. A six digit date of service is not correct.

d. The claim is correct and should be resubmitted.

b. "From" and "To" dates of service and the number of units do not match.

Response Feedback: The "From" and "To" dates include 3 days and should be shown as 3 units in Block 24G.

Case 1 - Mary Smith DOS 0124XX

What should be done to correct this claim from what is listed below?

I. Correct the diagnosis pointer

II. Add a modifier

III. Correct the place of service codes

IV. Correct the patient's insurance information on the claim

V. Change the number of units for the visits

a. IV

b. III and V

c. I and II

d. II and V

c. I and II

Response Feedback: Rationale: The diagnosis pointer for the office visit should be changed to B. Modifier 25 is appended to the office visit.

If a patient has insurance primary to Medicare, which Items must be completed in addition to Item 11?

a. Items 9a-9d

b. Items 4, 6, and 8

c. Items 5, and 11a-11c

d. Items 4, 6, 7, and 11a-11c

d. Items 4, 6, 7, and 11a-11c

Response Feedback: If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to Items 11a-11c. This is determined by having the patient complete the Medicare Secondary Payer (MSP) questionnaire. Items 4, 6, and 7 must also be completed.

Item 24D on the CMS-1500 claim form is used to report procedures, services, or supplies. How many modifiers can be added to Item 24D?

a. 1

b. 2

c. 3

d. 4

d. 4

Response Feedback: Four modifiers are allowed in Item 24D.

The following claim is submitted. Which of the following describes the reason for the denial?

a. An E/M service cannot be billed with a procedure code on the same date.

b. The dates of service do not include "From" and "To" dates.

c. Place of service code 22 cannot be used with 99213.

d. Modifier 25 is not assigned to 99213.

d. Modifier 25 is not assigned to 99213.

Response Feedback: "To" and "From" dates are not required when only one date of service is listed.

Place of service 22 can be used for 99213 as CPT® description reads "office" and "other outpatient services."

An E/M service is allowed on the same date of service with the use of modifer-25, showing the E/M service is significant and separately identifiable. The modifier is missing on the claim form and would be the reason for the denial of the E/M service.

For patients who have Medicare primary and a secondary insurance, how is the secondary insurance filed?

a. If it is a cross-over insurance, Medicare will cross the claim over to the secondary payer.

b. The secondary insurance is always printed to paper and sent with the Medicare EOB.

c. Insurance carriers do not pay secondary to Medicare so a claim is not files.

d. The claim is always crossed over to the secondary insurance from Medicare.

a. If it is a cross-over insurance, Medicare will cross the claim over to the secondary payer.

Response Feedback: If the patient has a primary and secondary insurance, the secondary insurer will not pay the claim until the primary insurance has made a determination.

For Medicare, if the patient has a secondary insurance on file, Medicare will cross the claim over to the secondary payer once Medicare has made a payment determination (paid or denied). For payers that do not cross claims over, once the EOB is received from the primary insurance, apply the payment or denial and submit a claim and copy of the primary insurance EOB to the secondary payer for consideration.

Patient names are entered onto the claim form with last name, first name, middle initial separated by commas. When entering professional names which of the following guidelines should be followed on Item 2 on the CMS-1500 claim form?

a. First name, middle initial, last name, professional suffixes and not separated by commas

b. Last name, first name, middle initial, and professional suffixes not separated by commas

c. Professional suffixes and titles should not be included

d. First name, middle initial, last name, professional suffixes, separated by commas

c. Professional suffixes and titles should not be included

Response Feedback: Professional suffixes and titles should not be included in Item 2 of the CMS-1500 claim form.

Case 2: Matt Smith 0124XX

After review of the case information provided and the completed claim, please select only from the choices given below on what you notice is in error on the claim. (Note: you may see other errors but only choose from the choices given.)

I. Primary insurance

II. Primary insurance policy number

III. Primary group number

IV. Date of birth

V. Site of service

VI. Place of service

VII. CPT® codes

VIII. Missing modifiers

IX. Diagnosis pointer

X. Units of service

a. VI and X

b. VII, VIII, IX, and X

c. II, VI, and X

d. V, VIII, and IX

a. VI and X

Response Feedback: The place of service for an office visit is 11, 23 is reported on the claim. The units of service should be one.

National provider identifier (NPI) numbers are issued to individual practitioners as well as other entities. Which of the following is not issued an NPI?

a. Facilities

b. DME suppliers

c. Healthcare organizations

d. Health insurance companies

d. Health insurance companies

Response Feedback: Insurance companies do not require an NPI as they are not providers of service.

Which statement is TRUE regarding condition codes for the UB-04 claim form?

a. A condition code identified the department for the revenue of the procedure.

b. Condition codes are listed in the order of occurrence instead of numerical order.

c. Condition codes are reported only on the CMS-1500 claim form.

d. A condition code is used to indicate an inpatient service is reported on an outpatient claim.

d. A condition code is used to indicate an inpatient service is reported on an outpatient claim.

Response Feedback: Condition Codes. The provider enters the corresponding code (in numerical order) to describe any conditions or events that apply to the billing period. For example, condition code 44 is reported when the physician orders inpatient services, but upon internal utilization review performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria. In this case, the claim is submitted as outpatient.

Item 10 on the CMS-1500 claim form has three boxes to be completed that will provide liability information. Which of these is not included?

a. Initial treatment

b. Employment

c. Auto accident

d. Other accident

a. Initial treatment

Response Feedback: Item 10 is to establish if the services provided are related to workers' compensation for injuries that happen on the job, auto accidents, and other accidents that may be paid by a third party and the primary health coverage can decide if they will pay or deny the claims.

When billing incident-to a physician, which Item do you enter for the ordering physician's NPI?

a. Item 17

b. Item 17b

c. Block 24I

d. Item 31

b. Item 17b

Response Feedback: Item 17b—Enter the National Provider Identifier (NPI) of the referring/ordering/supervising physician or non-physician practitioner listed in item 17. NPIs are required for all providers and facilities. Application for NPIs can be submitted online through the CMS website.

What type of code reports the event(s) related to the billing period on the UB-04 claim form?

a. CPT® codes

b. Revenue codes

c. Occurrence codes

d. Type of Bill

c. Occurrence codes

Response Feedback: UB-04 claim form (FLs 31, 32, 33 and 34) - occurrence codes and dates. The provider enters code(s) and associated date(s) defining specific event(s) relating to this billing period. Event codes are two alpha-numeric digits, and dates are six numeric digits (MMDDYY). When occurrence codes 01-04 and 24 are entered, the provider must make sure the entry includes the appropriate value code in FLs 39-41, if there is another payer involved. An example of an occurrence code is 04 Accident employment related. This is an indication it is a workers' compensation claim.

On the CMS-1500 form, which item number identifies the prior authorization or referral number?

a. 11

b. 23

c. 17

d. 22

b. 23

Response Feedback: Item 23—The prior authorization number is entered here. Not all payers require a prior authorization. This item can also be used to report the referral number, mammography pre-certification number, or Clinical Laboratory Improvement (CLIA) number, as assigned by the payer. The 10-digit CLIA number can also be entered in this field when a CLIA covered procedure is performed. For providers reporting HCPCS codes G0181 or G0182, the NPI of the home health agency or hospice agency is entered here. Only one condition is reported in this field. If additional conditions are required for reporting, they are reported on additional CMS-1500 claim forms.

When reporting line item services on multiple page CMS-1500 claims, which statement is TRUE?

a. The listed diagnosis can change from page to page.

b. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.

c. More than 12 diagnoses can be reported on a two-page claim.

d. Services related to the additional diagnoses can be on the same claim.

b. Only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages.

Response Feedback: Rationale: Multiple page claims allow only for reporting of diagnoses from the first page and if more than 12 diagnoses are required separate claims are to be reported.

Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found?

a. Medicare Secondary Payer (MSP) Manual

b. Medigap Policy

c. CMS Claims Processing Manual

d. CMS Program Integrity Manual

a. Medicare Secondary Payer (MSP) Manual

Response Feedback: The questions provided by Medicare to help determine if Medicare is primary or secondary are listed in the MSP Manual, Chapter 3, Section 20.2.1 Admission Questions to Ask Medicare Beneficiaries.

What is the purpose of the standard CMS-1500 claim form?

a. Bill services for hospitals

b. Bill services to the patient

c. Bill professional services for physicians

d. Used to file electronic claims

c. Bill professional services for physicians

Response Feedback: CMS-1500 claim forms are used to report professional services for physicians and suppliers. Hospitals report services on UB-04 claim forms.

Case 1 - Mary Smith DOS 0124XX

After the review of the case information provided and the completed claim, please select only from the choices given below on what you notice is in error on the claim.

(Note: you may see other errors but only choose from the choices given.)

I. Primary insurance

II. Primary insurance policy number

III. Primary group number

IV. Date of birth

V. Site of service

VI. Place of service

VII. CPT codes

VIII. Missing modifiers

IX. Diagnosis pointer

X. Units of service

a. VIII and IX

b. I, II, and III

c. IV, V, and IX

d. V, VI, and X

a. VIII and IX

Response Feedback: Rationale: The diagnosis pointer for the office visit should be B. Because an office visit and minor surgical procedure are reported together, modifier 25 should be appended.