AAPC CPB Chapter 12 Practical Application

Use CPB Chapter 12 Case 6.pdf to answer the following question. Based on the question above, what should the office do with errors on the claim form? A. Correct the demographics and resubmit the claim. B. Call Blue Cross/Blue Shield to have them update the claim information. C. Write off the denial. D. Contact the patient informing that she is now responsible for making the payment.

A. Correct the demographics and resubmit the claim. Response Feedback: Correct all errors found on the claim and then resubmit for payment.

Use CPB Chapter 12_Case 1.pdf to answer questions 1 and 2. After review of the information provided, are there any errors on the claim form? If so, which elements are incorrect? I. Type of Insurance II. Primary insurance policy number III. Primary group number IV. Federal Tax ID number V. Billing provider and NPI A. I and II B. II and IV C. III and V D. There are no errors on this claim.

A. I and II Response Feedback: The type of insurance should be marked as OTHER in Item 1. Item 1a is missing the three-character prefix required for BCBS ID numbers on the claim.

Use CPB Chapter 12 Case 7.pdf to answer questions 11 & 12. The office is following up on payment for this claim and has been informed that it's been denied. Based on review of the claim, what information is incorrect? I. Item 25 on the claim form II. Item 27 on the claim form III. Patient's demographic information IV. CPT Code(s) A. I, II and III B. II and III C. III and IV D. There are no errors on this claim.

A. I, II and III Response Feedback: Box 25 shows an incorrect selection of SSN instead of EIN and Box 27 the physician does not accept assignments from Blue Cross Blue Shield of Florida. Incorrect date of birth is on the claim form patient's demographic information is incorrect.

Based on the question above, what should the office do with errors on the claim form? I. Correct the provider information on the claim. II. Correct the patient's demographics. III. Change accepting assignment to yes. IV. There are no changes to made to this claim. V. Correct the CPT code(s) A. I, II and III B. II and III C. II and V D. There are no errors to correct on this claim.

A. I, II and III Response Feedback: Rationale: Change the providers information on the claim: Change Item 25 to show EIN instead of SSN. Change accepting assignment to yes in Item 27. The physician accepts assignment from Blue Cross Blue Shield of Florida. Correct patient's date of birth.

Use CPB Chapter 12_Case 1.pdf to answer the following question. What should be done to correct this claim? I. Correct the type of insurance on the claim. II. Correct the primary insurance information on the claim. III. Correct the EIN number in item 25. IV. Enter the group's NPI number in item 33. A. I B. I and II C. III and IV D. There are no errors on this claim.

B. I and II Response Feedback: The type of insurance should be marked as OTHER in Item 1. Correct the primary insurance ID in Item 1a.

Use CPB Chapter 12 Case 2.pdf to answer the following question. What should be done to correct this claim? I. Enter the Federal Tax ID number in item 25. II. Change the type of Federal Tax ID number. III. Change the number of units for the procedure. IV. Review documentation or query the provider to determine the correct diagnosis. V. Correct the modifier. VI. Correct the units to 1 on the claim form. A. I and II B. II and VI C. I, II, III, IV, and V D. There are no errors on this claim.

B. II and VI Response Feedback: Change the type of Federal Tax ID number to EIN. The description of 20552 states "single or multiple trigger point(s), 3 or more muscles;" this means that regardless of how many injections are made, and the total number of muscles injected over three, this code is only reported one time per day.

Use CPB Chapter 12 Case 8.pdf to answer the following question. The office is following up on payment for this claim and has been informed that it's been denied. Based on review of the claim, what information is incorrect? I. The patient demographic information II. The provider information III. CPT code(s) IV. ICD-10-CM code(s) V. The patient's insurance information. A. II only B. II, III and IV C. I and V D. II and III

B. II, III and IV Response Feedback: Provider's SSN is incorrect. EIN should have been marked instead of SSN in the claim form. The diagnosis code and CPT®® code on the claim form are incorrect. ICD-10-CM code should reflect M25.551. Code 27906 is reported when image guidance is performed with the injection. A parenthetical note under 27096 indicates, if CT or fluoroscopy imaging is not performed, use 20552.

Use CPB Chapter 12 Case 3.pdf to answer questions 5 and 6. After review of the information provided, will the claim be covered according to the medical policy? A. No; the modifier is not valid for the CPT code combination. B. No; the claim is not considered medical necessity. C. Yes; the CPT and ICD-10-CM codes are covered. D. Yes; diagnosis warrants three units.

B. No; the claim is not considered medical necessity. Response Feedback: According to the medical policy R51 is not a covered diagnosis for 20552.

Use CPB Chapter 12 Case 2.pdf to answer questions 3 and 4. After review of the information provided, are there any errors on the claim form? If so, which elements are incorrect? I. Federal Tax ID number II. Code correlation conflict III. Incorrect modifier IV. Diagnosis pointer V. Units of service A. II and III B. II and IV C. I, and V D. There are no errors on this claim.

C. I, and V Response Feedback: The federal tax ID number is entered in item number 25 but the SSN box is checked. According to the CPT code description, 20552 can only be reported one time per day; however, there are three units reported.

Use CPB Chapter 12 Case 3.pdf to answer the following question. Which statement is TRUE according to the medical policy provided? A. Continued injection therapy requires documentation that shows the prior injection provided ≥ 50% pain reduction for at least 4 weeks. B. The initial set of injections are required to be a minimum of 2 weeks apart. C. The patient must have tried NSAIDS ≥ 4 weeks, activity modification ≥ 6 weeks, and physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks. D. Injection therapy exceeds spans over at least two years.

C. The patient must have tried NSAIDS ≥ 4 weeks, activity modification ≥ 6 weeks, and physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks. Response Feedback: According to the medical policy: Trigger point injections (20552, 20553) meet the definition of medical necessity to treat trigger points when ALL of the following criteria are met: • Pain after 6 weeks with ALL of the following treatments: o NSAIDS ≥ 4 weeks (if not contraindicated); AND o Activity modification ≥ 6 weeks; AND o Physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks; OR • Worsening pain after 2 weeks with ALL of the following treatments: o NSAIDS (if not contraindicated); AND o Activity modification; AND o Physical therapy, chiropractic therapy or home exercise program; AND • No associated neurological deficit; AND • The initial set of injections may include up to 4 separate dates of service with injections given no sooner than 1 week apart; AND • For continued injection therapy beyond the initial set of injections (up to 4 separate dates of service), each subsequent injection requires that prior injection provided ≥50% pain reduction for 6 weeks; AND • Injection therapy has not exceeded 1 year (Medical Director review is required after one year)

Use CPB Chapter 12 Case 4.pdf to answer question 7. Based on the information provided, what should be the next action the biller should take? A. Write-off the balance as it is denied as a contractual obligation for the provider. B. Transfer the balance to patient responsibility. C. Verify the reported diagnosis code is reported to the highest level of specificity. D. The code is correct, refile the claim.

C. Verify the reported diagnosis code is reported to the highest level of specificity. Response Feedback: The denial reason is that the code is invalid. The first step for the biller is to look in the ICD-10-CM codebook and verify the code has been reported to the highest level of specificity. This diagnosis code requires another character to be complete.

Based on the question above, what should be done to correct this claim? A. Correct the patient's demographic information. B. Correct the provider information. C. Correct the coding on the claim. D. Both B and C

D. Both B and C Response Feedback: The diagnosis code on the claim form is incorrect. Should reflect M25.551. Provider's SSN is incorrect. EIN should have been marked instead of SSN in the claim form.

Use CPB Chapter 12 Case 6.pdf to answer the following question. Based on review of the claim, what information is incorrect? A. All information on the claim form is correct. B. Box 7 shows the incorrect state. C. Box 3 shows the incorrect date of birth. D. Both B and C are incorrect.

D. Both B and C are incorrect. Response Feedback: Box 7 shows the incorrect state and Box 3 has an error in the date of birth.

Use CPB Chapter 12 Case 9.pdf to answer the following question. Based on the information provided, what should be the next action the biller should take? A. Write-off the balance as it is denied as a contractual obligation for the provider. B. Transfer the balance to patient responsibility. C. Check with the provider to determine if the claim was correctly filled out. If yes, file an appeal. D. Check the medical record and ensure diagnosis coding is correct/more specific.

D. Check the medical record and ensure diagnosis coding is correct/more specific. Response Feedback: The denial reason is because the claim does not meet medical necessity with the ICD-10-CM code. Verify the office has correctly coded or correct the coding on the claim and then resubmit for payment.

Use CPB Chapter 12 Case 5.pdf to answer the following question. Based on the information provided, what should be the next action the biller should take? A. Write-off the balance as it is denied as a contractual obligation for the provider. B. Transfer the balance to patient responsibility. C. Check with the provider to determine if the claim was filed timely. If yes, file an appeal. D. Check with Blue Cross/Blue Shield for acceptable documents to prove timely filing of a claim. If the documents are found, file an appeal.

D. Check with Blue Cross/Blue Shield for acceptable documents to prove timely filing of a claim. If the documents are found, file an appeal. Response Feedback: The denial reason is because the claim was filed after the timely filing deadline. Refer to the BCBS provider manual for the acceptable documents to prove timely filing of a claim. Billers should have a list of timely filing deadlines for their BCBS carrier.

Use CPB Chapter 12 Case 10.pdf to answer the following question. Based on the information provided, what actions should the biller take? I. Check with the provider or coder regarding the coding on the claim. II. Determine when the claim was originally filed. III. Check with Blue Cross/Blue Shield for acceptable documents to prove timely filing of a claim. If the documents are found, file an appeal. IV. Write off the balance. A. I and II B. I, II, and III C. IV Only D. II and III

D. II and III Response Feedback: The denial reason is because the claim was filed after the timely filing deadline. Refer to the BCBS provider manual for the acceptable documents to demonstrate timely filing of a claim. Billers should have a list of timely filing deadlines for their BCBS carrier.