CPB Chapter 8

When two or more diagnoses codes reported in item 21 support a procedure, how many diagnosis codes should the provider report in item 24E for Medicare claims? A. 1 B. 2 C. 3 D. All diagnosis codes will be recognized if they are reported in item 21

A. 1 Response Feedback: If there are two or more diagnoses that support a procedure code, the provider should reference only one of the diagnoses from item 21 in item 24e for Medicare claims.

What regulation requires claims to be sent electronically unless certain circumstances are met? A. Administrative Simplification Compliance Act (ASCA) B. False Claims Act (FCA) C. Electronic Claims Act (ECA) D. Health Information Technology for Economic and Clinical Health Act (HITECH) Response Feedback: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless certain exceptions are met.

A. Administrative Simplification Compliance Act (ASCA) Response Feedback: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless certain exceptions are met.

The assignment of benefits is confirmed if a patient signs which block? A. Block 13 B. Block 17 C. Block 24 D. Block 27

A. Block 13 Response Feedback: Item 13—The patient's signature or the statement "Signature on File," or "SOF" in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization.

Which field(s) on the UB-04 reports the main reason for the encounter? A. FL 67 B. FL 67A-67Q C. FL 68 D. FL 69

A. FL 67 Response Feedback: FL 67—Principal Diagnosis Code. The hospital enters the ICD-10-CM code for the principal diagnosis which is the main reason for the encounter.

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. I, II, and IV B. I and III C. IV D. V

A. I, II, and IV Response Feedback: The diagnosis pointer for the office visit should be changed to B. Modifier 25 is appended to the office visit. The secondary insurance information needs to be added to the claim form.

Block 10 on the CMS 1500 has 3 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: Workers' compensation for injuries that happen on the job, auto accidents, and other accidents may be paid by a third party and the primary health coverage can decide if they will pay or deny the claims.

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 Manual (MSP) B. Medigap Policy C. CMS Claims Processing Manual D. CMS Program Integrity Manual

A. Medicare Secondary Payer Manual (MSP) 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.

Which statement is TRUE regarding Block 7 on the CMS-1500 claim form? A. This block is left blank when the patient has a secondary insurance. B. This block is only completed when block 4 is completed. C. This block is always completed with the patient's information. D. This block is always completed with the patient's spouse's information.

B. This block is only completed when block 4 is completed. Response Feedback: Enter the insured's address and telephone number. Complete this item only when item 4 is completed.

Patient Information: Name: Mary Smith Address: 7896 Nowhere St City: Mytown State: FL Zip: 33333 Telephone: 954-777-7777 Gender: Female Status: Married Date of Birth: 09/15/1954 Employer: Retired Work Related: No Auto Accident: No Other Accident: No Date of Accident: Referring Physician: Address: Telephone: NPI #: Insurance Information: Primary Insurance: Medicare Policy #: 123783444B Group #: Name of Insured: Self Secondary Insurance: AARP Address: P.O. Box 1017 City: Montgomeryville State: PA Zip: 18936-3333 Policy #73945275 Group #: Name of Insured: Self Services performed: 11400, 99213-25 Diagnosis: Benign neoplasm of upper limb (D23.60), Pharyngitis (J02.9) Location: Hope Primary Care 6734 Main St, Mytown, FL 34567 407-222-3333 NPI: 7878987890 Provider: Susan Smith, MD EIN:242424256 DOS: 1/24/2016 1. 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, IX B. VII, VIII, IX, AND X C. II, VI, X D. X

A. VIII, IX Response Feedback: 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.

When completing CMS-1500 form, dates of service is found on Block 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 are not completed B. "From" and "To" dates of service and the number of units do not match C. A 6 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.

When billing incident-to a physician, which block do you enter the ordering physician's NPI? A. Block 17 B. Block 17b C. Block 24I D. Block 31

B. Block 17b 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.

Which block on the CMS-1500 claim form contain information regarding Medigap? A. Block 1 B. Blocks 9, 9a, 9b, 9d C. Blocks 11, 11a, 11b, 11c D. Medigap is not identified on the claim form.

B. Blocks 9, 9a, 9b, 9d Response Feedback: Item 9a—Enter the policy and/or group number of the secondary insurance. (eg, Medigap insured preceded by MEDIGAP, MG, or MGAP). Item 9b—For Medigap, enter the insured's 8-digit birth date (MM|DD|CCYY) and sex. Item 9c—For Medigap, leave blank if a Medigap Payer ID is entered in item 9d. Item 9d—Enter the 9-digit PAYERID number of the Medigap insurer. The PAYERID can be obtained from the insurance carrier. If no PAYERID number exists, then enter the Medigap insurance program or plan name

In Block 4 of the CMS-1500, what is entered for 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 insurance name

B. SAME Response Feedback: Item 4—If there is insurance primary to Medicare, either through the patient's or spouse's employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.

Accepting assignment means that a provider of service will - A. Accept the allowed amount as payment in full with no patient liability accessed B. Write off the difference between the charged amount and the allowed amount as a contractual write-off for the provider. C. Accept the amount the insurance company pays as payment in full D. Accept what the insurance company pays, and bill the patient for the balance.

B. Write off the difference between the charged amount and the allowed amount as a contractual write-off for the provider. Response Feedback: The provider agrees that the contracted amount is to be accepted as the full reimbursement. The patient may have liability if the plan has a deductible or co-pay.

Prior authorization it is reported in Item 23. What other information can be reported in this area of the CMS-1500 claim form? A. NPI number B. mammography pre-certification number C. patient identification number D. patient account number

B. mammography pre-certification number Response Feedback: Not all payers require a prior authorization. Item 23 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 patient is a child covered under the father's insurance policy. Which item on the CMS-1500 form is the father's date of birth listed? A. 3 B. 14 C. 11a D. Father's date of birth should not be listed

C. 11a Response Feedback: Item 11a—Enter the insured's 8-digit birth date (MM|DD|CCYY) and sex if different from item 3. If the gender is unknown, leave it blank.

UB-04 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.

Patient names are entered onto the claim form with Last name, first name, middle name or initial separated by commas. When entering professional names which of the following guideline should be followed? A. Last name, first name, middle name or initial separated by commas B. Last name, first name, middle name or initial not separated by commas. C. First name, middle initial, last name, credentials and no commas D. First name, middle initial, last name, credentials, separated by commas

C. First name, middle initial, last name, credentials and no commas Response Feedback: Professional names are listed differently than patient names and they are not separated by commas.

Identify the correct method to enter the date of birth on a paper field. A. YY/MM/DD B. MM/DD/YY C. MM/DD/CCYY D. DD/MM/CCYY

C. MM/DD/CCYY Response Feedback: According to the National Uniform Claim Committee the correct method for paper field date of birth (DOB) is MM/DD/CCYY.

On the UB-04, 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 Response Feedback: FL 50A-C—Payer Identification. If Medicare is the primary payer, the provider must enter "Medicare" on line A. Entering Medicare indicates that the provider has determined that Medicare is the primary payer.

Which statement is TRUE regarding diagnosis codes on the UB-04? A. The UB-04 claim is only submitted for inpatient hospitals. B. Medicare requires the use of ICD-10-CM codes only on the UB-04 claims not the CMS 1500 claims. C. Medicare requires the use ICD-10-CM codes as of 10/1/15. D. ICD-9-CM and ICD-10-CM codes can be entered on the same UB-04.

C. Medicare requires the use ICD-10-CM codes as of 10/1/15. Response Feedback: The UB-04 is submitted for inpatient and outpatient hospital, CAHs and CORFs. ICD-10-CM codes are reported on UB-04 claims and CMS 1500 claims. Do not enter ICD-9-CM and ICD-10-CM codes on the same claim form. Medicare accepts ICD-10-CM codes as of 10/1/15.

What type of code reports the event(s) related to the billing period? A. CPT® codes B. Revenue codes C. Occurrence codes D. Type of Bill codes

C. Occurrence codes

When an item is checked yes in blocks 10a through 10c, what does this mean? A. The patient only has one insurance. B. The patient has a primary and a secondary insurance. C. The claim may be covered by workers' compensation, auto insurance, or liability insurance. D. The patient does not have insurance.

C. The claim may be covered by workers' compensation, auto insurance, or liability insurance. Response Feedback: Any item checked "YES" indicates there may be other insurance primary to the patient's health insurance. For example, if the encounter was to treat a patient's injury while at work, workers' compensation is the primary payer not the patient's health insurance.

What is the definition of an attending provider? A. Any provider who provides care to the patient B. The patient's primary care provider C. The provider with overall responsibility for the patient's medical care D. The provider with the primary responsibility for surgical procedures

C. The provider with overall responsibility for the patient's medical care Response Feedback: The individual with overall responsibility for the care that is being reported on the encounter.

Facility charges are reported on which claim form? A. UB-05 claim form B. CMS-1500 claim form C. UB-04 claim form D. Either CMS-1500 or UB-04 claim form

C. UB-04 claim form Response Feedback: The UB-04 claim form is used to report facility charges to the payer for reimbursement.

What is the appropriate POS code to report services rendered in an urgent care facility? A. 23 B. 17 C. 24 D. 20

D. 20 Response Feedback: POS code 20 is reported when services are provided in an urgent care facility. POS 23 for services provided in an Emergency Room of a Hospital, POS 24 for Ambulatory Surgical Center services and POS 17 for services rendered in Walk-in Retail Health Clinic. Place of Service codes can be found in the front of the CPT® codebook.

Item 24D 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.

Which transaction is NOT specified in the 5010 transaction standards? A. Claims B. Eligibility C. Acknowledgement for Healthcare Insurance D. Acknowledgement for Patient Payments

D. Acknowledgement for Patient Payments Response Feedback: The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).

Medicare refers to the insured's ID as what? A. Subscriber number B. Beneficiary number C. Health insurance subscriber number D. Health insurance claim number

D. Health insurance claim number Response Feedback: The patient's insurance ID for Medicare is the Medicare Health Insurance Claim Number (HICN). This information is found on the patient's insurance card.

National Provider 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.

When filing professional fee (provider) claims, which code set is NOT reported on the CMS-1500 claim form? A. CPT® codes B. HCPCS Level II codes C. ICD-10-CM codes D. ICD-10-PCS codes

D. ICD-10-PCS codes Response Feedback: ICD-10-PCS codes are only reported on the UB-04 for inpatient services.

What does the acronym NUCC stand for? A. National Unified Claims Committee B. National Uniform Criteria Committee C. National Unified Claims Coordinators D. National Uniform Claim Committee

D. National Uniform Claim Committee Response Feedback: NUCC stands for National Uniform Claim Committee

Item 14 Qualifier is used to indicate what information? A. Onset of Current Symptoms or Illness B. Location of injury C. LMP D. both a and c

D. both a and c Response Feedback: In Item 14, enter either an 8-digit (MM|DD|CCYY) or 6-digit (MM|DD|YY) date of current illness, injury, or pregnancy (LMP). Enter the applicable qualifier to the right of the vertical dotted line to identify which date is being reported. Qualifiers include: 431 to report Onset of Current Symptoms or Illness or 484 if reporting Last Menstrual Period

When a provider "accepts assignment" the difference between the charged amount and the allowed amount: A. is billed to the patient. B. can be submitted again for reconsideration. C. is written off as patient hardship. D. is considered a contractual write off.

D. is considered a contractual write off. Response Feedback: Accepting assignment means that the provider agrees to accept the payer's reimbursement amount as payment in full and must write off the remaining balance as a contractual write off.

CMS-1500 Claim Form revisions undergo: A. one NUCC review prior to approval. B. one CMS review prior to approval. C. one HHS and one CMS review and approval. D. multiple reviews prior to approval and implementation

D. multiple reviews prior to approval and implementation Response Feedback: The approval process for CMS-1500 Claim Form revisions includes multiple reviews and approvals. Once the updates have been approved by NUCC, the form is submitted to CMS for approval and then awaits public comment through CMS and OMB before receiving final approval and implementation.