Revenue Cycle

CCS-P · 48 questions

• A coder prepares a professional claim for an office procedure but the charge line has no diagnosis pointer linking the CPT service to a supporting ICD-10-CM diagnosis. What must be corrected before submission?
• In a group clinic, the billing provider NPI on a professional claim is the group, but the rendering provider NPI is entered as another physician who did not perform the visit. What clean-claim issue must be fixed?
• Clinic documentation shows a specific injectable drug dose was administered, but the claim’s HCPCS drug line reports units that do not match the dose and HCPCS unit definition. What should the coder do before submission?
• Eligibility checking fails because the patient’s insurance member ID on the claim draft has a transposed character compared with the insurance card. What is the correct pre-submission action?
• A physician furnishes a Medicare telehealth visit, but charge entry bills place of service 11 (office) as if the patient were seen in person. What claim-data correction is needed?
• A specialty-center procedure requires prior authorization, and authorization was obtained, but the claim is missing the authorization number in the required claim field/loop. What should be done before submission?
• Charge entry shows the same CPT reported twice on the same date for one patient without documentation or a modifier that supports a distinct second service. What is the correct scrub action before submission?
• An EOB denies a clinic procedure as bundled into another service billed the same day. What is the most appropriate next action?
• A remittance advice posts contractual adjustment remark CO-97, indicating the benefit for a service is included in another service already adjudicated. What should the billing team do next?
• Primary insurance pays partially and assigns coinsurance as patient responsibility on the EOB. The patient also has secondary coverage. What is the correct financial next step?
• A payer denies a professional claim for timely filing. What should the revenue-cycle team evaluate before writing the balance off?
• A Medicare Administrative Contractor issues an Additional Documentation Request (ADR) for an office-billed service. What is the appropriate response?
• A remittance pays zero with a remark that the patient’s maximum benefits for the service category have been met. What should staff do before filing an appeal?
• A claim rejects because the payer cannot find the patient under the submitted eligibility data. Demographics have now been corrected. How should the claim be handled?
• Which statement correctly describes how Medicare physician payment is built under RBRVS for a typical CPT service?
• The same CPT is priced with different practice-expense RVUs depending on whether the physician service is billed in a nonfacility (office) versus facility setting. What financial impact should the coder recognize?
• Two surgical procedures are performed for the same patient on the same day and multiple procedure payment reduction (MPPR) applies. What financial impact is expected for the secondary procedure under typical Medicare physician MPPR rules?
• Medicare updates the physician fee schedule conversion factor while RVU assignments for a CPT remain unchanged. What is the financial impact?
• Two clinics bill the same CPT with identical RVUs, but they are in different Medicare localities. Why might payment differ?
• A clinic coder considers selecting a higher office E/M level than the documentation supports because it would increase work RVUs and payment. What is the correct approach?
• A surgeon’s global surgical package RVUs include routine postoperative visits in the global period. The patient returns for a typical related postop check. What payment expectation is usually correct for a separate E/M?
• A physician performs a knee injection in clinic. Diagnoses on the claim include knee pain and unrelated essential hypertension. How should diagnosis pointers be set for the injection CPT line?
• A screening colonoscopy in the ambulatory setting converts to a biopsy when a polyp is found. How should diagnosis coding and pointers support the claim?
• A multi-specialty clinic bills outpatient physical therapy. The referral lists lumbar spondylosis, but the therapist’s notes document only right-shoulder adhesive capsulitis treated that day. Which diagnosis-linking action best supports the therapy claim?
• A county clinic orders a lipid panel. The chart already documents hyperlipidemia as an established diagnosis known before the draw, yet the claim uses only an unspecified abnormal laboratory finding R-code. What is the most appropriate diagnosis approach for medical-necessity linking?
• An orthopedic clinic bills a bilateral joint injection. Documentation and ICD-10-CM laterality support disease on both sides. Which diagnosis-association practice best aligns with bilateral procedure billing when laterality matters?
• During a preventive visit at a community health center, a patient receives a routine immunization and is not treated for an acute illness. Which diagnosis-linking approach is most appropriate for the vaccine administration?
• A specialty clinic schedules advanced imaging. The MAC LCD lists specific ICD-10-CM families as covered indications. The chart supports both a covered diagnosis and a noncovered symptom code. How should the coder align diagnosis pointers for medical necessity under the LCD?
• A Medicare Advantage panel at a multi-specialty group asks what Hierarchical Condition Categories (HCCs) primarily do with ICD-10-CM diagnoses. Which statement best describes their purpose?
• In CMS-HCC logic, a more severe related condition and a less severe related condition both map to the hierarchy family. What is the key hierarchy concept for payment?
• A primary-care clinic participates in Medicare Advantage risk adjustment. A patient’s chronic HCC-relevant conditions were coded last year but have not been addressed in the current calendar year. What annual-capture principle should guide the coding team?
• An auditor finds an HCC-mapped diagnosis pulled only from an inactive problem list with no MEAT (monitored, evaluated, assessed, or treated) evidence in the year’s encounters. What integrity conclusion is most accurate?
• A clinic revenue-cycle huddle reviews how Medicare Advantage risk scores are built. Beyond demographics, what is the coder’s primary contribution to the risk-score story?
• While reviewing ambulatory diagnoses for risk adjustment, a new coder assumes every ICD-10-CM code maps to an HCC. Which statement corrects that misconception?
• A compliance lead notes that the clinic’s HCC crosswalk still cites an older CMS-HCC model after CMS published an updated model version. What awareness should coding operations apply?
• A family-practice note documents type 2 diabetes with diabetic chronic kidney disease, with staging detail in the assessment. For risk-adjustment ICD-10-CM accuracy, what should the coder do?
• An adult visit documents morbid obesity and a qualifying BMI value in the clinician’s assessment. How should the coder approach risk-adjusted diagnosis capture?
• A patient’s problem list shows an old myocardial infarction, and today’s visit addresses stable chronic conditions with no acute coronary syndrome. Which coding approach best fits the encounter’s risk-adjustment story?
• Oncology follow-up in a specialty clinic documents ongoing chemotherapy for a primary malignancy. Which malignancy coding concept is most accurate for risk adjustment?
• A billing clerk proposes copying last year’s HCC-mapped diagnoses onto this year’s claims without clinician revalidation. What is the correct coding response?
• A transplant clinic visit documents a functioning kidney transplant status relevant to ongoing management. Which risk-adjustment coding practice is appropriate?
• A patient’s record supports two related chronic diagnoses that fall under an HCC hierarchy. What should the physician-office coder do regarding reporting and hierarchy application?
• A clinic workqueue shows some payer rejections that can clear with additional information and others that require formal correction or appeal after a firm nonpayment determination. Which distinction should drive prioritization?
• A professional claim for an office procedure is denied. One notice cites lack of medical necessity for the service; another patient’s claim was denied because coverage was not active on the date of service. How do these denial types differ in root cause and fix?
• Remittance advice shows one denial for NCCI procedure-to-procedure bundling and another for a duplicate claim submission of the same service. What distinction should the coder recognize?
• A prior-authorization-required MRI is denied for missing authorization, while a separate claim is denied because an incorrect CPT was reported for the documented service. How should remediation differ?
• A patient’s claim is denied for coordination of benefits because the clinic billed the secondary payer as primary. What is the appropriate remediation focus?
• Two imaging claims are denied: one as experimental/investigational under the plan’s coverage policy, and another for exceeding the plan’s allowed frequency for that service. How should the denial types be differentiated?