AAPC CPB - Chapter 13 Review Exam Questions and Answers

On 05/02/19, a claim for a fine needle aspiration biopsy with ultrasound guidance was reported with CPT code 10022, ICD-10-CM code D49.2 for DOS 05/01/2019. Why would the claim be denied? a. Not medically necessary b. Invalid CPT code for DOS c. Invalid ICD-10-CM code for DOS d. Timely filing - Answer- b. Invalid CPT code for DOS CPT codes 11400 and 12031 were reported on a claim. The insurance carrier denied 12031 as bundled with 11400. According to CPT® guidelines for Excision for Benign Lesions what action should the biller take? a. Write-off 12031 as repairs are included in excisions. b. Add modifier 59 to 12031 and submit a corrected claim. c. Add modifier 51 to 12031 and submit a corrected claim. d. Appeal the claim. - Answer- d. Appeal the claim. What is one way to assist in lowering denials for non-covered services? a. Keep every payer policy on file b. Call insurance companies after any services are rendered c. Be aware of the most common exclusions in the office's major plans d. Appeal all non-covered service denials - Answer- c. Be aware of the most common exclusions in the office's major plans A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received? a. Coordination of benefits issue b. Other Coverage issue c. Prior authorization issue d. Non-covered service - Answer- b. Other Coverage issue What rejections/denials are the easiest to prevent with good front office policy? I. Incorrect patient information II. Eligibility expiration III. Medical necessity IV. Liability denials a. I, II b. I, II, IV c. I, III, IV d. I, IV - Answer- b. I, II, IV If a claim is denied, investigated, and found to be denied in error, what should a biller do? a. Appeal the claim b. Write the claim off c. Balance bill the patient d. Refile the claim - Answer- a. Appeal the claim Under what Federal Act must insurance companies implement effective appeals processes? a. The Social Security Act b. The Health Insurance Policies Act c. The Federal Records Act d. The Patient Protection and Affordable Care Act - Answer- d. The Patient Protection and Affordable Care Act An initial denial is received in the office from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna's policy, what must the biller do? a. Refile the claim b. Submit a Level 1 appeal c. Submit a Level 2 appeal d. Submit a Reconsideration - Answer- d. Submit a Reconsideration According to Aetna's published guidelines, what is the timeframe for filing an appeal? a. Within 60 calendar days of the initial claim decision b. Within 180 calendar days of the initial claim decision c. Within 60 calendar days of the previous decision d. Within 30 calendar days of the previous decision - Answer- c. Within 60 calendar days of the previous decision A denial is received in the office indicating that a service was billed and denied due to bundling issues. The medical record is obtained and, upon review, it is documented that the second procedure is a staged procedure that was planned at the time of the initial procedure. When the claim is reviewed, no modifier was attached to the codes on the claim. What should be done to resolve the claim? a. Write the claim off b. Refile the claim c. Balance bill the patient for the claim amount d. Add modifier 58 to the procedure and follow the payer's guidelines for appeals - Answer- d. Add modifier 58 to the procedure and follow the payer's guidelines for appeals Which type of denial is more likely to happen when the patient is insured through an HMO?