AAPC CPB - Chapter 9 Practical Application
| Questions and Correct Solutions 2024
Case 1 - Clearinghouse Rejections Report
Status: 11/19/20XX Contents: C4450 - Principal Diagnosis Code must be valid; REJECTED BY SYSTEM EDI;
Rejected
Patient Name: Adams, David
Patient Number: 384594
Payer: HEALTHSPRINGMEDICARE
Submission Date: 11/19/XX
Date of Service: 11/09/XX
Charge: $557.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for David
Adams, Date of Service 11/19/20XX?
I. Review the medical records to verify the ICD-10-CM code is correct.
II. Review the ICD-10-CM codebook to verify it is a correct diagnosis code.
III. Adjust the charge as this is not a covered diagnosis by the insurance carrier.
IV. Override the clearinghouse edit as this is a valid code.
a. II and III
b. I and II
c. I, II, and IV
,d. II and IV - Answer - b. I and II
Response Feedback:
According to the Clearinghouse report, the diagnosis code is invalid. The biller should look in the ICD-10-
CM codebook to determine the validity of the code. In the ICD-10-CM codebook, the code requires
another character. The medical record should be reviewed to determine the additional character and a
correct claim refiled.
Case 2 - Clearinghouse Rejections Report
Status: 10/18/20XX Contents: C4655 - Not eligible (Inactive) for service; REJECTED BY SYSTEM EDI;
Rejected
Patient Name: Smith, John
Patient Number: 584263
Payer: AAPC Health Plan
Submission Date: 10/18/XX
Date of Service: 10/17/XX
Charge: $450.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for John
Smith, Date of Service 10/18/20XX?
I. Verify the insurance card information in the patient's file.
II. Verify coverage dates for the insurance carrier.
III. Adjust the charge as the patient is not eligible for coverage.
IV. Override the clearinghouse edit.
, a. II and III
b. IV
c. I and II
d. III and IV - Answer - c. I and II
Response Feedback:
The clearinghouse rejected the service because the patient is not eligible for coverage according to the
carrier files. The biller should pull the insurance information from the patient's file and verify coverage
dates for the insurance.
Case 3 - Clearinghouse Rejections Report
Status: 9/17/20XX Contents: C4120 - Invalid information procedure
code/modifier for 99213-22; REJECTED BY SYSTEM EDI; Rejected
Patient Name: Williams, Kara
Patient Number: 543789
Payer: AAPC Health Plan
Submission Date: 9/17/XX
Date of Service: 9/16/XX
Charge: $250.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for Kara
Williams, Date of Service 9/16/20XX?
I. Check with the provider to determine what codes should be reported.
| Questions and Correct Solutions 2024
Case 1 - Clearinghouse Rejections Report
Status: 11/19/20XX Contents: C4450 - Principal Diagnosis Code must be valid; REJECTED BY SYSTEM EDI;
Rejected
Patient Name: Adams, David
Patient Number: 384594
Payer: HEALTHSPRINGMEDICARE
Submission Date: 11/19/XX
Date of Service: 11/09/XX
Charge: $557.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for David
Adams, Date of Service 11/19/20XX?
I. Review the medical records to verify the ICD-10-CM code is correct.
II. Review the ICD-10-CM codebook to verify it is a correct diagnosis code.
III. Adjust the charge as this is not a covered diagnosis by the insurance carrier.
IV. Override the clearinghouse edit as this is a valid code.
a. II and III
b. I and II
c. I, II, and IV
,d. II and IV - Answer - b. I and II
Response Feedback:
According to the Clearinghouse report, the diagnosis code is invalid. The biller should look in the ICD-10-
CM codebook to determine the validity of the code. In the ICD-10-CM codebook, the code requires
another character. The medical record should be reviewed to determine the additional character and a
correct claim refiled.
Case 2 - Clearinghouse Rejections Report
Status: 10/18/20XX Contents: C4655 - Not eligible (Inactive) for service; REJECTED BY SYSTEM EDI;
Rejected
Patient Name: Smith, John
Patient Number: 584263
Payer: AAPC Health Plan
Submission Date: 10/18/XX
Date of Service: 10/17/XX
Charge: $450.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for John
Smith, Date of Service 10/18/20XX?
I. Verify the insurance card information in the patient's file.
II. Verify coverage dates for the insurance carrier.
III. Adjust the charge as the patient is not eligible for coverage.
IV. Override the clearinghouse edit.
, a. II and III
b. IV
c. I and II
d. III and IV - Answer - c. I and II
Response Feedback:
The clearinghouse rejected the service because the patient is not eligible for coverage according to the
carrier files. The biller should pull the insurance information from the patient's file and verify coverage
dates for the insurance.
Case 3 - Clearinghouse Rejections Report
Status: 9/17/20XX Contents: C4120 - Invalid information procedure
code/modifier for 99213-22; REJECTED BY SYSTEM EDI; Rejected
Patient Name: Williams, Kara
Patient Number: 543789
Payer: AAPC Health Plan
Submission Date: 9/17/XX
Date of Service: 9/16/XX
Charge: $250.00
Provider: Post, Alexis
According to this clearinghouse rejections report, what actions should be taken on the claim for Kara
Williams, Date of Service 9/16/20XX?
I. Check with the provider to determine what codes should be reported.
