Billing Regulations| CPC Professional Exam Rehearsals| Written Test with Verified Q&A

Billing Regulations| CPC Professional Exam Rehearsals| Written Test with Verified Q&A Accountable Care Organizations (ACO) is an organization working to better coordinate patient care For which reason might Medicare deny payment on a claim? When the service is not deemed medically necessary under Medicare guidelines. What is the purpose of the National Correct Coding Initiative (NCCI) edits in medical billing? To prevent improper coding and overbilling by identifying inappropriate code combinations. How does the Medicare 72-hour rule affect hospital billing? Any outpatient services within 72 hours of admission must be billed as part of the inpatient claim. Under HIPAA, what is required of covered entities when dealing with patient information? They must ensure the privacy and security of Protected Health Information (PHI). What is the function of the Explanation of Benefits (EOB) in the billing process? It provides a summary of what the insurance covered, including any patient responsibility. 2 When might a claim be submitted to secondary insurance? When the primary insurance has completed payment or denial, any remaining balance can be sent to secondary insurance. What is the purpose of a patient’s Advance Beneficiary Notice (ABN)? To notify the patient in advance if Medicare may not cover a service, allowing them to decide if they still wish to proceed. What is the difference between fraud and abuse in medical billing? Fraud is intentional deception to gain payment, while abuse involves actions that unintentionally misrepresent facts for reimbursement. How often must HIPAA training be conducted for employees who handle patient information? Annually, to ensure compliance with privacy and security regulations. What does the “Medically Unlikely Edits” (MUE) program do? It limits the number of times certain procedures and services can be reported on the same day. What is the “Birthday Rule” in determining primary insurance for a dependent child? The parent with the earliest birthday in the year has the primary insurance. How are “incident-to” services billed in a physician’s office? 3 They are billed under the supervising physician's National Provider Identifier (NPI) as long as strict requirements are met. What is the purpose of the remittance advice in the claims process? It provides a detailed report from the payer about each service billed and any adjustments or denials. When can a “write-off” be applied to a patient’s balance? When a contractual adjustment or disallowed amount must be removed per insurance agreements. What is the primary purpose of a coding audit in a medical billing context? To ensure accuracy and compliance in the coding and billing of healthcare services. How does a “bundling” policy impact billing? It combines multiple services into one code, often resulting in a lower reimbursement rate than if billed separately. What is the role of a clearinghouse in medical billing? To act as an intermediary between healthcare providers and payers, ensuring claims ar