AAPC CPB - Chapter 13 Review
A claim reported with ICD-10-CM code S31.40 is denied for an invalid ICD-10-CM code.
What action should the biller take?
a. Call the insurance carrier, S31.40 is a valid ICD-10-CM code.
b. S31.40 requires an additional character, pull the medical record or query the provider
for the correct code. Submit the claim with the appropriate six-character code.
c. S31.40 requires an additional character, pull the medical record or query the provider
for the correct code. Submit the claim with the appropriate seven-character code.
d. S31.40 is for an injury and is not covered. - ANS - c. S31.40 requires an additional
character, pull the medical record or query the provider for the correct code. Submit the
claim with the appropriate seven-character code.
A denial is received in the office for timely filing. The payer has a 60-day timely filing
policy for appeals. The internal process is investigated and it is found that the appeal
was filed at 90 days. What can be done?
a. Write off the claim amount
b. Refile the appeal
c. Refile the original claim to start the timely filing limit over
d. Balance bill the patient - ANS - a. Write off the claim amount
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 - ANS
- d. Add modifier 58 to the procedure and follow the payer's guidelines for appeals
, 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 - ANS - b. Other Coverage issue
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 - ANS - c. Within 60 calendar days
of the previous decision
According to Cigna's appeals process, how many level of internal appeals are offered?
a. One
b. Two
c. Three
d. Four - ANS - a. One
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 - ANS - d. Submit a Reconsideration
Claim rejections are due to what?
a. Claims that don't meet coverage criteria
b. Claims that are already adjudicated
c. Claims that do not contain necessary information for adjudication
d. Claims that require medical record documentation - ANS - c. Claims that do not
contain necessary information for adjudication
A claim reported with ICD-10-CM code S31.40 is denied for an invalid ICD-10-CM code.
What action should the biller take?
a. Call the insurance carrier, S31.40 is a valid ICD-10-CM code.
b. S31.40 requires an additional character, pull the medical record or query the provider
for the correct code. Submit the claim with the appropriate six-character code.
c. S31.40 requires an additional character, pull the medical record or query the provider
for the correct code. Submit the claim with the appropriate seven-character code.
d. S31.40 is for an injury and is not covered. - ANS - c. S31.40 requires an additional
character, pull the medical record or query the provider for the correct code. Submit the
claim with the appropriate seven-character code.
A denial is received in the office for timely filing. The payer has a 60-day timely filing
policy for appeals. The internal process is investigated and it is found that the appeal
was filed at 90 days. What can be done?
a. Write off the claim amount
b. Refile the appeal
c. Refile the original claim to start the timely filing limit over
d. Balance bill the patient - ANS - a. Write off the claim amount
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 - ANS
- d. Add modifier 58 to the procedure and follow the payer's guidelines for appeals
, 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 - ANS - b. Other Coverage issue
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 - ANS - c. Within 60 calendar days
of the previous decision
According to Cigna's appeals process, how many level of internal appeals are offered?
a. One
b. Two
c. Three
d. Four - ANS - a. One
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 - ANS - d. Submit a Reconsideration
Claim rejections are due to what?
a. Claims that don't meet coverage criteria
b. Claims that are already adjudicated
c. Claims that do not contain necessary information for adjudication
d. Claims that require medical record documentation - ANS - c. Claims that do not
contain necessary information for adjudication
