I85PREP
⌘ K
NCICS study materials
NCICS study resources

NCICS practice questions

One question at a time. Build your NCICS understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Medical Billing and Coding Services

A hospital's chargemaster lists a drug at $80 per unit. The payer contract reimburses 75% of the chargemaster price. What amount is reimbursed per unit?

  1. $60 Correct answer.
  2. $20
  3. $105
  4. $75

Explanation

Contractual reimbursement is calculated by multiplying the chargemaster amount by the agreed percentage: $80 × 0.75 = $60. The remaining $20 is a contractual adjustment written off in the billing system.

Question 2Medical Billing and Coding Services

Which identifier is used on a CMS-1500 claim to report the diagnosis codes that justify the services billed?

  1. Box 1, payer type
  2. Box 33, billing provider information
  3. Box 21, current ICD-10-CM codes Correct answer.
  4. Box 24E, units of service

Explanation

On the CMS-1500 form, Box 21 carries the ICD-10-CM diagnosis codes that support medical necessity for the reported procedures. Box 24E instead reports units per line, and Box 33 identifies the billing provider.

Question 3Medical Billing and Coding Services

A claim is submitted for a patient whose coverage terminated before the date of service. Denial of the claim is most likely based on which reason?

  1. Missing referring provider NPI
  2. Incorrect place-of-service code
  3. Bundling of the procedure
  4. Eligibility failure at the time of service Correct answer.

Explanation

Payers verify eligibility against the date of service, so coverage that ended before that date produces a denial for ineligibility. Bundling, NPI, and place-of-service issues are separate edit categories.

Question 4Medical Billing and Coding Services

Which code set is used to report inpatient hospital procedures on a UB-04 claim?

  1. HCPCS Level II
  2. CPT Category I
  3. ICD-10-CM
  4. ICD-10-PCS Correct answer.

Explanation

ICD-10-PCS is the procedure classification system for inpatient hospital reporting in the United States. CPT is used for outpatient and physician services, and ICD-10-CM covers diagnoses.

Question 5Medical Billing and Coding Services

A patient pays a fixed $30 before the insurer processes any charges. What is this payment called?

  1. Copayment Correct answer.
  2. Deductible
  3. Premium
  4. Coinsurance

Explanation

A copayment is a fixed dollar amount collected at the time of service. Coinsurance is a percentage share, a deductible is an amount paid before coverage begins, and a premium is the periodic plan charge.

Question 6Medical Billing and Coding Services

Which action best describes the purpose of a preauthorization before a scheduled surgical procedure?

  1. Obtaining payer approval for medical necessity in advance Correct answer.
  2. Assigning the diagnosis codes after discharge
  3. Submitting the final claim to the clearinghouse
  4. Collecting the patient's copayment at check-in

Explanation

Preauthorization asks the payer to review and approve planned services for medical necessity before they occur. Without it, the payer may reduce or deny payment even when the service was appropriate.

Question 7Medical Billing and Coding Services

Which modifier indicates that a procedure was performed on both sides of the body?

  1. -22
  2. -59
  3. -LT
  4. -50 Correct answer.

Explanation

Modifier -50 reports a bilateral procedure performed on both sides during the same session. Modifier -LT identifies only the left side, -59 signals a distinct procedural service, and -22 indicates increased procedural services.

Question 8Medical Billing and Coding Services

What does an NPI identify on a health care claim?

  1. The diagnosis code
  2. The patient's insurance policy number
  3. The claim's place of service
  4. The provider or supplier Correct answer.

Explanation

The National Provider Identifier is a unique 10-digit number assigned to health care providers and suppliers. It identifies the entity that rendered or billed the service, not the patient or diagnosis.

Question 9Medical Billing and Coding Services

A payer allows $200 for a service, the patient has a $40 copayment, and the provider is contracted. What amount should the provider expect from the payer, assuming the copayment is collected from the patient?

  1. $200
  2. $40
  3. $160 Correct answer.
  4. $240

Explanation

The payer pays the allowed amount minus the patient's copayment: $200 − $40 = $160. The provider collects the remaining $40 from the patient and may not bill beyond the allowed amount.

Question 10Medical Billing and Coding Services

A claim for a procedure is denied as not medically necessary even though the diagnosis is documented. Which step should the coder take first?

  1. Resubmit the identical claim without changes
  2. Write off the balance immediately as bad debt
  3. Review the diagnosis-to-procedure linkage and payer coverage policy Correct answer.
  4. Change the diagnosis to a higher-paying code

Explanation

A medical necessity denial usually reflects a mismatch between the reported diagnosis and the payer's coverage criteria. Reviewing the linkage and the applicable local or national coverage determination is the appropriate first step.

Question 11Medical Billing and Coding Services

Under the National Correct Coding Initiative, when two codes are bundled and the edit is modifier-overridable, which modifier pair is commonly used to show the services were distinct?

  1. -LT and -RT
  2. -25 and -59 Correct answer.
  3. -26 and -TC
  4. -22 and -50

Explanation

Modifier -25 indicates a significant, separately identifiable evaluation and management service, and -59 indicates a distinct procedural service. Together they are used to bypass certain NCCI edits when documentation supports separate services.

Question 12Medical Billing and Coding Services

A provider performs a service for a patient covered by a plan with which the provider has no contract. What is the provider's billing obligation regarding charges?

  1. Submit no claim and bill the patient the entire charge
  2. Bill the patient the full charge minus any payer payment Correct answer.
  3. Accept the payer's allowed amount as payment in full
  4. Collect the difference between charge and allowed amount from the patient

Explanation

Without a participating provider agreement, the provider is not bound by the payer's allowed amount and may bill the patient for the balance after any payment. Contracted providers, by contrast, must accept the allowed amount.

Question 13Medical Billing and Coding Services

Which element is essential for a clean claim to avoid front-end rejection by a clearinghouse?

  1. The provider's malpractice carrier name
  2. A copy of the patient's operative report
  3. The patient's employer's phone number
  4. A complete diagnosis pointer for each service line Correct answer.

Explanation

Clearinghouses run edits that require each service line to point to at least one valid diagnosis code. Missing or mismatched diagnosis pointers cause front-end rejections before the payer ever reviews the claim.

Question 14Medical Billing and Coding Services

A patient has a $1,000 deductible that has not been met and receives a service with an allowed amount of $600. What amount does the patient owe, assuming no other cost sharing?

  1. $0
  2. $300
  3. $1,000
  4. $600 Correct answer.

Explanation

Because the deductible is unmet and the allowed amount ($600) is less than the remaining deductible ($1,000), the patient owes the full allowed amount. The deductible balance is reduced to $400 afterward.

Question 15Medical Billing and Coding Services

A coder reports an evaluation and management code with modifier -25 alongside a minor procedure on the same day. What documentation must support the modifier?

  1. A separately identifiable E/M service beyond the procedure's usual work Correct answer.
  2. That the E/M service was the only service rendered
  3. That the procedure was performed bilaterally
  4. That the patient was new to the practice

Explanation

Modifier -25 is appropriate only when the E/M service is significant, separately identifiable, and above the usual preoperative and postoperative work of the procedure. The record must document that distinct service.

Question 16Medical Billing and Coding Services

A hospital bills a Medicare inpatient stay. Which claim form and code set combination is correct?

  1. CMS-1500 with CPT procedure codes
  2. UB-04 with ICD-10-PCS procedure codes Correct answer.
  3. CMS-1500 with ICD-10-PCS procedure codes
  4. UB-04 with HCPCS Level II procedure codes only

Explanation

Institutional inpatient claims are submitted on the UB-04, and inpatient procedures are coded with ICD-10-PCS. The CMS-1500 is used for professional and outpatient claims with CPT or HCPCS codes.

Question 17Medical Billing and Coding Services

A payer denies a claim because the service was rendered by a provider not credentialed with that plan. Which corrective action is most appropriate?

  1. Change the rendering provider's NPI to a credentialed colleague's
  2. Appeal the denial with proof of the provider's credentialing status Correct answer.
  3. Adjust the date of service to fall within the credentialing period
  4. Rebill the service under the group's tax ID only

Explanation

When a denial stems from credentialing, the remedy is to demonstrate that the provider was credentialed as of the date of service, or to complete credentialing and request reconsideration. Altering identifiers or dates to obtain payment is fraudulent.

Question 18Medical Billing and Coding Services

Which statement accurately describes the difference between a claim rejection and a claim denial?

  1. A rejection means payment was made; a denial means it was not
  2. A rejection is always appealable; a denial never is
  3. A rejection occurs before payer adjudication; a denial occurs after adjudication Correct answer.
  4. A denial is issued by a clearinghouse; a rejection by the payer

Explanation

Rejections are front-end edits that prevent a claim from entering adjudication, often for formatting or data errors. Denials come from the payer after adjudication and generally carry appeal rights.

Question 19Medical Billing and Coding Services

A provider performs a laboratory test and a related office visit on the same day. The payer's policy states the lab is included in the visit when performed on the same date. What coding concept applies?

  1. Unbundling
  2. Bundling Correct answer.
  3. Modifier -22
  4. Global surgical package

Explanation

Bundling means that services considered integral to a primary service are not separately payable. When policy includes the lab in the visit, reporting both separately would be unbundling.

Question 20Medical Billing and Coding Services

A patient's secondary payer is billed after the primary payer pays part of the claim. What is the secondary payer's typical responsibility?

  1. Paying only the patient's copayment
  2. Denying the claim because a primary payer exists
  3. Paying the full charge again
  4. Paying the remaining patient responsibility up to its own allowed amount Correct answer.

Explanation

Coordination of benefits requires the secondary payer to consider the primary payment and cover remaining eligible amounts, such as deductible or coinsurance, up to its own allowed amount. It does not duplicate the primary payment.

Question 21Medical Billing and Coding Services

An audit finds that a coder consistently assigned a higher-level E/M code than the documentation supported. Which compliance risk does this represent?

  1. Downcoding
  2. Balancing
  3. Upcoding Correct answer.
  4. Unbundling

Explanation

Upcoding is the assignment of a code reflecting a higher level of service than the documentation supports. It creates false claims exposure under fraud and abuse laws and is a common audit finding.

Question 22Medical Billing and Coding Services

A payer's fee schedule lists $150 for a procedure, and the provider's charge is $180. The patient has 20% coinsurance. What is the patient's coinsurance amount?

  1. $36
  2. $150
  3. $30 Correct answer.
  4. $24

Explanation

Coinsurance is calculated on the allowed amount, not the billed charge: $150 × 0.20 = $30. The provider must write off the $30 difference between the charge and the allowed amount.

Question 23Medical Billing and Coding Services

A claim is denied for lack of medical necessity on a service that the provider believes was appropriate. Which appeal strategy is strongest?

  1. File a duplicate claim to trigger reprocessing
  2. Request that the patient pay the full charge
  3. Resubmit the claim with a different diagnosis code
  4. Submit a redetermination with clinical documentation supporting necessity Correct answer.

Explanation

The strongest appeal presents the payer's own coverage criteria alongside clinical documentation showing the service met them. Changing codes or filing duplicates does not address the necessity question and may create compliance problems.

Question 24Medical Billing and Coding Services

A provider bills a global obstetric code but another physician provided only the delivery. Which modifier arrangement correctly reflects the split?

  1. -26 on the global code
  2. -TC on the global code
  3. -54 on the delivery-only service Correct answer.
  4. -59 on the delivery-only service

Explanation

Modifier -54 identifies surgical care only when one physician provides the procedure and another provides preoperative or postoperative care. Modifiers -26 and -TC apply to professional and technical components, not to split surgical care.

Question 25Medical Billing and Coding Services

A coder discovers that a previously submitted claim used an incorrect procedure code that resulted in overpayment. What is the correct compliance response?

  1. Wait until the next audit to disclose the error
  2. Refund the overpayment and submit a corrected claim Correct answer.
  3. Apply the overpayment to another patient's balance
  4. Keep the payment because the payer did not detect the error

Explanation

Receiving an overpayment creates a duty to return it within the timeframe set by law, typically 60 days under the Medicare statute. The corrected claim and refund document the good-faith correction.

Question 26Medical Billing and Coding Services

Which code set is used to report diagnoses on a professional claim in the United States?

  1. CPT
  2. ICD-10-CM Correct answer.
  3. ICD-10-PCS
  4. HCPCS Level II

Explanation

Diagnoses on professional claims are reported with ICD-10-CM, the clinical modification of the ICD-10 system maintained for US morbidity coding. CPT and HCPCS Level II describe procedures, supplies, and drugs rather than diagnoses. ICD-10-PCS is an inpatient procedure classification and is not used for diagnosis reporting.

Question 27Medical Billing and Coding Services

A coder needs to report a procedure that has no dedicated CPT code but is described in the CPT manual's index. What should the coder look for first?

  1. A diagnosis code that matches the procedure
  2. An unlisted procedure code in the correct section Correct answer.
  3. A revenue code from the UB-04 manual
  4. A HCPCS Level II code for the service

Explanation

When no specific CPT code exists, the CPT manual provides unlisted procedure codes organized by body system or section, and these are reported with supporting documentation. Unlisted codes signal the payer that manual review is needed. A revenue code describes a billing category on facility claims, and a diagnosis code never substitutes for a procedure code.

Question 28Medical Billing and Coding Services

Which identifier is assigned to a health care clearinghouse that transmits claims electronically?

  1. Taxpayer Identification Number
  2. Clinical Laboratory Improvement Amendments number
  3. Electronic Data Interchange Identifier Correct answer.
  4. National Provider Identifier

Explanation

Under HIPAA administrative simplification, the Electronic Data Interchange Identifier is the standard identifier for clearinghouses and other trading partners in electronic transactions. The NPI identifies individual and organizational providers, and the TIN identifies the tax-reporting entity. The CLIA number identifies a laboratory's certification.

Question 29Medical Billing and Coding Services

A claim is submitted with a procedure code that requires a laterality indicator but no modifier is appended. What is the most likely outcome?

  1. The claim is automatically downcoded to a lower level
  2. The claim is paid at the full allowed amount
  3. The claim is rejected or denied pending corrected coding Correct answer.
  4. The claim is forwarded to the secondary payer first

Explanation

Many payers require laterality modifiers on procedures that can be performed on either side of the body, and omitting one commonly causes a rejection or denial. The coder must correct the claim and resubmit with the proper modifier. Payers do not pay full amounts for incomplete coding, and secondary billing does not begin until the primary adjudicates.

Question 30Medical Billing and Coding Services

What does the term 'clean claim' mean in medical billing?

  1. A claim with no patient balance remaining
  2. A claim for a service covered at 100 percent
  3. A claim submitted within 24 hours of the service
  4. A claim that passes payer edits without missing or invalid data Correct answer.

Explanation

A clean claim contains all required data elements in valid format and passes front-end edits, allowing adjudication without manual correction. It is a data-quality concept, not a statement about patient balances or coverage levels. Speed of submission alone does not make a claim clean.

Question 31Medical Billing and Coding Services

Which claim form is used to bill professional services under the CMS-1500 format?

  1. UB-04
  2. CMS-1500 Correct answer.
  3. ADA dental claim form
  4. NCPDP pharmacy claim

Explanation

The CMS-1500 is the standard paper and electronic format for professional claims submitted by physicians and other non-institutional providers. The UB-04 is used for institutional claims such as hospital services. Dental and pharmacy claims use their own specialized formats.

Question 32Medical Billing and Coding Services

A patient has met the deductible and has 20 percent coinsurance on an allowed amount of $500. What amount does the patient owe?

  1. $0
  2. $400
  3. $500
  4. $100 Correct answer.

Explanation

Coinsurance is a percentage of the allowed amount that the patient pays after the deductible is satisfied. Twenty percent of $500 is $100, and the plan pays the remaining $400. The allowed amount itself is not the patient's responsibility when coinsurance applies.

Question 33Medical Billing and Coding Services

What is the primary purpose of the remittance advice a payer sends after adjudicating a claim?

  1. To authorize a scheduled surgical procedure
  2. To explain payment, adjustments, and patient responsibility Correct answer.
  3. To request additional clinical documentation
  4. To verify the patient's eligibility for coverage

Explanation

The remittance advice reports how each claim line was adjudicated, including paid amounts, contractual adjustments, denials, and patient responsibility. It is the basis for posting payments and managing accounts receivable. Eligibility checks, prior authorization, and documentation requests occur before or separate from remittance.

Question 34Medical Billing and Coding Services

A provider participates in a payer's network. The payer's allowed amount is $300 and the provider billed $350. What is the contractual adjustment?

  1. $300
  2. $50 Correct answer.
  3. $350
  4. $0

Explanation

For a participating provider, the difference between the billed charge and the allowed amount is written off as a contractual adjustment. Here $350 minus $300 equals $50. The provider may not bill the patient for that difference under the network agreement.

Question 35Medical Billing and Coding Services

A coder is selecting a diagnosis code from the ICD-10-CM tabular list and finds a note reading 'code first' under a condition. What does this instruction mean?

  1. The manifestation should be sequenced before the underlying condition
  2. The code should be reported only when the condition is the principal diagnosis
  3. The underlying condition should be sequenced before the manifestation Correct answer.
  4. Only one code may be reported for the encounter

Explanation

A 'code first' note indicates that the underlying etiology or cause should be sequenced before the manifestation code. This sequencing rule reflects the relationship between the two conditions. It does not restrict the number of codes or limit reporting to a principal diagnosis only.

Question 36Medical Billing and Coding Services

A payer's explanation of benefits shows a denial code for 'procedure not covered under the patient's plan.' What is the most appropriate next step?

  1. Bill the secondary payer before notifying the patient
  2. Appeal the denial without additional information
  3. Resubmit the identical claim to the same payer
  4. Check the plan's benefit exclusions and consider an ABN or patient responsibility Correct answer.

Explanation

When a service is excluded by the plan's benefits, the provider should verify the exclusion and, where Medicare rules apply, obtain a valid Advance Beneficiary Notice before the service. The patient may then be responsible for the charge. Resubmitting identical claims or appealing without a coverage basis will not resolve the denial.

Question 37Medical Billing and Coding Services

What is the main distinction between a payer's fee schedule and a provider's charge master?

  1. The fee schedule is used for inpatient claims, while the charge master is used for outpatient claims
  2. The fee schedule applies only to Medicare, while the charge master applies only to Medicaid
  3. The fee schedule lists only diagnosis codes, while the charge master lists procedure codes
  4. The fee schedule is the payer's maximum payment amount, while the charge master lists the provider's standard prices Correct answer.

Explanation

A fee schedule sets the amount a payer will allow for a service, while the charge master is the provider's internal list of standard charges. Payment is typically the lesser of the billed charge or the allowed amount. Neither document is limited by code type or claim setting in the way the other options suggest.

Question 38Medical Billing and Coding Services

A coder reports an add-on code without its primary procedure code on the same claim. What is the most likely result?

  1. The add-on code is converted to a diagnosis code
  2. The add-on code is denied because the primary procedure is missing Correct answer.
  3. The add-on code is paid at the full rate
  4. The add-on code is automatically bundled into the primary service

Explanation

Add-on codes describe services that are always performed in addition to a primary procedure and cannot stand alone. Without the primary code on the same claim or date of service, the payer will deny the add-on. There is no conversion to a diagnosis code, and bundling requires the primary code to be present.

Question 39Medical Billing and Coding Services

A coder must determine which of two similar procedure codes to report when the documentation describes a more extensive version of the service. What coding principle applies?

  1. Report the code with the lowest relative value unit
  2. Report the code with the highest reimbursement regardless of documentation
  3. Report both codes to ensure payment
  4. Report the code that most specifically describes the documented service Correct answer.

Explanation

Coding should reflect the service actually documented, using the most specific code that fully describes it. Reimbursement and relative value units are not valid criteria for code selection. Reporting both codes when only one service was performed constitutes upcoding.

Question 40Medical Billing and Coding Services

A payer requires a referral from the primary care physician before a specialist visit. The patient arrives without one. What should the billing staff do first?

  1. Submit the claim and wait for a denial
  2. Bill the patient for the entire visit immediately
  3. Bill the claim with a modifier indicating no referral
  4. Contact the payer or PCP office to obtain or verify the referral Correct answer.

Explanation

When a plan requires a referral, staff should verify or obtain it before or at the time of service to preserve coverage. Billing without the referral risks denial, and the patient should not be billed prematurely while the referral is being resolved. Modifiers do not substitute for a required referral.

Question 41Medical Billing and Coding Services

Which action best supports accurate coding of a complex operative report?

  1. Coding from the preoperative note alone
  2. Coding only from the discharge summary
  3. Reading the entire report and identifying each distinct procedure and its documentation Correct answer.
  4. Selecting codes based on the surgeon's billing history

Explanation

Accurate surgical coding requires reading the full operative report to capture each distinct procedure, approach, and documented detail. Discharge summaries and preoperative notes may omit operative specifics. Billing history is not documentation and cannot justify code selection.

Question 42Medical Billing and Coding Services

A coder discovers that a claim was submitted with a modifier that changed payment incorrectly. What is the appropriate corrective action?

  1. Post the incorrect payment and move on
  2. Wait for the payer to audit the claim
  3. Submit a new claim with the corrected modifier and appropriate adjustment Correct answer.
  4. Change the patient's record to match the claim

Explanation

Coding errors should be corrected through a replacement claim or adjustment, with any overpayment refunded as required. Altering records to match an incorrect claim is improper. Waiting for an audit does not fulfill the provider's compliance obligation.

Question 43Medical Billing and Coding Services

A patient has Medicare as primary and a Medigap policy as secondary. After Medicare pays its share, what does the Medigap plan typically cover?

  1. The entire billed charge regardless of Medicare's allowed amount
  2. Part or all of the Medicare coinsurance and deductible Correct answer.
  3. Only services Medicare denies as not medically necessary
  4. The provider's full charge minus the Medicare payment

Explanation

Medigap policies are designed to cover Medicare cost-sharing, such as coinsurance and deductibles, within policy limits. They do not pay the full billed charge or services Medicare deems not medically necessary. The Medicare allowed amount remains the basis for payment.

Question 44Medical Billing and Coding Services

What is the purpose of a payer's clinical edit such as a diagnosis-to-procedure pairing rule?

  1. To determine the provider's network status
  2. To verify patient eligibility before the visit
  3. To calculate the patient's copayment amount
  4. To check that the diagnosis supports the medical necessity of the procedure Correct answer.

Explanation

Clinical edits compare diagnosis and procedure codes to confirm that the service is medically supported for the reported condition. They operate during claim adjudication, not during eligibility verification. Copayment calculation and network status are separate determinations.

Question 45Medical Billing and Coding Services

A provider performs a service for a patient whose coverage was terminated before the date of service. The claim is denied for no coverage. What is the most appropriate action?

  1. Bill the payer's secondary plan without verification
  2. Resubmit the claim with a different date of service
  3. Appeal the denial as a coding error
  4. Verify the termination date and bill the patient as self-pay if coverage had ended Correct answer.

Explanation

When eligibility has ended, the provider should confirm the termination date and, if the service was not covered, bill the patient as self-pay. Changing dates or appealing without a coverage basis is improper. Secondary plans require their own eligibility verification.

Question 46Medical Billing and Coding Services

A coder is reviewing a claim where the units of service exceed what the documentation supports. What compliance risk does this present?

  1. Improved accuracy in payment
  2. Underpayment to the provider
  3. A reduction in the patient's coinsurance
  4. Overutilization and potential false claims exposure Correct answer.

Explanation

Reporting more units than documented overstates the service and can constitute overutilization or a false claim. Compliance programs require that billed units match documentation. Overstated units do not reduce patient coinsurance and are not a payment accuracy improvement.

Question 47Medical Billing and Coding Services

A payer's policy states that a global surgical package includes routine postoperative care. A provider reports an office visit during the global period for a complication unrelated to the surgery. What should the coder do?

  1. Report the visit with modifier -24 because it is unrelated to the surgery Correct answer.
  2. Report the surgical code again
  3. Bundle the visit into the global surgical code
  4. Report the visit without any modifier

Explanation

Modifier -24 identifies an evaluation and management service during a postoperative period for a condition unrelated to the surgery. Related routine care is included in the global package and should not be separately billed. Reporting the visit unmodified or repeating the surgical code would be incorrect.

Question 48Medical Billing and Coding Services

A coder is reviewing a claim where the diagnosis code is less specific than the documentation allows. What is the likely effect on the claim?

  1. The claim will be automatically forwarded to the secondary payer
  2. The claim will be rejected for a missing NPI
  3. The claim will always be paid at the highest rate
  4. The claim may be denied or downcoded for lack of specificity Correct answer.

Explanation

Payers and coding guidelines require the highest level of documented specificity, so vague diagnosis codes can trigger denials or downcoding. Specificity affects medical necessity validation and payment. It does not cause automatic secondary forwarding or NPI-related rejections.

Question 49Medical Billing and Coding Services

A provider performs a service that requires prior authorization, but the authorization was obtained for a different date. What is the best course of action?

  1. Submit the claim with the existing authorization number
  2. Bill the patient without contacting the payer
  3. Change the date of service to match the authorization
  4. Request a corrected authorization or verify whether the payer allows date changes Correct answer.

Explanation

Authorization numbers are typically tied to specific dates and services, so the provider should request correction or confirm the payer's policy on date changes. Using the wrong authorization number risks denial. Altering the date of service to fit an authorization is fraudulent, and billing the patient before resolution is premature.

Question 50Medical Billing and Coding Services

A coder identifies that a payer's local coverage determination lists a diagnosis as non-covered for a procedure, but the physician documented a covered diagnosis as the reason for the service. What should the coder do?

  1. Report both diagnoses to guarantee payment
  2. Report the non-covered diagnosis because it appears in the record
  3. Report the procedure without a diagnosis code
  4. Report the covered diagnosis only if the documentation supports it as the reason for the service Correct answer.

Explanation

The code reported must reflect the diagnosis documented as the reason for the service, and coding to match coverage is improper unless the documentation supports it. Coders may query the physician for clarification when documentation is ambiguous. Reporting unsupported diagnoses or omitting diagnoses violates coding rules.