HEIT 1250 - Bell Ringer Chapter 11

Which of the following is a billing error related to coding linages and medical necessity?

• services not consistent with a diagnosis

• billing with invalid or outdated codes

• not satisfying the conditions of coverage for a service

• billing for a consultation instead of an office visit

Why would a claim be denied even though no error has been made on the claim?

• The service is not covered.

• The service has been unbundled.

• There is missing or invalid claims data.

• The service does not fall under CARC coding protocols.

How can service providers minimize denials based on MS-DRG coding issues?

• have documentation to support the diagnosis

• have patients sign an advance beneficiary notice

• have information verified at check-in

• have documentation needed to organize an appeal

When is a clinical validation denial most likely to occur?

• when the coded diagnosis lacks clinical evidence

• when the service is not covered under Medicare

• when eligibility assessment is not performed

• when service referrals are missing

What is one of the goals of establishing a denials management program within a facility?

• recovering denied payments

• increasing revenue

• identifying trends in coding procedures

• conducting root cause analysis

When conducting a root cause analysis, why is it important to consider what happened and why it happened?

• to determine where the problem started

• to determine the consequence is no corrective action is taken

• to track all claim denials by department, physician, and steps in coding

• to track all proof that makes you entitled to payment

How can a denials management program use the information provided by data tracking?

• to correct trends through education

• to organize denials by department

• to collect and record information

• to prove the appeal is based on the payer's misinterpretation

If you believe the payer made an error when denying a claim, how can you crease a compelling appeal?

• provide proof you are entitled to the payment

• following the billing department's procedures for appeals

• show the service met the required terms of the patient's plan

• use a template with no additional information

What should an administrative appeal focus on?

• the physician's intent to admit the patient

• documentation that supports the DRG that was billed

• circumstances that led to a hospital admission

• new medications and treatments provided after discharge

How can a provider get payment for a claim denied because of a coding issue without filing an appeal?

• refile within 30 days with a corrected code

• have the billing department utilize software for submission

• communicate the error to the payer

• follow the payer's guidelines on claims