Scenario Based Quiz - Primary Paid More Than Secondary Allowed Amount

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1. When does a CPT get denied for denial 23?




2. If you receive the status on call as the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has paid less than the secondary allowed amount then what will be your next valid questions?




3. If the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has already paid more than the secondary allowed amount then what will be your action?




4. If the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has paid less than the secondary allowed amount and the rep agrees to send the claim back for reprocessing then what will be your action?




5. If a CPT with a billed amount of $100.00 is denied by primary insurance for denial 23 then what will be your action?




6. If a CPT with a billed amount of $150.00 is allowed by primary insurance for $40.00, paid for $30.00 and patient responsibility is $10.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $35.00 then how much amount will be paid by secondary insurance?




7. If a CPT with a billed amount of $200.00 is allowed by primary insurance for $60.00, paid for $45.00 and patient responsibility is $15.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $60.00 then how much amount will be paid by secondary insurance?




8. If a CPT with a billed amount of $250.00 is allowed by primary insurance for $80.00, paid for $64.00 and patient responsibility is $16.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $64.00 then how much amount will be paid by secondary insurance?




9. If a CPT with a billed amount of $130.00 is allowed by primary insurance for $35.00, paid for $0.00 and patient responsibility is $35.00 as Deductible. For secondary insurance, the allowed amount for the same CPT is $35.00 then how much amount will be paid by secondary insurance?




10. If a CPT with a billed amount of $170.00 is allowed by primary insurance for $50.00, paid for $20.00 and patient responsibility is $30.00 (Deductible - $20.00 and Coinsurance - $10.00). For secondary insurance, the allowed amount for the same CPT is $20.00 then how much amount will be paid by secondary insurance?








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Modifier Based Quiz - Part 2

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1. When an operating physician plans to perform a surgical procedure alone but during an operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time then which modifer is used by the assistant surgeon to report the surgical procedure?




2. When a service is performed repeatedly on the same day by different physicians then which modifier is used with repeated service to get it reimbursed?




3. When an assistant at surgery services is provided by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) then which is used by the assistant surgeon to report the service?




4. When 2 distinct services are performed on the same day and both are independent of each other & performed on 2 different body parts then which modifier is used to indicate both these services are distinct and separate procedures?




5. When an assistant surgeon assists a primary surgeon and is present for the entire operation or a substantial portion of the operation then which modifier is used by the assisting physician to report the surgical procedure as the operating surgeon?




6. When surgery is performed on a patient and during the postoperative period, an E/M service is performed that is not related and included in the surgery then which modifier is used with the E/M code to bill it separately?




7. When a physician does not perform the service completely & reduces or cancels it before completion then which modifier is used to identify the service is reduced?




8. When a service is performed repeatedly on the same day by the same physician then which modifier is used with repeated service to get it reimbursed?




9. When an assistant at surgery service is provided by an MD since there is not a qualified resident available then which is used by the assistant surgeon to report the service?




10. When a physician needs to perform major surgery and an E/M service is given on the same day or a day before the surgery then which modifier is used to reimburse E/M service?








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Scenario Based Quiz - Patient Enrolled in Hospice

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1. What are the correct hospice eligibility criteria from the below options?




2. When does a physician service get billed to hospice insurance?




3. When do we use the modifier 'GV'?




4. When do we use the modifier 'GW'?




5. What could be the valid reasons for the claim to be denied for denial code - B9?




6. If you receive the status on call as the claim is denied as the patient enrolled in a hospice and the DOS does not lie between the hospice enrollment period then what will be your next valid questions?




7. If you receive the status on call as the claim is denied as the patient enrolled in a hospice and the DOS lies between the hospice enrollment period then what will be your next valid question?




8. If the claim is denied as the patient enrolled in a hospice and the DOS does not lie between the hospice enrollment period and the rep agrees to send the claim back for reprocessing then what will be your action?




9. If the claim is denied as the patient enrolled in a hospice and the DOS lies between the hospice enrollment period and the rep provides the hospice information then what will be your action?




10. If the claim is denied as the patient enrolled in a hospice and the DOS lies between the hospice enrollment period but the rep did not provide any information about hospice and there is no detail of Medicare available then what will be your action?








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Modifier Based Quiz - Part 1

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1. When a physician performs surgery and prior to performing surgery gives general anesthesia then which modifier is used with the surgery code to include anesthesia under surgery?




2. When a service along with an E/M service are performed on the same day by the same physician or other qualified health care professional then which modifier is used with the E/M code to reimburse separately?




3. When the same services are performed on both sides of the body (left & right) during the same operative sessions or on the same day then which modifier is used to bill the services together on a single line?




4. When a physician performs a surgical procedure and needs to perform additional work which is significantly greater than the usual requirement due to complications & medical emergencies then which modifier is used with the surgical procedure to report the additional work?




5. Which modifier is used to bill the professional component of a service?




6. When a physician discontinues performing a service due to risk to the patient or due to equipment failure then which modifier is used to identify the service is discontinued?




7. When a service requires local anesthesia but due to unusual circumstances & complications the physician gives general anesthesia to perform the service then which modifier is used with anesthesia service?




8. Which modifier is used to bill the technical component of a service?




9. When a physician performs multiple surgical services at the same session and the second procedure is not a component code of the first procedure then which modifier is used to bill secondary service?




10. When surgery is performed on a patient and during the postoperative period, an E/M service is performed which is not related and included in the surgery then which modifier is used with the E/M code to bill it separately?








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150: Payer deems the information submitted does not support this level of service

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Denial Occurrences:
  • This denial can occur mostly for 3 reasons,
               1. CPT has reached the maximum allowance for a specific time period.
               2. Medically not necessity / Coding issue.
               3. Medical Records Requested.
  • Always check the remark code when working on this denial. Sometimes, the remark code provides the correct reason for denial.
On Call Scenario:
                                                
                                                Claim denied as payers deems the information
                                               submitted does not support this level of service
                                                                                 ↓
                                                             May I know the exact issue?
                                                   ↙                           ↓                             ↘
               CPT has reached the                Medically not necessity /           Medical records
           maximum allowance for                   Coding issue                              requested
            a specific time period                                 ↓                                             ↓  
                            ↓                                         Click Here                             Click Here
                   Click Here

Important Notes:
  • Click on the link to follow a specific scenario.
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Scenario Based Quiz - Globally Inclusive to Surgery/Globally Inclusive

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1. What is the Pre-operative period?




2. What is the Intra-operative period?




3. What is the Post-operative period?




4. If you receive the status on call as the claim is denied for globally inclusive to main surgery and the DOS lies between the global period then what will be your next questions?




5. If you receive the status on call as the claim is denied for globally inclusive to main surgery and the DOS does not lie between the global period then what will be your next questions?




6. If the claim is denied for globally inclusive to main surgery and the DOS lies between the global period then what will be your action?




7. If the claim is denied for globally inclusive to main surgery and the DOS does not lie between the global period and rep agrees to send the claim back for reprocessing then what will be your action?




8. If a service with DOS - 10/19/2023 is denied for globally inclusive to main surgery and the main surgery was performed on 07/20/2023 and the global period is 90 days then Is this service denied correctly?


9. If a service with DOS - 10/01/2023 is denied for globally inclusive to main surgery and the main surgery was performed on 07/28/2023 and the global period is 60 days then Is this service denied correctly?


10. If a service with DOS - 11/16/2023 is denied for globally inclusive to main surgery and the main surgery was performed on 08/19/2023 and the global period is 90 days then Is this service denied correctly?






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Scenario Based Quiz - Non Covered Charges as Provider is Out of Network

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1. What could be the possible reason for the claim to be denied for denial code - 242?




2. Do PPO & POS plans cover out-of-netowrk benefit?


3. Do HMO & EPO plans cover out-of-netowrk benefit?


4. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network then what will be your next valid question?




5. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network and the rep confirms the patient plan as HMO then what will be your next valid questions?




6. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network and the rep confirms the patient plan as PPO then what will be your next valid questions?




7. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as POS and agrees to send the claim back for reprocessing then what will be your action?




8. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as HMO then what will be your action?




9. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as EPO and there is secondary insurance available then what will be your action?




10. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as HMO and there is no secondary insurance available then what will be your action?








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