Chapter 25 — Exercises

How to use these. This chapter rewards drill. Section B and Section E should be done from memory after one read, because item numbers are a vocabulary and vocabulary is memorized, not reasoned.

Section H is the one that transfers. Reading a claim you did not build is the actual job, and the instinct it corrects — check the codes first — is the instinct almost everyone has.

Section A — What the form is (items 1–8)

A.1 What is the CMS-1500 for? What is its electronic equivalent?

A.2 Who maintains it? What free document do they publish?

A.3 Almost nobody submits paper. Give two reasons to learn the form anyway.

A.4 A rejection message names an item. A different one names a loop. What is each describing?

A.5 Why is a paper claim printed in red ink?

A.6 Name four things that may not appear on a paper claim, and say what they have in common.

A.7 What does the scanner explain about the form's shape? Name two design features it accounts for.

A.8 The form has a version date printed on it. Why does that matter?

Section B — Items 1–13 (items 9–18)

State the item number for each:

B.9 The insured's ID number.

B.10 The patient's name.

B.11 The insured's name.

B.12 The patient's relationship to the insured.

B.13 Whether the condition is related to employment or an accident.

B.14 The other insured's name.

B.15 Whether there is another health benefit plan.

B.16 A child is covered on a parent's policy. What goes in item 2, item 4, and item 6?

B.17 "Signature on file" appears in items 12 and 13. What does it assert? Name three other fields in this book that make the same kind of assertion.

B.18 Items 9a–9d are blank. Name the two possible reasons, and say why the distinction matters.

Section C — Items 14–23 (items 19–28)

State the item number for each:

C.19 The referring provider's NPI.

C.20 The diagnosis codes.

C.21 Additional claim information — the narrative field.

C.22 The resubmission code and original reference number.

C.23 The prior authorization number.

C.24 Outside lab charges.

C.25 Item 14 carries a date. What else must it carry, and why?

C.26 How many diagnoses fit in item 21? How are they labeled? What else is in that item?

C.27 A claim is resubmitted to correct an error and item 22 is left blank. What has the practice created?

C.28 Item 23 has two possible contents. Name both and say what determines which applies.

Section D — Item 24 (items 29–38)

State the column letter for each:

D.29 The place of service.

D.30 The procedure code and modifiers.

D.31 The diagnosis pointer.

D.32 The charge.

D.33 The units.

D.34 The rendering provider's identifier.

D.35 How many service lines does the form have? What happens when a claim needs more?

D.36 How many modifiers fit on a line? What do you do when you need five?

D.37 What goes in 24F — the charge, the allowed amount, or the expected payment? (Chapter 23) Why does the answer matter?

D.38 What is in the shaded area of a service line? Name three things that land there.

Section E — Pointers (items 39–46)

E.39 How many diagnoses in item 21? How many pointers per line? Why is the asymmetry a problem?

E.40 Letters or numbers? Which version uses which?

E.41 State the four pointer rules.

E.42 A supporting diagnosis is on the claim but is not pointed at the line. What happens? (Chapter 22)

E.43 Item 21 reads A = J44.1 (COPD with exacerbation), B = I10, C = E11.9. Point an office visit, a spirometry, and a venipuncture drawn for an A1c.

E.44 In E.43, a coder points all three lines at A B C. Name what is wrong with it, and say why "it denies" is not the primary objection.

E.45 Account 10-4471's line 4 is 36415 pointing at B. Explain.

E.46 State the rule for deciding whether to point a line at a diagnosis, in one sentence.

Section F — Providers and identifiers (items 47–56)

F.47 Name the three provider identities on the form and their items.

F.48 Which one is a person? Which one gets paid?

F.49 When is item 32 required?

F.50 Distinguish a Type 1 from a Type 2 NPI.

F.51 A solo physician practicing as a professional corporation may have both. Which goes where?

F.52 What does an NPI prove? Name three things it does not.

F.53 What is a taxonomy code for? (Chapters 15 and 16) Name two tests that turn on it.

F.54 (Chapter 15) An incident-to claim qualifies. Whose NPI goes in 24J, and at what percentage is it paid?

F.55 The same field on a claim that does not qualify. What has the claim asserted, and what kind of error is it?

F.56 What does item 27 report? When is it a fact, and when is it a decision?

Section G — Rejections (items 57–62)

G.57 Distinguish a rejection from a denial. (Chapters 27 and 29)

G.58 Name the seven rejection causes.

G.59 How many of the seven are front-end fields? What does that tell you?

G.60 A claim rejects for item 17b. Name the four possible causes and say which one the billing office cannot fix.

G.61 What is a companion guide? What does it settle that the NUCC manual does not?

G.62 Name the two other payer-published documents this book has told you to read, and the chapters.

Section H — Read a claim you did not build (items 63–68)

Use §25.9's 📋 Read the Chart. For each, name the item and what is wrong.

H.63 Item 4 is blank and item 11d says "yes."

H.64 Item 17 contains the name of the physician who performed the service.

H.65 Line 1 has place of service 22; item 32 is blank.

H.66 A therapy line carries 2 units.

H.67 Item 27 says "no" on a claim from a contracted group.

H.68 A coder reviews this claim by checking items 21 and 24D only. What will they find, and what will they miss? State the general lesson.

Section I — The Encounter (items 69–72)

I.69 Build item 21 for Account 10-4471. Give the four codes, their letters, and the ICD indicator.

I.70 Give the pointers for all four service lines and justify each in one sentence.

I.71 Item 17 is blank, item 20 says "no," and item 29 says \$30.00. Explain each.

I.72 Name three things correctly absent from this claim and the chapter that decided each.