Chapter 26 — Exercises

How to use these. Section C — the type of bill — should be drilled until it is automatic; it is three answers, not a number. Section E's four families are distinguished by shape, and students who learn them by subject matter get them wrong.

Section I is the transferable one. Reading a facility claim in the right order is the actual skill, and it does not start with the codes.

Section A — Why institutions bill differently (items 1–8)

A.1 Give the UB-04's two names.

A.2 What is its electronic equivalent? Its professional counterpart's?

A.3 Which committee maintains it? What does that committee publish, and is it free?

A.4 What are the form's fields called?

A.5 What is a physician selling? What is an institution selling?

A.6 Name the three consequences of that difference for the claim.

A.7 (Chapter 16) How many claims does one facility encounter produce? How many patient balances?

A.8 Name three things a payer needs to know about a stay that do not fit in a procedure code.

Section B — The form locators (items 9–16)

B.9 Name the six blocks and roughly what each covers.

B.10 Which two form locators do the most work? What does each say?

B.11 Which block repeats, and what appears on the final page?

B.12 Distinguish FL 3a from FL 3b.

B.13 What breaks when they are confused? Which chapter's process depends on it?

B.14 Name the three fields that hold diagnoses and the question each answers.

B.15 A claim's FL 67 and FL 69 are always identical across a facility's admissions. What does that suggest?

B.16 What does FL 48 report? Why is omitting a known non-covered charge worse than reporting it?

Section C — Type of bill (items 17–26)

C.17 Read 0131 digit by digit.

C.18 Read 0111.

C.19 What facility type is 2? 3? 7? 8?

C.20 For a hospital, what bill classification is 1? 3?

C.21 What frequency is 1? 7? 8?

C.22 What do frequencies 2, 3, and 4 form? What two rules govern them?

C.23 A facility submits a corrected claim with frequency 1. What has it created?

C.24 (Chapter 25) What is the professional-claim equivalent of that error?

C.25 Give the type of bill for: a hospital outpatient encounter billed complete.

C.26 Give the type of bill for: a void of a hospital inpatient claim.

Section D — Revenue codes (items 27–36)

D.27 What does a revenue code say? What does a HCPCS code say?

D.28 Give the department for 0250, 0270, 0300, 0320, 0450, 0636.

D.29 What is 0001, and where does it appear?

D.30 What do the 011x–021x codes encode besides the department?

D.31 A stay moves from intensive care to a medical/surgical unit. What appears on the claim?

D.32 A patient requests a private room where semi-private was medically sufficient. Where does the differential go?

D.33 State the room-and-board sanity check.

D.34 Why does a drug sometimes belong under 0636 rather than 0250? What does 0636 require?

D.35 A chest radiograph is performed on a patient who arrived through the emergency department. Which revenue code, and why?

D.36 Where does a facility's revenue-code-to-HCPCS pairing actually live? Name three failures that arrive as claim denials and are really maintenance problems.

Section E — Circumstance codes (items 37–44)

E.37 Name the four families and what each reports.

E.38 State the one-word distinction for each: fact, date, range, amount.

E.39 Why does the professional claim have nothing like these?

E.40 Sort into families: a date of injury · four covered days · a qualifying stay from March 2 to March 5 · an inpatient admission changed to outpatient before discharge · a patient's Part A deductible amount.

E.41 Which item in E.40 do students most often misplace, and why?

E.42 (Chapter 16) What is Condition Code 44, and which family is it?

E.43 (Chapter 16) A skilled nursing claim needs the dates of a qualifying inpatient stay. Which family, and why does the field matter?

E.44 Name the four departments that contribute to a facility claim's circumstance codes.

Section F — Discharge status and providers (items 45–54)

F.45 What does FL 17 report?

F.46 Give the status for: discharged home · transferred to a short-term general hospital · transferred to a skilled nursing facility · left against medical advice · expired · still a patient.

F.47 State the transfer rule.

F.48 Name both directions of getting FL 17 wrong and their payment consequences.

F.49 Why is a status of 30 on a non-interim claim a problem? Which other field does it have to agree with?

F.50 Name three patterns reviewers look for in discharge status.

F.51 What is the remedy, and who can run it?

F.52 Name the four provider fields and what each is for.

F.53 Which is conditionally required, and on what condition?

F.54 Which of the four is the billing provider? Explain your answer.

Section G — Dates and windows (items 55–60)

G.55 What does FL 6 report? State its three rules.

G.56 An interim first claim runs through March 10 and a continuing claim starts March 10. What is wrong?

G.57 State the three-day payment window.

G.58 How long is the window for certain excluded facilities?

G.59 How are diagnostic and non-diagnostic services treated differently in the window?

G.60 A facility disputes a recoupment on the ground that the outpatient claim was correct. Evaluate that argument.

Section H — The Encounter as a facility claim (items 61–66)

H.61 (Chapter 23) Northgate is acquired and converted to a provider-based department. What changes about the professional claim?

H.62 What appears that did not exist before? Give the type of bill.

H.63 Give the three revenue code lines and what each carries.

H.64 What is the principal diagnosis on the facility claim, and why?

H.65 Professional allowed falls from \$216.28 to \$148.60 and a facility claim of \$212.40 appears. Compute the total and the patient's share, and give both as multiples of the independent case.

H.66 State what the counterfactual is for — and what it is not an argument about.

Section I — Reading a claim (items 67–72)

I.67 State the six-step reading order. What comes last, and why?

I.68 Name the three things wrong more often than the codes.

I.69 A claim's FL 3a holds a number that is the same on all of this patient's claims. What is wrong?

I.70 FL 17 says 01. FL 80 says "transferred to Community Rehab." Name the error, the correct value, and the payment direction.

I.71 A pharmacy line carries a large charge and no HCPCS. What should be checked?

I.72 An eight-day admission has I10 as the principal diagnosis and J44.1 secondary. Evaluate, and name the chapter that governs.