Chapter 29 — Exercises

How to use these. Section D is the chapter. The integrated triage is ninety seconds of work that decides whether the next hour is worth spending, and a student who can run it cold is more useful on their first day than one who has memorized reason codes.

Section G is where most practices get their own performance wrong. Work it carefully, especially the denominator questions — they are not pedantry.

And Section I should be attempted before reading §29.10. Everything you need is in Chapters 14, 20, 21, and 28.

Section A — Denial versus rejection (items 1–7)

A.1 Define a denial. Define a rejection.

A.2 Which has appeal rights? Which stopped the timely filing clock?

A.3 How is each corrected and resubmitted, and what happens if you swap the two methods?

A.4 Where does each one arrive? Name the document.

A.5 Describe the structural failure of a denial queue fed only by remittances. Which earlier case study is fourteen months of it?

A.6 State the one-line fix in a job description.

A.7 Why do denials and rejections not compete for the same hour? What does that imply about scheduling the work?

Section B — The taxonomy (items 8–17)

B.8 Name the seven categories and the owner of each.

B.9 How many of the seven are not the coder's? Which two are typically largest by volume?

B.10 Which category is a liar, and what does it usually mean?

B.11 How does an eligibility denial usually present? What is the tell?

B.12 An authorization exists and the service still denies. What is the likely problem, and which chapter named it?

B.13 Coding denials split three ways. Name them and say why §29.4 keeps them apart.

B.14 What is distinctive about the documentation family?

B.15 For each, give the category, the owner, and whether it is winnable: CO-29 · CO-197 · PR-204 · CO-18 · CO-16 with an invalid rendering provider identifier · CO-50.

B.16 Which of the six in B.15 is worth an argument on the merits? Which belongs to a different department entirely?

B.17 Before closing a CO-29, what one question should you ask? (Chapter 27)

Section C — Hard, soft, preventable (items 18–25)

C.18 What does hard versus soft describe? What does preventable versus not describe?

C.19 Draw the two-by-two and populate each cell with an example.

C.20 Which quadrant is the expensive one, and why?

C.21 Give two examples of soft-and-preventable and two of hard-and-preventable.

C.22 Does "preventable" mean somebody was careless? Explain, and say what the alternative framing is.

C.23 What turns a soft denial into a hard one? What follows for queue design?

C.24 Give an example of a denial that is preventable and was correctly handled at every step.

C.25 Why is misreading "preventable" as "somebody erred" the largest cause of under-reported prevention data?

Section D — Root cause and the integrated triage (items 26–38)

D.26 Distinguish the remedy from the root cause.

D.27 A claim denies for a missing modifier and the biller adds it. What does a typical system record? What is wrong with that?

D.28 Name the five possible root causes of a missing-modifier denial. Which chapter owns each?

D.29 (Chapter 20) Give the four reasons a valid code does not pay. Which is the only arguable one?

D.30 (Chapter 21) Give the six-way edit triage. How many branches say do not appeal?

D.31 (Chapter 22) Give the two-way necessity test.

D.32 State the order in which the three frameworks are applied. Roughly how long does the whole triage take?

D.33 What is the triage's value? (It is not that it wins appeals.)

D.34 Give the fifteen-item root-cause category list.

D.35 Why must the list have no catch-all "other"?

D.36 Why is "credentialing" a separate category? What happens to a credentialing denial routed to a biller?

D.37 Why must "payer error" be available as a category? Which chapter's findings depend on it?

D.38 (Chapter 26) What is the chargemaster root cause, and why does the denial not name it?

Section E — Working the queue (items 39–48)

E.39 Give the three sort keys in order.

E.40 Why is deadline first? Give the comparison that makes it obvious.

E.41 Why is category second? What are twelve denials of one kind?

E.42 State the rule for denials with no appeal rights, and name the RARC that says so explicitly.

E.43 Give the six steps of working a single denial.

E.44 Why does classification come before the decision?

E.45 (Chapter 21) What should you do if the pattern is larger than this claim, and how should it be reported?

E.46 State the four questions that find a queue in trouble.

E.47 A queue reports "closed last month: 138, of which resolved: 49, of which no action: 0." Name two findings.

E.48 A queue is sorted descending by charge and its oldest item is 287 days old. Are these two facts related? Explain.

Section F — Corrected claims (items 49–55)

F.49 Give the professional and institutional mechanisms for a replacement and for a void.

F.50 What does each form produce if you get it wrong? Why is it the same failure twice?

F.51 When do you replace and when do you void? Give an example of each.

F.52 What do you need from the remittance to submit a corrected claim?

F.53 Distinguish a corrected claim from an appeal in one sentence each.

F.54 What can go wrong if you submit a corrected claim when you meant to appeal?

F.55 For each, say appeal / correct and resubmit / void / close / escalate, and give the root cause: units double the documented dose · CO-97 with N19 on a documented separately identifiable service · no prior authorization on a completed service · duplicate with no internal match · RARC MA130 · rendering provider not enrolled.

Section G — The denial log and the numbers (items 56–68)

G.56 List the fields a denial log row needs.

G.57 Which two fields do practices leave out, and why do they matter most?

G.58 Define: denial rate · initial denial rate · first-pass resolution rate · overturn rate · preventable denial rate.

G.59 (Chapter 21) Why measure denials resolved rather than denials worked? When are the two numbers identical, and why is that exactly where to look?

G.60 (Chapter 21) What does "split categories finely enough to see zero" mean? What does an averaged overturn rate conceal?

G.61 (Chapter 27) Why must the rejection rate sit beside the denial rate? What happened in the case study that lacked one?

G.62 (Chapter 28) What does the preventable administrative write-off count give you, and which section made it possible?

G.63 State the three denominator choices, and give an example of how each changes the number.

G.64 Account 10-4471 has one denied line of four on one claim. Give the denial rate by claim and by line.

G.65 Why can counting only zero-pay lines understate denials?

G.66 State the three rules that make a denial rate usable.

G.67 Why is comparing your rate to a published benchmark risky? What does §29.9 recommend instead?

G.68 From Northgate's month: give the denial rate, the two largest root causes and their combined share, the preventable percentage, and the overturn rate. Verify the overturn rate from the counts.

Section H — Prevention and the case for it (items 69–78)

H.69 Name the three places prevention can happen and what each fixes.

H.70 Which one improves the record rather than the claim?

H.71 State the principle "prevent where the information exists." When is a modifier denial not preventable at the edit?

H.72 What must an edit that stops a claim do? What happens if it does not?

H.73 State the economic argument for prevention in one sentence.

H.74 State the line an edit may not cross. Give the wording of an acceptable rule and an unacceptable one for modifier 25.

H.75 (Chapter 21) What did Account 31-2245 cost, and why could eleven defensible claims not be defended?

H.76 Name the five things that work when making the case for prevention.

H.77 Why present a comparison rather than a benchmark? Why ask for a measurement rather than a commitment?

H.78 The answer is no. Name the three responses that are worth something and the one that is not. Why write down what you found and when you reported it?

Section I — The Encounter's CO-97 (items 79–86)

I.79 (Chapter 6) On what day does the denial reach a person?

I.80 Read the three codes on line 1 and state the payer's assertion in a sentence.

I.81 Run branch 1 of the triage. Which of the four reasons does the payer's code place this in, and what would that ordinarily mean?

I.82 Run branch 2. What is the modifier indicator, what does the claim carry, and what does the branch conclude?

I.83 (Chapter 14) Give the four elements supporting modifier 25. Which of them have nothing to do with the knee?

I.84 Give the root cause, the hard/soft classification, and the decision.

I.85 Give the three touches and their minutes. What is the total?

I.86 The log entry says "preventable: yes" on a claim that was correct in every respect and won on appeal. Explain why both are true, and state what a scrubber rule or a documentation template would have changed.