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A payer publishes a Local Coverage Determination (LCD) stating that it will only cover a specific laboratory test when the patient has one of five listed diagnosis codes. A provider orders the test for a patient whose diagnosis is not on the LCD list. The billing specialist knows the test will be denied. What is the most appropriate action?

A provider performs a procedure that is not described by any existing CPT code. What should the billing specialist do?

A provider orders a series of physical therapy sessions for a patient recovering from knee surgery. The insurance company approves 12 sessions. After 12 sessions, the provider determines that the patient needs 6 additional sessions. What must the billing specialist do before scheduling the additional sessions?

A billing specialist learns that a commercial payer has retroactively reduced its reimbursement rates for a series of services that the practice already billed and received payment for during the prior quarter. The payer is now requesting refunds for the overpayment based on the new rates. What should the specialist review first?

A medical equipment supplier offers a physician a free vacation in exchange for referring patients to the supplier for durable medical equipment. The billing specialist learns about this arrangement. Which federal law does this arrangement most clearly violate?

A physician asks a coder to change a diagnosis code to one that is ‘more likely to be covered’ by the patient’s insurance, even though the medical record does not support that diagnosis. What should the coder do?

A practice notices that claims submitted to a particular payer are consistently denied for ‘timely filing.’ The claims are being submitted within 30 days of the date of service. Upon investigation, the billing specialist discovers the payer’s contract specifies a 90-day filing limit. What is the most likely cause of these denials?

After posting payments from the primary insurance, the billing specialist identifies a remaining balance that the patient’s secondary insurance should cover. What is the next step?

A billing specialist is preparing a claim for a patient who received services at two different locations on the same day from the same provider group. How should the specialist handle the place of service codes on the claim?

A patient’s credit card is declined when the billing specialist attempts to process a $35 copay. The patient has no other form of payment. What is the most appropriate action?

A patient has a high-deductible health plan (HDHP) with a $3,000 annual deductible. It is February, and the patient has paid $200 toward their deductible so far this year. The patient presents for an office visit with an allowed amount of $175. How much is the patient responsible for?

A managed care organization pays a primary care physician a fixed monthly fee for each enrolled patient regardless of whether the patient receives services. What is this payment model called?

A billing specialist reviews the practice’s charge lag report and notices that charges for services rendered on Fridays are consistently not entered into the system until the following Wednesday, a delay of five days. What is the most significant risk of this pattern?

A practice’s charge entry error rate has been increasing over the past several months. The billing manager conducts an analysis and finds that most errors involve incorrect procedure code selection. Which intervention would most effectively reduce the error rate?

A patient with known hypertension presents for a routine office visit. During the visit, the provider also evaluates the patient for a new complaint of lower back pain. How should the billing specialist assign the diagnosis codes?

After posting payments from a remittance advice, the billing specialist discovers that three claims were paid below the contracted rate. What is the appropriate next step?