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Coding Alignment Sentry Rules
Queue Overview
Routing for Out of State Bills
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Coding Alignment Sentry Rules Continued
100

If x7093 flags on your RVU bill what is it directing you to do?

  • Treatment billed was rendered by the provider
  • Number of units billed is appropriate for total time documented in the records  
100

When moving bills to additional verification, which endnotes should be removed?

Verify any flagging ENs are removed 

Example: x369, x2066, C6136, ETC

100

If the rendering provider state is an Out of State Provider and the patients residence is New York which queue should the bill route to?

Audit

100

True or False: Ambulance codes A0425, A0427, and A0429 need documentation to allow payment.

False, Ambulance bills do not require medical records

100

In Chiropractic manipulation, there are 5 spinal regions that can be manipulated, as well as extra spinal areas. What are those 5 regions?

  • Cervical
  • Thoracic
  • Lumbar
  • Sacral
  • Pelvic (including sacroiliac joint)
200

When processing a high level E&M bill x7081 flags. Which program should be used to review?

Codify

200

When working in the duplicate queue, what should you do when you receive a response to a claim level/MCR delay?

  • Enter claim note of what was received and EFF scan date and time where documentation can be found in claim system
  • Send diary to MCR to see note
  • Commit duplicate bill out of scope
200

If the rendering provider state is a Pennsylvania provider and the patients residence is Pennsylvania which queue should the bill route to?

Ready for Coding


200

What are the 3 steps you should follow for any line that requires a denial or other coding adjustment?

1- Update the correct amount allowed.

2- Remove the system endnotes.

3- Apply the appropriate coding endnotes.

200

What endnote will flag for anesthesia bills?

X5624 Manual review needed for anesthesia time

300

When processing acupuncture bills, how many initial treatment codes should be billed per date of service?

1

300

When processing a bill in the IME/Peer Denial Review queue what should you do if the bill is in a specialty covered by the IME and some, but not all, DOS are being denied per the IME?

  • Apply appropriate endnote to denied lines 
  • Note in Description box which lines are denied for IME 
  • Remove overrides for any payable lines 
  • Check IME N/A box
  • Revise and Analyze
  • Process bill if it routes to a Coding queue
300

If the rendering provider state is an Out of State provider and the patients residence is any other state which queue should the bill route to?

Coding 3

300

When the medical records are needed and the medical records UDF is checked in error what should you do?

  • Verify no documents in the envelope.
  • Remove system overrides.
  • Uncheck the Medical Records user defined field (UDF).
  • Do not check the Review Complete UDF.
  • Revise/analyze.

    • System will auto populate endnote x303.
  • Place the bill in the Additional Verification Bill Status Reason.
  • Click Save.
300

What should you do if your bill flags with X2? (Before Date of Loss)

  • Review bill image and confirm the date of service is before the date of loss
  • Correct date in MDP if necessary 
  • If before date of loss and bill not reviewed by the Medical Claims Rep (MCR)
  • Send to MCR Review
400

What endnote may flag indicating the provider may have billed for the same procedure multiple times during the same visit?

BONUS (100 PTS): What endnote should be used if denying?

X99

  • X4212: Procedure once per date of service (DOS).
400

When working the No Tax ID queue what should you do once the TIN is updated?

  • Remove all overrides
  • Revise and Analyze
  • Save bill once moved by the system
400

If the rendering provider state is a Florida provider and the patients residence is Florida which queue should the bill route to?

Incomplete

400

True or False: RX Drug Codes, Ambulance Codes, Low-Level ER Evaluation and Management Codes, and Electrical Stimulation Supply Codes do not require medical records.

True. Codes J0000, J3490, National Drug Codes, A0425, A0427, A0429, 99281, 99282, A4245, A4557, and A4558 do not not require medical records.

400

What queue should all codes that receive BR endnotes route to? (x42 By Report, x5726 BRRVU, x5727 BR Time)

Coding 3

500

Any CPT in which Allowed Amount is greater than or equal to $150 per unit is considered which sentry rule and what is the endnote that flags?

High-Dollar Charge

X7107 

500

When working the approved for payment queue how can we verify if the bill should be in the AFP queue before processing?

If bill line overrides are checked and/or the Rvw Complete box is checked, bill may need moved.

500

If the rendering provider state is a New Jersey provider and the patients residence is New Jersey which queue should the bill route to?

Out of State

500

What are the 5 steps for any line that can be paid with system pricing?

1- Remove the override.

2- Check Rvw Complete.

3- Revise and analyze.

4- Click Save.

5- If a send to Provider Network appears:

  • Click Now. Otherwise, Submit the bill.
500

Which queue will non specific radiology bills route to? (x6415)

Coding 2