Question

multiple choice question

centers for medicare and medicaid services (cms) rules state that a medicare claim will be ______ when the most specific code available is not used.

accepted
rejected
pending
delayed

Explanation:

Analyze the question prompt

The question asks about the Centers for Medicare and Medicaid Services (CMS) rules regarding Medicare claims when the most specific code available is not used.

Apply CMS and coding guidelines

Using the CMS Role and ICD-10 Coding Guidelines knowledge points:

• Under HIPAA and CMS guidelines, medical coding requires reporting diagnoses and procedures to the highest level of specificity.
• If a claim is submitted with an incomplete, truncated, or non-specific code when a more specific code is available, the claim does not meet billing requirements.
• Consequently, CMS rules dictate that such a claim will be rejected (or returned as unprocessable) rather than accepted, pended, or merely delayed.

Evaluate the given options

• accepted: Incorrect, as non-specific codes violate coding standards.
• rejected: Correct, because claims lacking maximum specificity are rejected by the payer.
• pending: Incorrect, as claims are not held in suspense for lack of basic coding specificity.
• delayed: Incorrect, although a rejection causes a delay in payment, the official action taken on the claim itself is a rejection.

Answer:

• accepted
• rejected (Correct answer)
• pending
• delayed