Question

when billing a centers for medicare and medicaid services (cms) program, what will happen to a claim if the most specific code available is not used?

multiple choice

claim will be paid with a 10 percent penalty.
claim will not be processed.
claim will be rejected.
claim will be paid at a lower rate.

Explanation:

Analyze CMS coding requirements

Under Centers for Medicare & Medicaid Services (CMS) guidelines, medical claims must be coded to the highest level of specificity available. This is a core requirement of Coding Specificity. If a claim is submitted with an incomplete or non-specific code when a more specific code is available, it does not meet HIPAA standards or CMS billing requirements.

Determine the outcome of a non-specific claim

When a claim lacks the required level of specificity, CMS and other payers cannot accurately determine the medical necessity or the exact nature of the service or diagnosis. Consequently, the claim is not merely paid at a lower rate or penalized; rather, the system cannot process it as a valid claim. Therefore, the Medicare Claim Rejection protocol is triggered, and the claim will be rejected. The provider must correct the code to the highest level of specificity and resubmit the claim.

Answer:

• (A) Claim will be paid with a 10 percent penalty.
• (B) Claim will not be processed.
• (C) Claim will be rejected. (Correct answer)
• (D) Claim will be paid at a lower rate.