Question 1

A 76-year-old woman visited her dermatologist's office in response to a large suspicious nevus on her back. The dermatologist excised the nevus and sent it to the pathology lab for examination. The patient experienced pain excision site, due to its large size and was prescribed pain medication. What two part of Medicare insurance will the patient need to pay for the dermatologist's office visit and the prescription charges?

A)Medicare Parts A and B
B)Medicare Parts B and C
C)Medicare Parts B and D
D)Medicare Parts D and E

Medicare Parts B and D

Accepted Answer

The two parts of Medicare insurance that the patient will need to have to pay for the charges are: Medicare Parts B and D. Medicare Part B covers outpatient office visits, which in this case, would cover the dermatologist's office visit charges, while Medicare Part D covers pharmacy or prescription charges, which in this case, would cover the patient's pain medication charges. Medicare Part A only covers inpatient services, such as inpatient hospital or hospice services, while Medicare Part C is a combination program that combines Medicare A and B services.

Question 2

Larry works at a cola bottling company and as one of his job duties, he is required to lift heavy boxes of syrup onto pallets. He is also required, by the safety department, to wear a back brace and hernia belt. Larry was lifting a large box of syrup on to a pallet when he suffered a severe abdominal hernia. Will worker's compensation insurance cover his medical costs?

A)Yes
B)No
C)Only if he was wearing the back brace and hernia belt while he was lifting the box
D)Only if he was clocked in and lifting the box as one of his job duties

Only if he was wearing the back brace and hernia belt while he was lifting the box

Accepted Answer

Worker's compensation insurance will only cover his medical costs if Larry was wearing the back brace and hernia belt as he was lifting the box because that is one of his safety requirements. The safety requirement states that Larry must wear the proper safety equipment when performing his job duties. If he is injured while not wearing the proper safety equipment, then worker's compensation insurance is not liable for his injury .

Question 3

A physician performs a rhinoplasty on a 2-year-old male with nasal breathing problems. The child was born with a congenital cleft lip and palate with nasal deformity. The cleft and partial deformity was repaired when the boy was an infant, but the breathing problems have persisted, and are a direct result of the congenital nasal deformity. Now that the child can withstand a more intensive procedure, the surgeon performs the rhinoplasty to complete the correction of the deformity. What will likely happen with the processing of this claim, as long as they receive documentation of the procedure's medical necessity?

A)Insurance will deny the claim as a cosmetic procedure
B)Insurance will pay for the claim as medically necessary
C)Insurance will initially deny the claim as medically necessary and then pay for the cosmetic procedure
D)Insurance will not process the claim

Insurance will pay for the claim as medically necessary

Accepted Answer

During the processing of the claim, insurance will likely pay for the claim as medically necessary. Even though it is a rhinoplasty, which can be done as a cosmetic procedure, in this case it is considered medically necessary due to the fact that the child is experiencing breathing problems from the congenital deformity and needs a rhinoplasty to correct the problem. If the procedure was purely for cosmetic reasons (if the patient wanted simply to change the shape of his nose), then insurance would not pay for it, as it would not be medically necessary.

Question 4

What are the correct steps to coding for the best payment outcome?&#10;A)Identify the reason for the encounter based on what the physician documented as the diagnosis without reviewing the medical record. Find the diagnosis in the Tabular List and choose the code with the highest specificity. Assign the code and submit to insurance.&#10;B)Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Tabular List, confirm it in the Alphabetic Index, assign the code without regard to the specificity and submit to insurance.&#10;C)Identify the reason for the encounter based on the diagnosed reason and confirmation within the medical record. Find the diagnosis in the Alphabetic Index, review entries for modifiers, choose the best code and locate it in the Tabular List, then determine whether the code is the highest level of specificity. If so, assign that code to the encounter. Sequencing is very important, so review this prior to final billing submission.&#10;D)Identify the reason for the encounter based on what the physician documented as the diagnosis after reviewing the medical record. Find the diagnosis in the Alphabetic Index, find it in the Tabular List, and use the first code available without regard to modifiers or specificity.

Accepted Answer

The proper way to code is to identify the reason for the encounter using the documentation for support. Then to consult the Alphabetic Index, review stipulations for modifiers, and confirm with the Tabular List. Using the Tabular List, specificity can be coded at its highest level, based on documentation. Assign the code, making sure that the sequence is correct before submitting to the insurances.
Always remember to consult the Alphabetic List, reading all options, cross references, abbreviations, and/or modifiers before moving onto the Tabular List. The Tabular List will allow the highest specificity by referring to the number of characters required in the code and prompting this change before sequencing and submitting to the insurance company for payment.

Question 5

What are Medically Unlikely Edits (MUEs)?&#10;A)Units of service edits created by CMS to lower the Medicare Fee-For-Service paid claims error rate&#10;B)Codes that cannot be reported together because they are mutually exclusive of each other&#10;C)&#34;Add-on&#34; codes that describe a service that can only be reported with another service listed as the primary code&#10;D)Misuse of column two codes with column one codes

Accepted Answer

Medically Unlikely Edits (MUEs) are considered to be units of service edits created by CMS to lower the Medicare Fee-For-Service Paid Claims Error Rate.

Question 6

What does &#34;place of service&#34; reporting refer to?&#10;A)It refers to the location of the billing department, whether in a hospital or physician's office or independent.&#10;B)It refers to the primary location of the provider seeing the patient. If the provider is an outpatient physician, but sees the patient inside the hospital, then the place of service is the outpatient physician's office.&#10;C)Only services in the hospital or in the providers' office are considered &#34;place of service&#34; for reporting purposes.&#10;D)It refers to the location of the setting in which the patient is treated.

Accepted Answer

"Place of service" reporting refers to the location of the setting where the patient is treated or the service is provided.
Evaluation and management codes can be specific to the setting in which the patient is seen. Certain procedures or services may be specific to a setting, such as therapeutic, diagnostic or prophylactic. Facilities may also be specified whether in the hospital, at home, in a physician's office or in a nursing home. Whatever location in which the encounter occurs is the "place of service."

Question 7

What is special about services provided in a patient's home?&#10;A)When services are provided in the home by a physician or provider who is not part of an agency, this is considered &#34;non-facility&#34; services&#10;B)When services are provided by a provider or physician who is part of an agency, such as home health, then the service is considered to be provided within a facility&#10;C)Answers A and B are both correct about in home patient care services&#10;D)None of the above options are correct about patient care within the home

Accepted Answer

Both A and B are correct. Services provided within the home by someone part of an agency are considered facility services. Services provided by a physician or provider who is not part of an agency are not facility services, they are termed "non-facility" services.

Question 8

Only physicians can use place of service reporting in the CPT guidelines.&#10;A)True, only physicians are considered to be able to provide services to patients.&#10;B)False, the words &#34;physician,&#34; &#34;qualified healthcare professional,&#34; or &#34;individual&#34; can all be used and even other entities may report the service.&#10;C)False, the term &#34;physician&#34; encompasses all healthcare providers whether registered nurses, physician assistants or nurse practitioners. These terms leave out physical therapists, speech therapists, occupational therapists and other entities that may provide necessary services for the patient.&#10;D)True, only physicians can provide facility and non-facility services and code for them.

Accepted Answer

The CPT guidelines specify that terms such as "physician," "qualified healthcare professional," and "individual" are not used to exclude, instead it is meant that other entities besides those specific ones can report services too, unless specifically stipulated in a procedural guideline.

Question 9

What is the Federal Anti-Kickback Law and Regulatory Safe Harbors?&#10;A)It protects patients and federal healthcare programs from fraud and abuse by stopping the corrupting influence of money on healthcare decisions. It states that anyone who knowingly and willfully receives or pays anything of value to influence the referral of federal healthcare program business can be held accountable for a felony.&#10;B)It allows physicians to accept money for referrals to certain providers or services for patients within a federal healthcare program.&#10;C)It protects physicians from being charged with a felony if they willfully receive or pay anything of value to influence their medical decisions and best plan of care for the patient.&#10;D)It protects patients, part of federal healthcare programs, from being referred to other providers that aren't in the best interest of the patient.

Accepted Answer

This is a federal law that prevents fraud and abuse from happening when one provider may refer to another specific provider and when that provider would then benefit from anything of value.
Physicians are not allowed to accept money or other payment of value for recruitment or referrals of patients. The law doesn't protect providers from being charged with a felony when this happens; instead it specifies the fines associated with this felony. It doesn't protect patients from being referred out, only from physician's receiving a kickback from the referral.

Question 10

The National Correct Coding Initiative (NCCI) promotes correct coding of healthcare services and prevents payment for incorrectly coded services. There are tables present for these edits to the coding. How often are these edits updated at the Centers for Medicare & Medicaid Services (CMS)?

A)Monthly
B)Quarterly
C)Semi-annually
D)Annually

Accepted Answer

These edits are updated quarterly and can be found on the CMS website.
The NCCI Edit Tables are updated quarterly, not monthly, semi-annually or annually.

Question 11

What are mutually exclusive NCCI edits?&#10;A)Code pairs that are unlikely to be performed on the same day on the same patient&#10;B)Code pairs that are likely to be performed on the same day on the same patient&#10;C)Code pairs that are unlikely to be performed on the same day giving a different result&#10;D)Code pairs that are billed together &#34;bundled services&#34;

Accepted Answer

The answer of What are mutually exclusive NCCI edits?&#10;A)Code pairs...

Question 12

Can you report component codes separately?&#10;A)Yes, you can report component codes separately and may receive better reimbursement if you do.&#10;B)No, you cannot report component codes separately because this type of code only reports a portion of the service described. Look for comprehensive codes that are &#34;bundled&#34; to maximize reimbursement.&#10;C)Yes, you can report component codes separately. Even though it is bundled with another service, you can report both the component and the comprehensive codes.&#10;D)Yes, you should report component codes separately. Many times there is more than one component of a procedure and by separating each you can use multiple codes.

Accepted Answer

The answer of Can you report component codes separately?&#10;A)Yes, you...

Question 13

What do NCD and LCD stand for?&#10;A)National Category for Determinations (NCDs) and Legal Coverage Determinations (LCDs)&#10;B)National Coverage Determinations (NCDs) and Locally Covered Detriments (LCDs)&#10;C)National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)&#10;D)National Coding Database (NCDs) and Labs Coverage Database (LCDs)

Accepted Answer

The answer of What do NCD and LCD stand for?&#10;A)National...

Question 14

What do NCD/LCDs specify?&#10;A)They specify under which clinical circumstances a service can be considered reasonable and necessary&#10;B)They specify what codes are unreasonable or unnecessary for every specialty and how much will be reimbursed for something that isn't reasonable or necessary&#10;C)They specify benefit categories and exclusions for reimbursement&#10;D)They specify codes that have been decided to be too high cost or too experimental and that will never be covered by the insurance

Accepted Answer

The answer of What do NCD/LCDs specify?&#10;A)They specify under which...

Question 15

What are the parts of the NCD?&#10;A)LCD Information, Coding Information, and General Information&#10;B)Tracking Information, LCD Information, Coding Information, and National Coverage Analyses&#10;C)Tracking information, Description Information, Transmittal Information, and National Coverage Analyses&#10;D)Coding Information, Description Information, Transmittal Information

Accepted Answer

The answer of What are the parts of the NCD?&#10;A)LCD...

Question 16

What are common reasons for Medicare to deny an item or service as &#34;a medical necessity&#34;, thus requiring an ABN to be issued?&#10;A)The service or item is experimental or investigational&#10;B)The service or item is not indicated for the particular diagnosis or treatment that the patient is being seen or treated for&#10;C)The service or item is not considered safe and effective&#10;D)All of the above

Accepted Answer

The answer of What are common reasons for Medicare to...

Question 17

What comprises the Total Relative Value Unit (RVUt)&#10;A)Work (RVUw), Practice (PE-RVU), and Malpractice (RVUm)&#10;B)Facility (RVUf), Work (RVUw) and Practice (PE-RVU)&#10;C)Diagnosis (RVUd), Work (RVUw) and Malpractice (RVUm)&#10;D)Work (RVUw), Malpractice (RVUm) and Diagnosis (RVUd)

Accepted Answer

The answer of What comprises the Total Relative Value Unit...

Question 18

What are the different types of Practice Relative Value Units (PE-RVUs)?&#10;A)Outpatient and interagency&#10;B)Outpatient and inpatient&#10;C)Facility and non-facility&#10;D)Physician and non-physician

Accepted Answer

The answer of What are the different types of Practice...

Deck 6: Compliance and Regulatory