AAPC CPB - Chapter 7 Review

MUE is the acronym for:

a. Medicare Unlikely Edits

b. Medically Unnecessary Edits

c. Medicare Unnecessary Edits

d. Medically Unlikely Edits

d. Medically Unlikely Edits

Based on NCCI edits, when a procedure is bundled and has a CCM indicator of 0 - which of the following Modifiers is allowed?

a. 51

b. 59

c. 25

d. Modifiers are not allowed

d. Modifiers are not allowed

Which of the following is considered to be an anatomic modifier?

a. 77

b. LD

c. T5

d. Both B and C

d. Both B and C

Medicare states that reporting bundled codes in addition to the major procedural code is considered to be unbundling, and if repeated with frequency it is considered to be:

a. Abuse

b. Fraud

c. Misrepresentation

d. False Claims

b. Fraud

A patient is scheduled for a laparoscopic procedure that is converted to an open procedure after the procedure is initiated. Which of the following would be correct coding based on CMS NCCI edits?

a. Bill both procedures.

b. Bill only the laparoscopic procedure since that is what was scheduled.

c. Bill only the open procedure (most extensive).

d. Bill both procedures with a modifier appended to the Column 2 code.

c. Bill only the open procedure (most extensive).

NCCI is the acronym for:

a. National Correct Coding Institute

b. National Correct Coding Initiative

c. National Coding Clinic Initiative

d. National Coding Coverage Institute

b. National Correct Coding Initiative

Services that are integral to the procedure being performed - such as cleaning and prepping the skin, opening and closing the surgical site, or any cultures being taken are considered:

a. Separately billable.

b. Are separately billable if they require additional time.

c. Are included and never separately billable.

d. Individually by payer.

c. Are included and never separately billable.

Modifier 59 is used to unbundle procedures with an indicator of 1. Under what circumstances would modifier 59 NOT be appropriate?

a. A benign lesion is removed from the upper left thigh that does not need suturing. A second benign lesion is removed from the lower left thigh but needs an intermediate suture repair.

b. Destruction of a premalignant lesion on the medial side of the right ankle and a biopsy of a second lesion on the arm.

c. Breast nodules removed from the right breast at 3 o'clock and at 9 o'clock.

d. Strapping of fracture of left ring and left pinkie finger.

d. Strapping of fracture of left ring and left pinkie finger.

Documentation requirements for medical necessity are NOT met by

a. Legible medical records for the patient.

b. Selecting an ICD-10-CM code that is supported in the medical record.

c. Selecting an ICD-10-CM code from an approved listing in an LCD or NCD.

d. Documentation that is authenticated by the provider of service.

c. Selecting an ICD-10-CM code from an approved listing in an LCD or NCD.

Codes that are considered to be bundled are based on Centers for Medicare & Medicaid (CMS) standards called:

a. LCDs

b. NCDs

c. NCCI

d. MUEs

c. NCCI

Services that are performed for treatment or diagnosis of an injury, illness, or disease in accordance with generally accepted standards of medical practice defines:

a. Compliance

b. Clinical standards

c. Medical necessity

d. HIPAA

c. Medical necessity

When applying an LCD to services, which of the following statements is TRUE regarding the CPT® and ICD-10-CM codes reported on a claim form?

a. The diagnosis should be altered to adhere to the guidelines of the LCD.

b. Documentation should provide medical necessity and support the CPT and ICD-10-CM codes reported.

c. The LCD contains suggestions for CPT and ICD-10-CM codes to be reported.

d. None of these statements is true.

b. Documentation should provide medical necessity and support the CPT and ICD-10-CM codes reported.

Local Coverage Determinations (LCDs) are established by Medicare Administrative Contractors (MACs) for what purpose?

a. LCDs are established to override NCDs.

b. LCDs are developed when no NCD is available.

c. LCDs establish coding standards for certain services.

d. LCDs make coverage determinations universal throughout jurisdictions.

b. LCDs are developed when no NCD is available.

An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier?

a. 24

b. 25

c. 22

d. 21

a. 24

Indicators are used to determine if modifiers are allowed or not allowed to bypass an edit. The indicators are:

a. 0, 1, and 9

b. 0, 1, and 2

c. 2 and 3

d. 3 and 9

a. 0, 1, and 9

National Coverage Determinations (NCDs) were established by CMS to indicate:

a. Services that will not be covered by CMS.

b. Medical services or procedures that are paid by Medicare with certain limitations.

c. Medical services or procedures that are paid by Medicare.

d. Services or procedures that can be provided for a Medicare beneficiary.

b. Medical services or procedures that are paid by Medicare with certain limitations.

What modifier is used to indicate two procedures are performed on the same day and should not be bundled?

a. 25

b. 24

c. 57

d. 59

d. 59

Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include:

a. Approved CPT codes when performing the procedure.

b. Diagnostic limitations for proposed procedures.

c. Comorbid conditions of the patient.

d. Experimental procedures.

d. Experimental procedures.

NCDs are released by which of the following entities:

a. Medicare Administrative Contractors (MACs)

b. Health and Human Services (HHS)

c. Office of Inspector General (OIG)

d. Centers for Medicare & Medicaid Services (CMS)

d. Centers for Medicare & Medicaid Services (CMS)

What does the NCCI file indicate?

a. The relative value units (RVUs) of surgical procedures.

b. Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider.

c. State whether Medicare or the Mac will pay for an item or service as medically necessary.

d. Indicates whether specific medical services, items, treatment procedures, or technologies can be paid for under Medicare.

b. Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider.

When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user:

a. A modifier is allowed.

b. The codes are not bundled and a modifier is not required.

c. A modifier is not allowed.

d. The edit is not applicable to this code set.

c. A modifier is not allowed.