Chapter 6: Visit Charges and Compliant Billing
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is not permitted, what amount is written off?
$50
If a participating provider's usual fee is $400 and the allowed amount is $350, what amount is written off?
$50
What are CCI edits?
A computerized system that identifies improper or incorrect CPT codes
Medicare's national policy on correct coding is called the ______.
Correct Coding Initiative
What does Medicare use to inform medical insurance specialists about global periods?
Global period status indicators
Medicare Physician Fee Schedule
MPFS
medically unlikely edits
MUE
Nasal catarrh, chronic:
Main Term: catarrh Diagnosis: J31.0*
Hypertrophy of tonsils
Main Term: hypertrophy Diagnosis:J35.1
Obstructive laryngitis
Main Term: laryngitis Diagnosis: J05.0
Chronic laryngotracheitis
Main Term: laryngotracheitis Diagnosis: J37.1
Which of the following are examples of CCI edits?
Prevents female-specific and male-specific codes for the same patient Prevents billing two procedures that could not possibly have been performed together Tests for unbundling of CPT codes
Physicians establish a list of their usual fees for
the procedures and services they frequently perform.
In calculations of RBRVS fees, the three relative value units are multiplied by
their respective geographic practice cost indices.
What is the formula for calculating an RBRVS charge using the Medicare Physician Fee Schedule?
(W + PE + M) * CF = Payment
Correct Coding Initiative (CCI)
- aka NCCI - Medicare's national coding policy - Computerized Medicare system that controls improper coding which would lead to inappropriate payment for Medicare claims. - Has coding policies based on: * Coding conventions in CPT * Medicare's national and local coverage and payment policies * National medical societies' coding guidelines * Medicare's analysis of standard medical and surgical practice - updated every quarter - many thousands of Current Prodedural Terminology (CPT) or CPT code combinations called CCI edits (aka procedure-to-procedure, or PTP, edits)
Identify the steps to calculating a Medicare payment in the correct order.
1. Determine the procedure code for the service. 2. Use the Medicare Fee Schedule to find the three RVUs—work, practice expense, and malpractice—for the procedure. 3. Use the Medicare GPCI list to find the three geographic practice cost indices. 4. Multiply each RVU by its GPCI to calculate the adjusted value. 5. Add the three adjusted totals, and multiply the sum by the conversion factor to determine the payment.
Medicare typically pays for what percentage of the allowed charge?
80 percent
Which of the following codes is used to report supplies and materials supplied by physician?
99070
Makayla Sorensen, a 4-year-old female, sees Dr. Pitassin, a pediatrician, for the first time with itchy spots all over her body. After a medically appropriate history and examination,, his MDM is of a low complexity. Dr. Pitassin diagnoses her with chickenpox.
99203
Loretta Stabler, an 81-year-old female, comes to see Dr. Gilman for her semi-annual check-up Dr. Gilman notes he last saw the patient 6 months ago for a regular checkup. Dr. Gilman completes a medically appropriate history an examination. He reviews and affirms the present medical plan of care. Loretta's condition is stable, her hypertension and diabetes (type 2) are in good control, and she has no new problems. There are minimal data for Dr. Gilman to review and several diagnoses to consider. The MDM is moderate.
99214
George Terazzo, an 81-year-old male, collapsed at church during services and was brought to the ED. Dr. Horatio took a comprehensive history, performed a comprehensive examination, and made the decision to admit George into the observation unit of the hospital due to an irregular heartbeat with an unknown cause. MDM is of moderate complexity.
99221*
Sue Appleton, a 46-year-old female, was admitted this morning for observation after an MVA. Dr. Rhodes documents a detailed history and a comprehensive exam with a straightforward MDM. Sue is doing fine; all test results are within normal range. Dr. Rhodes discharges Sue the same afternoon.
99234
A computerized system that identifies improper or incorrect codes
Edits
When a physician reports only the top two of the five-level E/M code range for established patients, this coding practice could be seen as ______.
Fraudulent
geographic practice cost index
GPCI
Which of the following are components of RBRVS?
GPCI Relative values Conversion factor
What was set up to give health care providers a coding system that describes specific products, supplies, and services that patients receive?
HCPCS
Aspiration pneumonia due to solids and liquids
Main Term: pneumonia Diagnosis: J69.8
Vasomotor rhinitis
Main Term: rhinitis Diagnosis: J30.0*
Acute recurrent empyema of sphenoidal sinus:
Main Term: sphenoidal* Diagnosis: J01.31*
The RBRVS-based allowed fees
Medicare Physician Fee Schedule (MPFS)
Dr. Smyth performed an appendectomy on Lynda Lyman. However, the operation took twice as long as usual because Lynda weighs 356 pounds.
Modifer -22
Dr. Clayton removed Ricky Pujara's gallbladder 10 days ago. Today, he comes to see Dr. Clayton because of a problem with his knee. Which modifier should be appended to the encounter's E/M code?
Modifier -24
Dr. Julienne performed a biopsy on the left external ear of Ben Maas, a 69-year-old male.
Modifier -LT
The OIG's annual list of planned projects under the Medicare Fraud and Abuse Initiative
OIG Work Plan
To correctly prepare claims, it is important to know the payers' billing rules that are stated in which of the following?
Patients' medical insurance policies Participation contracts
Recovery Audit Contractor
RAC
Recovery Audit Contractor program designed to audit Medicare claims
RAC
resource-based relative value scale
RBRVS
relative value scale
RVS
Which of the following items may be requested for a private-payer audit?
Referrals Laboratory test results Progress notes
Which of the following influence the GPCI?
Rental prices Local taxes Average physician salaries
What are the two main fee structures that payers use to establish payer fee schedules?
Resource-based Charge-based
What is the meaning of code linkage?
The CPT procedure codes match the ICD-10-CM diagnosis code.
A change to a patient's account
adjustment
The maximum charge allowed by a payer for a specific service or procedure
allowed charge
What is the term used for collecting the difference between a PAR provider's usual fee and a payer's lower allowed charge?
balance billing
If the provider's fees are always paid in full, the fees may be set ______.
below the payers' maximum allowable charges.
Which symbol is used to designate a new code?
bullet
A claim should report a _______ procedure code instead of ______ codes that describe parts of the complete procedure.
bundled multiple
The three main methods payers use to pay providers are allowed charges, contracted fee schedules, and ______.
capitation
Connection between a service and a patient's condition or illness
code linkage
Dollar amount used to multiply a relative value unit to arrive at a charge
conversion factor
Only a ______ biopsy should be reported if both a deep biopsy and a superficial biopsy are performed at the same location in order to pass CCI edits.
deep
A payer's review and reduction of a procedure code to a lower value than reported by the provider
downcoding
A mutually _______ code edit occurs when both services represented by the ______ could not have reasonably been done during a ______ encounter, so they cannot be billed together.
exclusive codes patient
What must the coder determine as part of selecting the correct E/M code?
extent of history
Audit conducted by an outside organization
external audit
Self-audit conducted by a staff member or consultant
internal audit
In the example in Figure 6.3, the lowest cost element in the Medicare RBRVS fees is
malpractice expense.
A CCI _____ indicator number shows whether the use of a modifier can bypass a CCI ______
modifier edits
A CCI column 1/column 2 code _______ edit is a Medicare code edit where CPT codes in column 2 will not be paid if reported on the _________ day as the column 1 code.
pair same
The OIG Work Plan describes
planned projects for investigating possible fraud in various billing areas.
Adjustments to a patient's account can be ______ or ______.
positive; negative
An internal audit conducted before claims are reported to payers
prospective audit
Internal audit of claims conducted before transmission
prospective audit
CMS rules about billing Medicare
published in the Federal Register and CMS manuals - Medicare Carriers Manual - Coverage Issues Mannual
CCI, updated every ______, has many thousands of CPT code combinations called CCI ______ that are used by computers in the Medicare system to check ________.
quarter edits claims
The goal of MUE is to
reduce clerical billing errors.
With RVS, each procedure in a group of related procedures is assigned a ______ in relation to a ______.
relative value base unit
correct claims
report the connection between a billed service and a diagnosis
Internal audit conducted after claims are processed and RAs have been received
retrospective audit
In CPT, what do Category II codes report?
services to track performance measurement
billing rules
stated in patients' medical insurance policies and in participation contracts * payer bulletins, websites, regular communication with payer to keep up-to-date
An encounter form containing E/M codes should list
the complete ranges of codes for each type or place of service listed.
Fee for a service or procedure that is charged by a provider for most patients under typical circumstances
usual fee
The amount that a participating provider must deduct from a patient's account because of a contractual agreement to accept a payer's allowed charge
write-off
If a nonparticipating provider's usual fee is $400, the allowed amount is $350, and balance billing is permitted, what amount is written off?
zero
methodical review
audit
Under the RBRVS payment system, adjustments to the conversion factor are enacted by ______.
Congress
Reisa Haven, a 39-year-old female, was sent by Dr. Alfaya to Dr. Avery, an OB-GYN, for an office consultation. She had been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort during sexual intercourse. In a detailed history, Dr. Avery noted the location, severity, and duration of her pelvic pain and related symptoms. In the review of systems, Reisa had positive findings related to her gastrointestinal, genitourinary, and endocrine body systems. Dr. Avery noted that her past medical history was noncontributory to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary systems with a complete pelvic exam. Dr. Avery ordered lab tests and a pelvic ultrasound in order to consider uterine fibroids, endometritis, or other internal gynecologic pathology. MDM complexity was moderate.
99243*
Catalina King came into the ED with what appeared to be a wrist sprain that she sustained during a baseball game when she slid into home base. She was in obvious pain, and the wrist was swollen and too painful upon attempts to flex. Dr. Ervin performed an expanded problem-focused history and exam before he ordered x-rays. Reports confirmed a simple fracture of the distal radius. MDM was low.
99282*
George Carter was discharged today from the Bracker Nursing Center after Dr. Mintz spent 25 minutes performing a final examination, discussing George's stay, and providing instructions to George's wife for continuing care.
99315
Heather Swann, a 68-year-old female, in good health, is a new patient at Victors Boarding Home. Dr. Cannon comes by to complete Heather's evaluation and documents an expanded problem-focused history and exam with an MDM of low complexity.
99341*
Marla Olden, a 38-year-old female, G2 P1, was admitted to Weston Hospital to deliver. Marla is considered a high-risk delivery. Dr. Kucherin was on standby for 30 minutes in the event a c-section was necessary. Marla delivered vaginally. Marla and baby are doing well. Code Dr. Kucherin's services.
99360
Loretta Reubens, an 18-month-old female, is admitted today by Dr. Smallerman into the pediatric critical care unit because of severe respiratory distress.
99471
Renay Griffith, a 25-year-old female, recently returned from working for the Red Cross overseas. She presents to the clinic for an evaluation of a rash. Dr. Leisom evaluates the patient and diagnoses her with cutaneous leishmaniasis related to her recent deployment to Iraq.
B55.1
How are UCR fees set?
By comparing usual fees, customary fees, and reasonable fees
Correct Coding Initiative
CCI
Which of the following regulates which tests can be completed in an in-office laboratory setting?
CLIA
The rules from the ______ about billing Medicare are published in the _______.
CMS Federal Register
The contractually set periodic prepayment amount to a provider for specified services to each enrolled plan member
Capitation rate
Decide whether the following are likely to be compliant or likely to be rejected.
Complaint - Clarify coding and billing questions with physicians - Be clear on professional courtesy and discounts to uninsured/low-income patients - Carefully define bundled codes and know global periods Rejected - Reporting only the top two of a five-level E/M code range for new or established patient office visits - Using Modifier -91 to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results
code linkage
The connection between a service and a patient's condition or illness; establishes the medical necessity of the procedure.
What influences the charge-based fee structures?
The fees that providers of similar training and experience have charged for similar services
What does the CCI modifier indicator of 0 represent?
The use of a CPT modifier will not change the edit, or mutually exclusive code edits will not be bypassed.
What is the purpose of medically unlikely edits?
To identify clerical errors or services that require a modifier
usual, customary, and reasonable
UCR
HCPCS modifiers that define specific subsets of modifier 59
X modifiers
