OST-249 - CPC Exam Prep - Chapter 5 - Compliance

What modifier should be appended to a CPT code when an ABN form has been secured for services that are believed to not be covered under the Medicare program?

-GA (Modifier -GA denotes that an ABN form was obtained prior to rendered services as it was believed this service may not be covered. None of the remaining modifiers pertain to services performed that would require an ABN.)

What modifier would be appended to CPT code 28505 open treatment of great toe fracture to denote the right great toe?

-T5 (T5 would be appropriate because it designates the great toe on the right foot per CPT.)

Breaching assignment agreements resulting in the beneficiary being balance billed is an example of what?

Abuse (Breaching assignment agreements and balance billing the patient is an example of abuse.) WRONG

When Medicare services being provided are believed to not be covered under the Medicare program, what form should be secured and signed by the patient prior to services rendered?

Advance Beneficiary Notice (ABN) (An ABN should be obtained when Medicare services are being rendered that are believed will not be covered by the Medicare program. While the Advance Beneficiary Notice (ABN) is a waiver form, it is more specific than a generic waiver form. Patient releases are typically signed to release records while an assignment of benefits assigns monies due on claims to the provider. Therefore, the most correct answer would be "Advance Beneficiary Notice (ABN).")

Which of the following scenarios constitutes a violation of Medicare's incident-to-billing provisions?

An established patient with a new complaint presents to the physician's office. The patient is seen by the nurse practitioner. (In order to bill services, incident to any new problem must first be evaluated by a physician. In addition, if the service is to be billed under the physician's name, the physician must participate and perform any portion of the service.) WRONG

What is the OIG Work Plan?

Areas of concern to be investigated during the calendar year by the OIG (The OIG Work Plan includes areas that the OIG have identified as areas of concerns that will be investigated during the current calendar year. While it is the investigation plan for the year, it is more specifically issues identified as areas of concern that will be investigated during the calendar year. Remember, for purposes of the CPC exam, always select the most correct answer.) WRONG

If a coder or biller finds that the documentation in a patient's chart does not support billing for a particular service, they should take which of the following step(s)?

Ask the physician to clarify and/or provide more information. (The coder or biller should either query the physician or request clarification and/or additional information. It would not be appropriate to complete the claim with fraudulent information or utilizing documentation other than for the current visit.)

A provider submits the following E/M services to the third-party carrier: Level 1 99211 10%, Level 9 99212 20%, Level 3 99213 40%, Level 4 99214 20%, Level 5 99215 10%. What is the common terminology when the carrier reviews levels of service to determine the appropriateness of the distribution levels?

Bell curve (The bell curve refers to the distribution of E/M codes for a given provider.) WRONG

Which of the following coding practices is NOT considered an example of unbundling?

Coding a service that is not considered to be reasonable and necessary (While coding for a service not considered medically necessary is inappropriate, it is not considered unbundling. Note the question asks which of the following is NOT unbundling. The remaining selections are all examples of unbundling and therefore, would not be appropriate in this scenario.)

Which of the following is NOT part of a physician compliance plan?

Develop practice E/M guidelines (While it is recommended the practices develop guidelines for E/M services, it is not part of the requirements for a compliance program.)

Presenting a claim on behalf of a person excluded from the Medicare program is an example of what?

Fraud (Presenting claims on the patient of a provider excluded from the Medicare program is considered fraud. Underbilling or overbilling would be billing fewer or more services, while abuse is usually submitting excessive services or medically unnecessary services.)

A new physician has joined the practice, and an application for a Medicare provider number has been submitted to Medicare for this provider. In the interim, how should the Medicare billing be handled for this new provider?

Hold charges until a Medicare provider number has been assigned. (A new physician may not bill Medicare for services until such time as a Medicare provider number has been assigned specific to that physician. According to Medicare guidelines, it would not be appropriate to bill services for a provider who has not been assigned a Medicare provider number under a different provider or the practice's group provider name. Based on CMS/Medicare guidelines, the practice may also not bill the patient for the services.) WRONG

Productivity for coding staff should be based on

Industry standards as well as the unique work for the practice. (Many factors should be taken into consideration when developing productivity standards for coding staff including standards from organizations such as AAPC, AHIMA, and MGMA as well as the specific work of the practice.) WRONG

What is one measure the practice can implement to minimize the possibility of the allegation of fraud and/or abuse?

Internal and/or external audits (Internal and external self-audits will assist the practice in minimizing the allegations of fraud and/or abuse. Not accepting Medicare assignment does not exclude the possibility of fraud/abuse allegations as even non-participating providers may commit fraud/abuse. Providers must submit claims on behalf of a Medicare recipient in order to obtain reimbursement for services; therefore, this would not decrease the possibility of fraud/abuse claims. The employment of an attorney also would not minimize allegations of fraud and/or abuse unless the attorney mandates or requires internal and external audits.)

A provider has set a standing office policy that states EKGs should be ordered and performed on all patients over the age of 35 regardless of their medical condition or complaint. What would be the common denial for this scenario?

Lack of medical necessity (Medical necessity must be met for all services performed. Standing orders will often result in denials for services that are not considered medically necessary.)

The name of the administrative contractor for each Medicare region is

MAC or Medicare administrative contractor. (The Medicare administrative contractor or MAC refers to the regional contractor for Medicare.)

Lab interpretation billing is performed by the provider. What documentation, in addition to the interpretation, is necessary to properly bill this service?

NPI number and order (The ordering provider's NPI number and a written or documented order must be present as well. While a written report may be appropriate in some instances, coding/billing guidelines allow for documentation of the results in handwritten format on the lab record as long as it contains the minimum documentation requirements.) WRONG

NCCI stands for

National Correct Coding Initiative.

During the physician's absence in the office, a patient is seen by the nurse, vital signs are taken, a urinalysis is performed, and the nurse calls in a prescription for medication for a UTI under the physician's name who is usually in the office. What services, if any, are appropriate for this encounter?

No service may be coded/billed. (As no licensed provider has supervised or performed the service, it would not be appropriate to bill for any service in this instance.) WRONG

Provider submits an average of 100 claims for E/M services per day. All E/M services performed in conjunction with a procedure are appended with modifier -25. Would this practice be appropriate?

No, not all procedures should have E/M services coded/billed. (Modifier -25 should only be appended to the E/M service when a "significantly, separately identifiable procedure" is performed in addition to the procedure.) WRONG

Patient reports to the office and demands a service be provided that the physician considered to be not medically necessary. As a participating provider, your office has given the patient a full explanation and requested the patient sign an Advance Beneficiary Notice; however, the patient has refused to sign. How should the physician handle this situation?

Obtain the signature of a witness on the ABN, render the service to the patient, and bill the service to Medicare with the appropriate modifier. (The ABN may be signed by obtaining the signature of a witness on the ABN and billing the service to Medicare. It would not be appropriate to refuse care or refer to another provider/physician. Rendering services would also not be appropriate, as without the ABN, the services would not be reimbursable.) WRONG

Which federal agency publishes the Annual Work Plan?

Office of the Inspector General (The Annual Work Plan is published by the Office of the Inspector General.)

What is one of the main reasons that providers are investigated for fraud and abuse?

Patient complaints (Patient complaints are one of the main reasons providers are investigated for fraud and abuse. The other main reasons providers are investigated are employee complaints and statistical analysis of claims submissions.)

What program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to health care providers under fee-for-service (FFS) Medicare plans?

Recovery Audit Contractors (RAC) (The RAC program was created to identify and recover improper Medicare payments.)

In addition to maintaining medical record documents for the facility/practice, what additional responsibility does medical records staff in the physician practice typically perform?

Release of records (Medical records staff typically maintains the records for the practice as well as release of records. They are typically not involved in non-records services such as payroll or billing for services.)

When a coder suspects fraud/abuse, what is the first action that should be taken?

Report to supervisor (Coders should report suspected fraud/abuse to their immediate supervisor. Only after reporting suspected fraud/abuse to a supervisor and no action is taken, should the coder consider other actions such as resigning or contacting an attorney.)

Patient calls the office and indicates their insurance carrier will not cover the previous visit for the date of service listed on the claim as it was prior to the effective date of her insurance and asks that the date be changed to include a date during which her insurance was valid. What would be the appropriate action by the staff?

Review the record to determine if the appropriate DOS was submitted. If so, inform patient the DOS must remain unchanged. (The staff should review the record to make certain the date of service reported is appropriate. If so, they should inform the patient the DOS was correct and must remain unchanged.)

What part of the HIPAA guidelines pertain to coding?

Standard code sets and standard claim forms (HIPAA guidelines indicate that all code sets and claim forms will be uniform. While the other choices are part of the HIPAA guidelines, they do not relate to coding and therefore are not the most correct answer.)

This Physician Self-Referral Law prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial ownership interest or compensation arrangement, unless an exception applies:

Stark Law (Under the Stark Law, physicians are prohibited from making referrals to entities in which they have financial ownership.)

Patient arrived at the outpatient facility earlier in the morning and a localization wire was placed by the radiologist under mammographic guidance in the x-ray suite. The surgeon infiltrated around the wire and an incision was made between the left areola and the wire. A generous excision was made at least 2 cm around the wire, removing the lesion in question in toto. The margins were marked and specimen sent to pathology. The following codes were coded/billed by the surgeon's office: 19125-LT, 19281-LT, and 76098. The surgeon's office received notification from Medicare indicating they are under investigation for inappropriate billing for the services. Determine what inappropriate billing practices have been coded/billed by the surgeon's practice.

Surgeon may not submit claims for radiological services not performed. (The surgeon did not perform the radiological services performed earlier in the day and therefore may not code/bill for the radiological services.) WRONG

New coding staff should be trained on the appropriate authority to report potential fraud/abuse or other activities that are contrary to compliance standards. According to OIG guidelines, what individual within the practice is usually designated with this responsibility?

The compliance officer (The compliance officer is the individual assigned as the authority to report potential fraud/abuse within the practice.)

All employees, coding or other, should understand that the medical records are the property of whom?

The practice/provider (The medical records are the property of the health care provider; however, the patient is entitled to copies of the records at their request.)

How should procedures designated as "each" in the CPT manual be coded/billed?

They should be billed as per unit on the claim form. (Procedures designated as "each" should be billed per unit.)

This federal program was created to identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped:

Zone Program Integrity Contractor (ZPIC). (The Zone Program Integrity Contractor (ZPIC) program was created to identify fraud and recoup inappropriate payments. The other programs listed were not created for this purpose.)

Filing claims for services deemed not medically necessary is an example of

abuse (Underbilling and overbilling are examples of billing excessively or billing fewer codes than are appropriate.)

The "+" sign in the CPT manual denotes

additional procedures billed in conjunction with another specified service. (The "+" sign refers to an "add on" procedure that is billed in addition to another specified procedure code.)

Under what circumstance(s) can a provider be considered for exclusion from the Medicare program? * Conviction of a misdemeanor or felony relating to fraud/abuse * all of those listed * Failure to pay medical education loans * Suspension of provider license

all of those listed (Conviction for fraud and abuse, suspension of the provider's license, and/or failure to pay medical education loans could result in exclusion from the Medicare program. All of the items listed constitute reasons a provider could be excluded from the Medicare program; therefore, "all of those listed" would be the most correct answer.) WRONG

Which of the following most certainly would describe upcoding?

billing for a procedure that is more extensive or intensive than what was actually performed (According to NCCI guidelines, a less extensive procedure performed in the same anatomical area is considered bundled in the more extensive procedure.) WRONG

In order for the most accurate coding to be produced by the practice, the management should ensure that

current year code books are maintained at all times. (Accurate coding may only be assigned if current year code books are maintained by the practice at all times. Management should make certain that only "definitive" sources are being utilized for coding purposes. Consulting with other coders, utilizing "cheatsheets," and coding newsletters are not considered definitive sources.)

NCCI edits refer to

edits that indicate whether procedures may be separately reported in conjunction with other procedures coded. (Edits that indicate whether procedures may be separately reported in conjunction with other procedures coded.)

Having knowledge that false statements were made with the intent to gain a greater amount than due is a definition of

fraud (Fraud is knowingly making false statements in order to gain reimbursement. Overbilling involves billing more services than were provided. Conversely, underbilling involves billing lesser or fewer services than were provided.)

Modifier -TA denotes

great toe, Left foot. (The "TA" modifier denotes the great toe of the left foot. Fingers and thumbs of the hand are noted with "F" modifiers. The great toe of the right foot would be designated with the modifier "T5.")

When further explanation for describing services provided is necessary, what might be appropriate to append to the CPT code?

modifier (A modifier provides additional information or clarification on services performed. None of the other choices are appended to the CPT code.)

When E/M services for unrelated services are billed within a global period, what modifier should be appended?

modifier -24 (Modifier -24 denotes an E/M service performed during a global period that is unrelated. Modifier -57 denotes decision for surgery, while modifier -25 is assigned to indicate a "significantly separately identifiable service." The modifier -59 is assigned to indicate separate and distinct services. Therefore, modifier -24 is appropriate in this instance.)

In a teaching setting, what documentation must be present for resident services to be coded/billed for an initial hospital admission by the teaching physician?

personal notation entered by teaching/attending physician documenting their participation and presence during the encounter (In addition to the documentation of the resident, the teaching physician must document their participation in the history, exam, and/or MDM components of the service. Documentation by the resident is also required; however, without the documentation by the teaching physician, the service may not be billed.) WRONG

When fraudulent actions are taken by a provider, what penalties may be imposed by the government?

possible imprisonment (Imprisonment may be one penalty imposed for fraudulent activities.)

Modifier -RT should be assigned to denote

right anatomical site. (The modifier "RT" denotes the right anatomical site. The right thumb, right index finger, and right toe are designated with specific modifiers "F5," "F6," and "T5," respectively.)

This designation in CPT indicates that a procedure code may only be assigned if it is the only procedure performed that is not an inherent part of another procedure or service.

separate procedure (Procedures designated as "separate procedure" in the CPT book indicate procedures that may only be coded when performed alone for that anatomical area.)

Abuse is defined as

the overuse or excessive use of medical and health services. (The overuse or excessive use of medical and health services is one example of abuse. The remaining choices are all examples of fraud.)

Common name for qui tam action is

whistleblower (Qui Tam legislation is frequently referred to as the whistleblower, named for the individual who "blows the whistle" on the provider or reports them to federal authorities.)