ASIPP Record Keeping, Quality Assurance, and Practice Management Questions Flashcards
1
Q
- What is the arrangement of CPT?
A. CPT is arranged into six sections involving evaluation
and management, anesthesiology, surgery, radiology,
pathology, and medicine
B. CPT is arranged into six sections with anesthesiology,
surgery, radiology, physical medicine rehabilitation,
pathology, and cardiology
C. CPT is arranged into six sections with surgery, radiology,
oncology, pathology, medicine, and neurosurgery
D. CPT is arranged into six sections with psychiatry, physiatry,
medicine, surgery, radiology, and pathology
E. CPT is arranged into six sections designated as evaluation,
management, surgery, techniques, pathology, and
radiology
A
- Answer: A
Source: Laxmaiah Manchikanti, MD
2
Q
- A 44-year-old patient suffering from alcoholism enters
a residential treatment program that emphasizes group
therapy but uses pharmacologic agents adjunctively.
The patient is given a drug the decreases the craving for
alcohol, possibly by interference with the neuroregulatory
functions of opioid peptides. Since the drug will not
cause adverse effects if the patient consumes alcoholic
beverages, it can be identifi ed as
A. Bupropion
B. Disulfi ram
C. Nalbuphine
D. Naltrexone
E. Sertraline
A
- Answer: D
3
Q
- Physicians may bill for ancillary services that are
“incident to” services rendered by non-physician,
auxiliary personnel as long as:Choose the answer that
best completes this sentence.
A. The service takes place in a physician’s offi ce.
B. The non-physician, auxiliary personnel is an employee
of a physician.
C. The physician is physically on-site and immediately
available when the auxiliary practitioner is providing
service.
D. The physician is immediately available.
E. Physicians are never permitted to bill for “incident to”
services under the Civil False Claims Act.
A
- Answer: C
Explanation:
Physicians may bill and be paid for ancillary services that
are “incident to” services rendered by non-physician,
auxiliary personnel in the physician’s private offi ce setting,
as long as supervision requirements are satisfi ed. The
physician must be physically on-site and immediately
available when the auxiliary practitioner is providing
services.
Source: See Medicare Carriers Manual, Part 3, Claims
Process, § 2050.
Source: Erin Brisbay McMahon, JD, Sep 2005
4
Q
1913. The degree to which the CPT and ICD-9 codes selected accurately refl ect the diagnoses and procedures are described as: A. Reliability B. Validity C. Completeness D. Timeliness E. Accuracy
A
- Answer: B
5
Q
- In assigning critical Evaluation and Management (E/M)
codes, three critical components are used. These are
A. History, nature of the presenting problem, time
B. History, examination, counseling
C. History, examination, time
D. History, examination, medical-decision making
E. History, medical-decision making, counseling
A
- Answer: D
6
Q
1915.Which of the following is coded as an adverse effect in
ICD-9-CM?
A. Paralysis secondary to multiple sclerosis
B. Rejection of transplanted heart
C. Dizziness due to side effect following administration of
Gabapentin
D. Non-functioning spinal cord stimulator due to defective
design.
E. Reaction to antibiotic administered prophylactically
A
- Answer: C
7
Q
- What are important aspects of Needlestick Safety and
Prevention Act of 2001
A. 24 areas of change
B. Two terms were added to defi nitions
C. It was enacted due to total of over 20 million needle
sticks a year
D. Risks of contracting disease were minimal
E. Psychological stress was the only issue
A
- Answer: B
Explanation:
Needlestick Safety & Prevention Act 0f 2001- Nov. 6, 2000
* Four areas of change
* Two terms added to defi nitions
* Why
- Total > 600, 000 Needle sticks a year
- 2/3 rd Hospital
- Risk of contracting disease
- Adverse side effects of treatments
- Psychological stress
Modifi cation of Defi nitions - Area 1
* Relating to Engineering Controls
- Defi nition: Includes all control measures that isolate
or remove a hazard from the workplace.
- Examples: blunt suture needles, plastic or mylar
wrapped capillary tubes, sharps disposal containers, and
bio-safety cabinets
Modifi cation of Defi nitions - Area 2
* Revision and Updating of the Exposure Control Plan
- Review no less than annually
- Refl ect a new or modifi ed task/ procedure
- Revised employee positions
- Refl ect changes in technology
- Document consideration and/or implementation of
medical devices
Modifi cation of Defi nitions - Area 3
* Solicitation of Employee Input
- Non-managerial employees who are responsible for
direct patient care and potentially exposed to injury
- Identifi cation, evaluation, selection of effective
engineering and work practice controls
- Document employee solicitation in Exposure Control
Plan
Modifi cation of Defi nitions - Area 4
* Record Keeping
- Sharps Injury Log
Type and brand of device involved
Department or work area of exposure incident
Explanation of how the incident occurred
Source: Laxmaiah Manchikanti, MD
8
Q
- A potential False Claims Act issue is billing patients for
medically unnecessary services. In this context, medically
unnecessary services are . . . Choose the answer that best
completes this sentence.
A. Those services not warranted by a patient’s documented
medical condition.
B. Those services that are not approved by the Health and
Human Services Department (HHS).
C. Those services not required for a patient’s survival.
D. Those services that do not yet have a CPT code.
E. Services that have not actually been performed on a patient.
A
- Answer: A
Explanation:
Explanation: Physicians practices should not seek
reimbursement for a service that is not warranted by a
patient’s documented medical condition. It is not safe to
assume that the reason a service is ordered can be inferred
from chart entries.
Source: 65 Fed. Reg. at 59439. In order to determine
whether a service is reasonable and necessary, thephysician
must apply the appropriate local medical review policy
(“LMRP”). For more information on LMRPs, go to
www.lmrp.net.
Source: Erin Brisbay McMahon, JD, Sep 2005
9
Q
- Which of the following has NOT been identifi ed as a
major risk area for physician practices?
A. Coding and billing
B. Reasonable and necessary services
C. Documentation
D. Unqualifi ed personnel
E. Improper inducements, kickbacks and self-referrals
A
- Answer: D
Explanation:
The OIG has identifi ed four major risk areas for physician
practices: 1) coding and billing; 2) reasonable and
necessary services; 3) documentation; and 4) improper
inducements, kickbacks and self-referrals.
Source: 65 Fed. Reg. at 59438.
Source: Erin Brisbay McMahon, JD, Sep 2005
10
Q
- Health Insurance Portability and Accountability Act
established the Health Care Fraud and Abuse Control
Program primarily to . . . Which one of the following
would not correctly complete this sentence?
A. Coordinate Federal, state, and local law enforcement efforts
relating to health care fraud and abuse.
B. Provide guidance to the health care industry regarding
fraudulent practices.
C. Conduct investigations, audits, and evaluations relating
to delivery and payment for health care around the
world.
D. Facilitate enforcement of remedies for health care fraud.
E. Create a national data bank to report adverse actions
against health care providers.
A
- Answer: C
Explanation:
Explanation: Answer (C) should be limited to the United
States.
Reference: The Department of Health and Human
Services and The Department of Justice Health Care Fraud
and Abuse Control Program Annual Report for FY 2003
(December 2004).
Source: Erin Brisbay McMahon, JD, Sep 2005
11
Q
- Which one of the following statements regarding the
Offi ce of Inspector General (OIG) is FALSE?
A. The OIG is an implementer of HIPAA’s Health Care
Fraud and Abuse Program.
B. The OIG excludes providers from Medicare, Medicaid, and other federal health programs for violating program
rules and regulations.
C. The OIG publishes compliance program guidance for
physicians and small group practices.
D. Penalties from the OIG may be avoided by the adoption
of an effective compliance program.
E. The OIG considers improper inducements, kickbacks
and self-referrals as the only major risk area for physician
practices
A
- Answer: E
Explanation:
Answer (e) is false because the OIG does not consider
improper inducements, kickbacks and self-referrals as the
only major risk area for physician practices. The OIG has
identifi ed four major risk areas for physician practices: 1)
coding and billing; 2) reasonable and necessary services; 3)
documentation; and 4) improper inducements, kickbacks
and self-referrals.
Source: 65 Fed. Reg. at 59438
Source: Erin Brisbay McMahon, JD, Sep 2005
12
Q
- Which of the following is NOT one of the seven elements
of an effective compliance program?
A. Regular auditing and monitoring
B. Designation of a compliance offi cer, compliance committee
or compliance contacts
C. Retaliation against employees who report legal or ethical
concerns
D. Education and training for all personnel in the practice
E. Written practice standards that include a code or standard
of conduct
A
- Answer: C
Explanation:
Although the scope of a compliance program will vary
according to a practice’s resources, an effective compliance
program should refl ect the following seven elements: (1)
regular auditing and monitoring, (2) written practice
standards that include a code or standard of conduct, (3)
designation of compliance offi cer, compliance committee
or compliance contacts, (4) education and training for all
personnel in the practice, (5) existence of response
mechanism and corrective action plan, (6) open lines of
communication, and (7) an enforced and well-publicized
disciplinary process.
Answer (c) is not correct because an effective
communication process is encouraged in a compliance
program and, to achieve this, the practice must establish a
procedure for communicating questions or complaints to
designated compliance personnel without raising concerns
about retaliation.
Source: 65 Fed. Reg. 59434.
Source: Erin Brisbay McMahon, JD, Sep 2005
13
Q
1922. The designated health services covered by the Stark Law include eleven categories. Which of the following is not a DHS category covered by Stark Law? A. Clinical laboratory services B. Physical therapy services C. Radiology services D. Ophthalmology services E. Home health services
A
- Answer: D
Explanation:
The DHS covered by the Stark Law include the following
eleven categories: clinical laboratory services, physical
therapy services,occupational therapy and speech language
pathology services, radiology services, radiation therapy
services and supplies, durable medical equipment and
supplies, parenteral and enteral nutrients, equipment and
supplies, prosthetics, orthotics, and prosthetic devices,
home health services, outpatient prescription drugs, and inpatient and outpatient hospital services.
Reference: 69 Fed. Reg. 16054 (2004).
Source: Erin Brisbay McMahon, JD, Sep 2005
14
Q
- Functions performed by the Practice Management
Software include the following:
A. Appointment and procedures scheduling and rescheduling
B. Management of accounts receivable and collections
C. Creation of electronic billing
D. Provider input terminal
E. Integration
A
- Answer: A
Explanation:
The function of the Practice Management Software
includes all aspects of patient management including
appointment, procedure scheduling, communication,
creating bills, managing accounts receivable, and creating
reports. The provider is an important part of the software,
but more so in the back offi ce. The Practice Management
Software responsibility is to ensure the vital functions of
the support system to the provider. This is independent of
clinical input.
Source: Hans C. Hansen, MD
15
Q
- A patient develops diffi culty during an interventional
procedure and the physician discontinues the procedure.
Identify the modifi er that may be reported by the physician
to indicate that the procedure was discontinued.
A. -52 reduced services
B. -53 discontinued procedure
C. -73 discontinued outpatient procedure prior to anesthesia
administration
D. -74 discontinued outpatient procedure after anesthesia
administration
E. -59 distinct procedural service
A
- Answer: B
16
Q
- The EMR incorporates different sectional components
to best manage the practice. The specifi c part of the EMR
that relates to clinical services, requiring provider input
is:
A. The front offi ce
B. The back offi ce
C. The integrated pad, or workstation
D. The server pod
E. The offi ce input at the front desk
A
- Answer: B
Explanation:
The back offi ce is associated with the clinical service side
of the electronic medical record. Input can be from a
number of sources, being a verbal integration into the
medical record, dictated and then transcribed cut and
pasted, data input by keyboard, or touch screen, and even
possibly by a pad or pen system.The key component of the
back offi ce, however, is the provider interface.
Source: Hans C. Hansen, MD
17
Q
- According to ICD-9-CM, which one of the following is a
mechanical complication of an internal implant?
A. Erosion of skin by spinal cord stimulator electrodes
B. Epidural abscess following catheterization
C. Post lumbar puncture headache after spinal
D. Side effects of morphine in an intrathecal pump
E. Accidental injection of phenol into epidural space
A
- Answer: A
18
Q
- If one knowingly submits or causes to be submitted
a false or fraudulent claim for payment to the federal
government, but with no intent to defraud the
government, this is a violation of which of the following?
A. The Criminal False Claims Act
B. The Civil False Claims Act
C. Stark Law
D. Controlled Substances Act
E. The Federal Anti-Kickback Law
A
- Answer: B
Explanation:
A. The Criminal False Claims Act makes it a felony to
make or cause to be made any “false statement or
representation of material fact in any application for any
benefi t or payment under a Federal health care program.
B. The Civil False Claims Act imposes liability if one
“knowingly” submits or causes to be submitted a false or
fraudulent claim for payment to the federal government. A
specifi c intent to defraud is not required.
C. Stark Law prohibits physicians from making referrals
for certain designated health services (DHS) to entities in
which the physician has a fi nancial relationship and the
service is billed to Medicare or Medicaid.
D. The Drug Enforcement Agency monitors prescriptions
of controlled substances pursuant to authority under the
Controlled Substances Act, Title II of the Comprehensive
Drug Abuse Prevention and Control Act of 1970.
E. The Federal Anti-Kickback Law prohibits the offer or
receipt of anything of value which is intended to inducethe
referral of a patient for an item of service that is
reimbursed under a federal health care program, including
Medicare and Medicaid.
Source:
A. 18 U.S.C. § 287, 1001; and 42 U.S.C. § 1320a-7b.
B. 31 U.S.C. § 3729.
C. 42 U.S.C. § 1395nn.
D. 21 U.S.C. § 801 et seq.
E. 42 U.S.C. § 1320a-7b(b).
Source: Erin Brisbay McMahon, JD, Sep 2005
19
Q
- One of managed care organizations policies to decrease
criticism of their one-sided contracts is:
A. Allowing the provider Medical Directors to determine
medical necessity.
B. Moving some of the objectionable provisions from the
contract to the policy and procedure manuals.
C. Allowing a vague description of the managed care
organization’s coding standards.
D. Adding a “least cost” standard to the contract.
E. Allowing a very general defi nition of the services to be
covered.
A
- Answer: B
Explanation:
They are moving some of the objectionable provisions to
the policy and procedure manuals, but by reference, these
become part of the contract.
Source: Marsha Thiel, RN, MA, Sep 2005
20
Q
- Which of the following would be LEAST likely to
infl uence the collection ratio
A. An increase in the practices billing rate
B. Discounts on payments not being applied properly
C. An increase in the practices billed amount for procedures
D. Unaddressed incorrect payments
E. Uncollected secondary billings.
A
- Answer: D
Explanation:
While discounts not applied correctly or in a timely
manner may affect aging they would have a minimal effect
on the collection ratio which involves dividing the net
collected amount by gross charges for a particular time
frame.
Source: Marsha Thiel, RN, MA, Sep 2005
21
Q
- An internal control weakness would best defi ned as
a condition in which errors or irregularities are not
detected within a timely period by:
A. An independent audit of reports on control procedures
B. Management when reviewing fi nancial statements
C. Outside consulting fi rms
D. Employees in the normal course of performing their
functions
E. The fi nancial manager during year end audits
A
- Answer: D
Explanation:
Checks and balances should be in place to detect errors or
irregularities by front line employees at the time the
irregularity occurs. This is the fi rst line of defense for
managing problems
Source: Marsha Thiel, RN, MA, Sep 2005
22
Q
- Employers are responsible for completing an Injury
and Illness Incident Form 301. Sally Jones was injured
at the clinic on May 10, 2005. Sally reported the injury
to the Human Resources Department the same day of
her injury. How many days does the HR staff have to
complete the Injury and Illness Form 301 in order to be
compliant?
A. Two
B. Seven
C. Ten
D. Fourteen
E. Thirty
A
- Answer: B
Explanation:
Employers are responsible for completing an Injury and
Illness Incident Form 301 within seven calendar days after
receiving information that a recordable work-related
injury or illness has occurred. An equivalent form can be
used if that form contains all the information asked for on
the OSHA 301
Supporting Documentation:
http://www.osha.gov/recordkeeping/index.html THEN
SELECT recording forms then select OPEN FORMS pdf
PAGE 10 OF 12
Source: Marsha Thiel, RN, MA, Sep 2005
23
Q
- During a given month, the practice has $30,000 in gross
charges of which about$15,000 will be written off via
contract adjustments, collects $40,000 in receipts and
writes $10,000 in checks to vendors. Under the cash
method of accounting, what would this practice show as
net income before taxes?
A. $5,000
B. $15,000
C. $30,000
D. $20,000
E. $25,000
A
- Answer: C
Explanation:
Under the cash method of accounting, revenue is recorded
when received and expenses recorded when paid.
Therefore, you would record $40,000 of revenue and
$10,000 in expenses.
Source: Marsha Thiel, RN, MA, Sep 2005
24
Q
- A practice has the following: Cash of $40,000; Accounts
Receivable of $60,000; Equipment of $10,000; Accounts
Payable of $20,000; Long term debt of $70,000 and
Capital of $20,000. Assuming the practice uses the accrual
method of accounting, what would the total assets be?
A. $40,000
B. $50,000
C. $90,000
D. $110,000
E. $120,000
A
1933. Answer: D Explanation: Cash of $40,000, accounts receivable of $60,000 and equipment of $10,000 are the assets. Source: Marsha Thiel, RN, MA, Sep 2005
25
Q
- Which of the following statements pertaining to pricing
philosophies is not true?
A. The relative value approach takes into account the cost of
professional liability insurance
B. The standard measure used by providers for the relative
value approach is Medicare’s Relative Value Units
C. The market-drive approach ties the providers fees to
those of similar providers in the area
D. The market-driven approach assumes that the patients
are price sensitive but unaware of cost differences
among providers
E. The Geographic Practice Cost Index is used to convert
Medicare’s national RVU values to regional values
A
- Answer: D
Explanation:
The market-drive approach assumes that the patients are
price sensitive and are also aware of the cost differences
among providers.
Source: Marsha Thiel, RN, MA, Sep 2005
26
Q
- Which one of the following statements regarding an
impact analysis performed by a medical provider is
correct?
A. An impact analysis should be done after changes are
implemented to a providers fee schedule
B. For an impact analysis to accurately calculate the affect of
new fees, the historical data should be weighted for the
types of services performed by the provider
C. An impact analysis is an excellent method of predicting
the coming year’s revenue based on a new or revised fee
schedule
D. The main purpose of an impact analysis is to calculate
how much future revenue will be generated by increasing
the providers charges
E. An impact analysis is basically a study of the affect a
decrease in a provider’s fee schedule will have on future
revenues
A
- Answer: B
Explanation:
An impact analysis applies the rates in a new or revised fee
schedule to services provided in the past. This analysis
will show what total charges would have been in a prior
period based on a new fee schedule. The historical data
should be weighted for the types of services provided
because a large portion of a provider’s charges are often
from a few key services. The analysis should be done
before the fee changes are implemented.
Source: Marsha Thiel, RN, MA, Sep 2005
27
Q
- Budgets are very useful for an organization for all of the following reasons EXCEPT:
A. Provides a benchmark to compare actual results to
B. Forces management to plan
C. Requires all areas of the company to communicate
D. Provides information on patient fl ow
E. Provides goals for the company to work toward
A
- Answer: D
Explanation:
A fi nancial budget provides information regarding
revenues and expenses and whether or not the company is
achieving its fi nancial goals. It does not provide clinical
information on the fl ow of patients through the offi ce.
Source: Marsha Thiel, RN, MA, Sep 2005
28
Q
- In looking at the fi nancial statements for the period, you
fi nd that your net collections have been decreasing over
the last few months. All of the following could be possible
causes EXCEPT:
A. Provider productivity
B. Payer mix
C. Number of patient visits
D. Inventory level of supplies
E. Billing/Collecting process
A
1938. Answer: D Explanation: Level of supplies in inventory does not affect net collections. Source: Marsha Thiel, RN, MA, Sep 2005
29
Q
- Which of the following is considered a Safe Harbor,
making it an exception to the Federal Anti-Kickback
Law?
A. Gifts offered to a patient that may affect the patient’s
choice of provider or treatment decisions, as long as
certain requirements are met.
B. Compensation arrangements with physicians or other
practitioners that are based upon the volume or value
of referrals for services with the practice, as long as certain
requirements are met.
C. Free medications given to a patient with the intention of
inducing the patient to chose a specifi c provider, as long
as certain requirements are met.
D. The sale of pharmaceutical samples to benefi ciaries, as
long as certain requirements are met.
E. Payments relating to the purchase and sale of physician
practices, as long as certain requirements are met.
A
- Answer: E
Explanation:
A. Gifts offered to patients or potential patients that may
affect the patient’s choice of provider or the treatment
decision are suspect under the Anti-Kickback Statute.
B. Compensation arrangements with physicians or other
practitioners that are based upon the volume or value of
referrals for services within the practice are suspect under
the Anti-Kickback Statute.
C. Giving a patient free medications with the intention of
inducing the patient to choose a specifi c provider is
suspect under the Anti-Kickback Statute.
D. The sale of pharmaceutical samples to benefi ciaries is
suspect under the Anti-Kickback Statute.
E. Payments relating to the purchase and sale of physician
practices are considered one of the exceptions, commonly
known as a safe harbor, under the Anti-Kickback Statute.
Source:
e) 42 CFR 1001.952(e) (1991).
Source: Erin Brisbay McMahon, JD, Sep 2005
30
Q
- Choose accurate statements about Evidence Based
Medicine (EBM):
A. EBM emphasizes examination of evidence for clinical
research
B. EBM de-emphasizes systematic collection of clinical
studies
C. EBM does not provide a role for synthesis of evidence
D. EBM emphasizes intuition
E. EBM depends on unsystematic experience
A
1940. Answer: A Explanation: EBM as plausible response * Emphasizes - Examination of evidence for clinical research - Systematic collection of clinical studies - Synthesis of evidence * De-emphasizes - Intuition - Unsystematic experience - Biological rationale (surrogates) Source: Laxmaiah Manchikanti, MD
31
Q
- Choose the accurate statements describing legitimate
professional courtesy:
A. When a physician practice waives coinsurance obligations
or other out-of-pocket expenses for other physicians
or family members, but only based on their
referrals.
B. When a hospital or other institution waives fees for
services provided to their medical staff, but not employees.
C. When an organization waives fees based on proportion
of referrals.
D. When a physician practice is able to collect full fee, by
increasing charges proportionately.
E. When a physician practice waives all or part of a fee for
services for offi ce staff, other physicians or family members.
A
- Answer: E
Explanation:
The following are general observations about professional
courtesy arrangements for physicians to consider:
* Regular or and consistent extension of professional
courtesy by waiving the entire fee for services rendered to
a group of persons (including employees, physicians or
their family members) may not implicate any of OIG’s
fraud and abuse authorities if membership in the group
receiving the courtesy is determined in a way that does not
take into account directly or indirectly any groupmember’s
ability to refer to or otherwise generate federal health care
program business for, the physician.
* Regular or consistent extension of professional courtesy
by waiving otherwise applicable copayments for services
rendered to a group of persons (including employees,
physicians or their family members), would not implicate
the Anti-Kickback Statute if membership in the group is
determined in a way that does not take into account
directly or indirectly any group member’s ability to refer
to, or otherwise general federal health care program
business for, the physician.
Source: Laxmaiah Manchikanti, MD
32
Q
1942. Currently, payment to the physician for outpatient surgery performed on a Medicare patient is based upon which prospective payment system? A. DRGs B. APGs C. RBRVS D. ASCs E. APCs
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
33
Q
1943. Level III Healthcare Common Procedure Coding System (HCPCS) codes are updated by A. CMS B. The fi scal intermediary C. AMA D. AHA E. OIG
A
- Answer: B
34
Q
- The medical decision-making is measured by all of the
following except:
A. Number of diagnoses/management options
B. Amount and complexity of data reviewed
C. Risk of complications
D. Specialty of the treating physician
E. Risk associated with diagnostic procedures
A
- Answer: D
35
Q
1945. The Unifi ed Medical Language System (UMLS) is a project sponsored by the: A. National Library of Medicine B. Centers for Medicare and Medicaid C. World Health Organization D. Offi ce of Inspector General E. American Medical Association
A
- Answer: A
Source: Laxmaiah Manchikanti, MD
36
Q
- In general, all three critical components (history,
physical examination, and medical decision making) for
the Evaluation and Management (E/M) codes in CPT
should be met or exceeded when
A. The patient is established
B. A new patient is seen in the offi ce
C. The patient is given subsequent care in the hospital
D. The patient is seen for a follow-up inpatient consultation
E. the patient is undergoing an interventional procedure
A
- Answer: B
37
Q
- The “cooperating party” responsible for maintaining
the ICD-9-CM Disease classifi cation is the
A. Centers for Medicare and Medicaid Services (CMS)
B. National Center for Health Statistics (NCHS)
C. American Hospital Association (AHA)
D. American Health Information Management Association
(AHIMA)
E. National Institutes of Health (NIH)
A
- Answer: B
38
Q
- Select the accurate statement about proper billing ?
A. Bill for items or services not rendered or not provided
as claimed
B. Submit claims for equipment, medical supplies and services
that are not reasonable and necessary
C. Double bill resulting in duplicate payment
D. Bill for non-covered services as if covered
E. Knowingly do not misuse provider identification numbers, which results in improper billing
A
- Answer: E
Explanation:
Documentation Summary
Never:
Bill for items or services not rendered or not provided
as claimed
Submit claims for equipment, medical supplies and
services that are not reasonable and necessary
Double bill resulting in duplicate payment
Bill for non-covered services as if covered
Knowingly misuse provider identifi cation numbers,
which results in improper billing
Unbundle (billing for each component of the service
instead of billing or using an all-inclusive
code)
Upcode the level of service provided
Source: Laxmaiah Manchikanti, MD
39
Q
- Which of the following is the best predictor for a patient
with pain becoming violent?
A. Progressive psychomotor retardation
B. Prior diagnosis of a Dependent Personality Disorder
C. Past history of violence or destruction of property
D. Shouting at the offi ce staff to be seen immediately
E. Shouting at the physician to change the medical record
A
- Answer: C
Source: Cole EB, Board Review 2003
40
Q
1950. DSM-IV-TR is used most frequently in what type of health care setting? A. Work hardening programs B. Ambulatory surgery centers C. Home health agencies D. Behavioral health centers E. Nursing homes
A
- Answer: D
41
Q
- Which of the following is classifi ed as a poisoning in
ICD-9-CM?
A. Reaction to contrast administered for epidurogram
B. Idiosyncratic reaction between various drugs
C. Carbazeran intoxication
D. Syncope due to cold medicine and a three martini lunch
E. Motor paralysis for 2 hours following adhesiolysis
A
- Answer: D
42
Q
- Under the RBRVS for physician payments, three (3)
components are assigned relative value units. These are:
A. Physician work, experience, and malpractice insurance
expense
B. Geographic index, wage index, and cost of living index
C. Conversion factor, CMS weight, and hospital specifi c
rate
D. Physician work, practice expense, and malpractice insurance
expense
E. Fee-for-service, per diem payment, and capitation
A
- Answer: D
43
Q
- A nomenclature of codes and medical terms which
provides standard terminology for reporting physicians’
services for third party reimbursement is:
A. Current Medical Information and Terminology (CMIT)
B. Current Procedural Terminology (CPT)
C. Systematized Nomenclature of Pathology (SNOP)
D. Diagnostic and Statistical Manual of Mental Disorders
(DSM)
E. International Classifi cation of Diseases, Ninth Revision
(ICD-9)
A
- Answer: B
44
Q
1954.Identify WRONG statement about speciality designation: A. 09 = interventional pain management B. To change designation, fi ll out new 855I provider enrollment form C. 72 = pain medicine D. 10 = anesthesia E. 14=Neurosurgery
A
1954. Answer: D Explanation: Designate Yourself as 09 * 05 = anesthesia * 72 = pain management * 09 = interventional pain management * 14 = Neurosurgery * To change designation, fi ll out new 855I provider enrollment form * Web site to get 855 form: - cms.hhs.gov/providers/enrollment/forms/ Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
45
Q
- Pay for performance is being considered by Medicare
and third party payors. Identify accurate statements.
A. Compensation incentives will not induce changes in the
quality of services
B. Outcome measures are easy to develop
C. Compensation incentives rest on the economic fi eld
of agency theory (method of compensation induces
conduct)
D. Quality measures are already in place
E. It is simple to fi nance incentives
A
1955. Answer: C Explanation: Pay for Performance Compensation incentives rest on the economic fi eld of agency theory Method of compensation induces conduct Compensation incentives will not induce changes in the quality of services Issues to Consider in Paying for Performance How to measure quality Vehicles for encouraging quality What to reward How to fi nance incentives Source: Laxmaiah Manchikanti, MD
46
Q
1956.What are the requirements for Past, Family, Social
History documentation?
A. Three items for level 1 & 2 offi ce visits
B. Three items for subsequent hospital care, follow-up,
consultations, subsequent nursing home care
C. None for level 3 offi ce visits
D. One (1) specifi c item from EACH of the three categories
for level 3 offi ce visit
E. One (1) specifi c item from EACH of the three categories
for complete comprehensive service
A
1956. Answer: E Explanation: Past, Family, Social History * None For Level 1 & 2 offi ce visits Subsequent Hospital Care, F.U. Consultations, Subsequent Nursing Home Care * Pertinent Level 3 One (1) specifi c item from ANY of the three categories * Complete - Comprehensive New Service One (1) specifi c item from EACH of the three categories Follow-up One (1) specifi c item from EACH of the two categories or Either Update or Repeat all items
47
Q
- Choose the correct statement for History of Present
Illness:
A. For level I service, 4 items are documented
B. For level II service, 4 items are documented
C. For level III service, 4 items are documented
D. For level IV service only 3 items are documented
E. For level V service only 3 items are documented
A
1957. Answer: C Explanation: History of Present Illness * Brief (1-3) Level 1 & 2 * Extended (4+) Level 3 and above or Status of 3+ multiple chronic conditions
48
Q
1958. Which of the following is a critical component of evaluation and management services? A. Time B. Counseling C. Medical decision making D. Coordination of care E. Nature of presenting problem
A
1958. Answer: C Explanation: The critical components of evaluation and management services are: History Examination Decision-making Other four components are: Counseling Coordination of care Nature of presenting problem Time
49
Q
- Medical record functions include all of the following
EXCEPT:
A. Support insurance billing
B. Provide clinical data for education
C. Provide clinical data for research
D. Promote continuity of care among physicians
E. Reduce quality of care
A
1959. Answer: E Explanation: Medical records function to: keep the practitioner out of the slammer support “medical necessity” reduce medical errors & professional liability exposure reduce audit exposure facilitate claim review support insurance billing provide clinical data for education provide clinical data for research promote continuity of care among physicians indicate quality of care
50
Q
- Identify the accurate statement showing the differences
between consultation and a referral visit:
A. A problem is well known in both
B. A patient is referred for evaluation and treatment for a
consultation
C. Course of treatment is well known and predetermined
for a consultation
D. A patient is treated and followed in a referral visit
E. No correspondence is required as care is transferred in
consultation
A
- Answer: D
51
Q
- What are the documentation requirements for Review
of Systems?
A. Review of one (1) system for problem focused visit
B. Review of two (2) systems for expanded focused visit
C. Review of one (1) system for detailed visit
D. Complete or 10+ systems for comprehensive visit
E. Complete or 10+ systems for detailed visit
A
- Answer: D
Explanation:
Review Of Systems
* Problem-Pertinent
Positive and negative responses related to problems
identifi ed in the HPI
* Extended
Positive and negative responses related to 2 - 9 systems
* Complete
Ten Systems must be reviewed
or
In place of documenting negative responses to the
remaining systems (up to 10), May note all other systems
negative
52
Q
1962.Multiple components of proper medical record
documentation DOES NOT include the following:
A. The reason for the patient visit
B. The indication of services provided
C. The location of the services
D. Itemized billing for services
E. Plan of action including return appointment
A
- Answer: D
Explanation:
Proper medical record documentation includes the
following:
Why did the patient present for care?
What was done?
Where were the services rendered?
When is the patient to return or what is the plan of
action?
Will there be follow-up tests or procedures ordered?
Source: Laxmaiah Manchikanti, MD
53
Q
1963. What are the CPT codes describing new patient offi ce visits? A. 99201, 99203, 99204, 99215 B. 99201, 99202, 99203, 99204 C. 99201, 99202, 99214, 99233 D. 99204, 99203, 99221, 99233 E. 99261, 99262, 99252, 99255
A
- Answer: B
54
Q
- Prevalence of errors in outpatient settings are common
in patient encounters. The most common error in the
outpatient setting is:
A. Communication error
B. Prescribing error
C. Improper diagnosis
D. Loss of patient data
E. Improper follow up with abnormal lab result
A
- Answer: A
Explanation:
Communication error is the most common type of error
in the outpatient setting. It is then followed by
discontinuity of care, and then by abnormal lab result
follow up. The next four errors, although not as common,
are well suited to the EMR as heralding alerts. These
include missing values and poor charting, prescribing
errors of dosage choice, allergy or interaction, clinical
mistakes of knowledge or skills, which would include
improper diagnosis, and the ubiquitous “other”. “Other”
is actually quite high. This would include lost charts,
improper fi ling, and violation of confi dentiality to name a
few. At 8%, or 8 out of 100 charts, applying to the typical daily practice seeing 100 patients a day, this category
“other” is actually a very high and unacceptable number.
The EMR will assist in reducing this number.
Source: Hans C. Hansen, MD
55
Q
1965.The electronic medical record assists the practice
with billing guidelines, CMS guidelines and following
standards of “Incident to” billing. “Incident to” billing
for physician extenders is a CMS guideline detailed in
Statute S2050, which states that:
A. Accountability of supervising physician. The nurse
practitioner, or PA’s can bill at 100% if the physician is
immediately available on-site and involved in medical
decision making
B. The practice may bill the physician extender, nurse practitioner,
or PA at 100% if available by telephone
C. Requires that an 85% allowance of the physician fee is
necessary if the physician only sees the patient every
other visit
D. 100% may be billed by the nurse practitioner or physician
extender if they use their own provider codes
E. The electronic medical record ensures improved data
assessment and decision making, supporting 100%
physician fee by the extender.
A
- Answer: A
Explanation:
“Incident to” is a concern for CMS, and a potential source
for fraud and abuse. It is the duty of the practice to
determine whether the physician extender, nurse
practitioner, or PA, is meeting the appropriate guidelines
that CMS requires for “incident to” billing. It is
incumbent upon the pain management physician to know
these rules if an extender is being utilized. To bill at 100%
physician fee,the physician is immediately available onsite,
intimately involved in medical decision making with
support of the nurse practitioner and PA in follow up
visits. The physician will see the patient at fi rst encounter,
defi ne diagnosis, and course of care. Follow up will
typically be at the third to fi fth visit by the physician,
ensuring correct diagnosis and treatment pathway. The
physician extender may follow up with the patient,assist in
management of the patient, and bill at 100% if the
physician is onsite and immediately available. The
extender should only bill 85% if the physician is not
immediately available, or is not involved in the initial
encounter. In all incidences, the physician should be
involved in medical decision making. Even if the extender
has their own provider numbers, these “incident to”
criteria must be met to apply the 100% physician fee. If an
extender bills under their own provider number, typically
only an 85% physician fee criteria will be met. Many
practices adopt the policy of just billing at the straight
85% fee to avoid regulatory scrutiny, and to avoid the
pitfalls of non-compliance, particularly during an audit.
Source: Hans C. Hansen, MD
56
Q
- Dr. Smith requests a consultation from an interventional
pain physician on a patient in the hospital. The physician
takes a detailed history, performs a detailed examination,
and utilizes moderate medical decision-making.
The physician orders diagnostic tests and prescribes
medication. He documents his fi ndings in the patient’s
medical record and communicates in writing with the
attending physician. The following day the physician
visits the patient to evaluate the patient’s response to the
medication, to review results from the diagnostic tests,
and discuss treatment options. What codes should the
physician report for the two visits?
A. An initial hospital visit and follow-up hospital care
B. An initial inpatient consult and initial hospital care
C. An initial inpatient consult and follow-up hospital care
D. An initial inpatient consult and a follow-up consult
E. An initial inpatient consult for both visits
A
- Answer: C
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
57
Q
- A system of preferred terminology for naming disease
processes is known as a :
A. Set of categories
B. Diagnostic listing
C. Classifi cation system
D. Medical nomenclature
E. International Classifi cation of Diseases
A
- Answer: D
58
Q
- Torts are civil wrongs recognized by law as grounds
for a lawsuit. These wrongs result in an injury or harm
constituting the basis for a claim by the injured party.
The primary aim of tort law is to provide relief for the
damages incurred and to deter others from committing
the same harm. Which of the following may the injured
person not sue for?
A. Loss of earning capacity
B. Three times medical expenses
C. Injunction to prevent release of protected information
D. Pain and suffering
E. Actual and potential reasonable medical expenses
A
- Answer: B
Explanation:
The injured person may sue for an injunction to prevent
the continuation of the tortuous conduct or for monetary
damages. Among the types of damages the injured party
may recover are: loss of earnings capacity, pain and
suffering, and reasonable medical expenses. They include
both present and future expected losses.
There are numerous specifi c torts including trespass,
assault, battery, negligence, products liability, and
intentional infl iction of emotional distress. Torts fall into
three general categories: intentional torts (e.g.,
intentionally hitting a person); negligent torts (causing an
accident by failing to obey traffi c rules); and strict liability
torts (e.g., liability for making and selling defective
products - See Products Liability). Intentional torts are those wrongs which the defendant knew or should have
known would occur through their actions or inactions.
Negligent torts occur when the defendant’s actions were
unreasonably unsafe. Strict liability wrongs do not depend
on the degree of carefulness by the defendant, but are
established when a particular action causes damage. Tort
law is state law created through judges (common law) and
by legislatures (statutory law).
Source: Gurpreet Singh Padda MD MBA
59
Q
- What authority does a Local Medicare Carrier have
regarding payment for an item or service that is noncovered
because of a National Coverage Decision (NCD)?
A. The coverage determination on whether specifi c medical
items and services are reasonable and necessary under
Medicare Law is published in the National Coverage
Manual and Local Carriers do not have the discretion
to pay for the services
B. The Medical Director of a Local Carrier has the authority
to review a comprehensive report and information on
the item or service sent by the treating physician and
pay the claim if, in his/her opinion, medical necessity
has been demonstrated.
C. The CAC may overturn the NCD and publish a local
coverage addendum that the specifi c item or service
may be paid under special circumstances.
D. The CAC and/or the Carrier Medical Director may
write to the Medicare Coverage Advisory Committee
(MCAC) for permission to pay for the item or service;
E. Medical Director of a Local carrier has overriding authority
on National coverage policies.
A
- Answer: A
Explanation:
An NCD is made after a comprehensive evaluation process
that often includes a technology assessment by anexpert(s)
outside CMS and/or the CMS Coverage Advisory
Committee. NCD’s are made according to a process
detailed in a Federal Register Notice dated April 27, 1999
(64 FR 22619). An NCD is binding on all Medicare
carriers, fi scal intermediaries, quality improvement
organizations, health maintenance organizations
(Medicare), competitive medical plans and health care
prepayment plans.
Source: CMS website www.cms.gov
Source: Joanne Mehmert, CPC, Sep 2005
60
Q
- How do Local Medicare Contractors that pay claims in
each state make coverage determinations?
A. All coverage determinations are updated and sent to the
Local Contractor by the Centers for Medicare and Medicaid
Services (CMS) once a year.
B. The Medical Director at each carrier reviews statistical
data to determine how much it has paid for each CPT
procedure code and reduces payments on the most
frequently paid codes by means of restrictive coverage
policies
C. A committee of physician specialists, (Carrier Advisory Committee (CAC)), in the State participates in the development
of Local Coverage Decisions (LCD).
D. All claims that have a valid CPT code are paid, there are
no exceptions.
E. All interventions without a National coverage policy are
considered for coverage
A
- Answer: C
Explanation:
Reference: www.cms.gov; Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Carriers are required to maintain CAC’s which are
intended to provide a formal mechanism for physicians in
the State to be informed and participate in the
development of coverage decisions in an advisory capacity.
CMS instructed Medicare Carriers by means of
Transmittal #106, March 4, 2005, that it is mandatory to
include Interventional Pain Management Specialists on
CAC Membership.
Source: CMS Web site: www.cms.gov; Chapter III
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
61
Q
- What level(s) E&M service can a registered nurse (R.N)
Perform?
A. If the physician is in the offi ce but does not see the patient,
and the nurse spends a long time with the patient
h/she may report a level 3 service: 99213
B. An R.N. may not report any E&M service codes
C. The only appropriate level of service for an R.N. to report
is 99211
D. An R.N. may report whatever level of service he/she
provides/documents
E. Under the advance nurse practitioner act, nurses are entitled
for equal payment as physicians.
A
- Answer: C
Explanation:
The description of CPT code 99211 includes the
statement,“that may not require the presence of a
physician”. Medicare allows an R.N. to report code 99211
as an “incident to” service, i.e., the physician must be in the
offi ce. Services such as an evaluation when a patient
comesto pick up a prescription refi ll or a patient that
is seen for a drug screen are clinical examples listed in
Appendix C of the CPT Manual. Regardless of the extent
of the R.N.’s service, (work performed, length of time
spent) the only appropriate code h/she may report is
a Level I, 99211.
Source: Medicare Carriers Manual 100-4; CPT Manual
Source: Joanne Mehmert, CPC, Sep 2005
62
Q
- How do you report the unlisted drug code J3490 so payer
knows how much to reimburse for the drug?
A. List the code J3490 in the “procedure code “ fi eld (24D)
and the amount of the drug given in the number of services
fi eld, (24G) attach a letter that describes the drug
B. List code J3490 in 24D and number “1” in the units/
services fi eld (24G) and list the name of the drug, the
amount given and the strength in the information fi eld
(Box 19 on the 1500).
C. CMS doesn’t pay for unlisted drugs; they should not be
reported to Medicare
D. List J3490 in 24D, and the amount used in 24G and
always send an invoice with the claim for the unlisted
drug
E. Collect from the patient.
A
- Answer: B
Explanation:
Since the drug is “unlisted” the description J3490 does not
include an amount; therefore the number of services listed
in 24G is “1”. A complete description of the substance and
amount administered is listed in the informational fi eld,
which is Box 19 on a paper claim 1500. The insurance
payer wants to know what drug and how much of the drug
was administered.
An NDC number listed in the “information” fi eld will
provide an exact description. There are some
circumstances (compound drugs used in pumps) where
the invoice may be required or would provide necessary
information for the payer to determine payment; however
as a general rule, it is not necessary to attach an invoice.
Source: Medicare policies; HCPCS Manual
Source: Joanne Mehmert, CPC, Sep 2005
63
Q
- How do you determine the “number of services/units”
to list on the CMS 1500 form (or electronic fi eld) for the
“J” codes?
A. All “J” codes are reported as “1” unit
B. List the number of mgs, mls, mcgs, or units that are
administered to the patient in the “number of services
fi eld”.
C. Each “J” code lists a specifi c dosage, such as, “per 10
mg”.
D. Convert the amount listed in the “J” code to ml’s and
calculate the number of ccs were used
E. All “J” Codes are reported as “10” units.
A
- Answer: C
Explanation:
The quantity of the “J” codes is listed in various forms that
must be taken into consideration when calculating the
number of units/services to report. For example, Depo
Medrol, a commonly used drug for epidural injections
comes in 3 different amounts, (J1020, 20 mg, J1030, 40 mg
and J1040, 80 mg) and is one of the least complicated
drugs to bill. When 80 mgs of Depo is administered,
report J1040 x 1 unit.
Aristocort Forte is described as J3302, per 5 mg. When 40
mg is administered, the number of units/services will be
listed as ‘8’ since it will take 8 units of 5 mg each to reach a
dosage of 40 mg. It is particularly important to coordinate
with the provider to ensure that h/she documents the
amount of the drug used and lists the name and amount
on the charge ticket in such a manner that the coding
person bills the correct number of units.
The most straightforward method for most coding/billing
staff is to describe the drug on the charge ticket using the
same measurement that is listed in the HCPCS “J” code
description. The provider’s documentation should state
the amount given using the same description, (e.g., units,
cc’s, mg).
Source: Joanne Mehmert, CPC, Sep 2005
64
Q
- Do non-Medicare payers allow physicians to report nonphysician
services as “incident to” if they meet the same
requirements as Medicare?
A. Yes, all payers recognize the “incident to” billing concept
B. The term “incident to” is unique to Medicare and “incident
to” regulations are Medicare regulations.
C. Non-Medicare payers do not pay for services unless the
physician is present in the room with the patient during
the provision of the service
D. None of the above
E. All of the above.
A
- Answer: B
Explanation:
Billing rules for services provided by non-physician
providers vary from payer to payer. Non-Medicare payers
may reimburse non-physicians differently. Providers
should review their participation agreements for all of
their contracted payers as well as the State laws in which
they are providing services. In cases where physicians, as
the collaborating physician, have complete leeway to delegate services that are within the non-physician’s scope
of practice, the services will generally be reported as if
rendered by the physician.
Medicare’s requirement that the physician be “in the
offi ce”may not pertain to other insurers unless the
payer specifi es that they apply. Many states allow a
general delegation of authority with responsibility
retained by the physician without requiring on-premises
supervision.
In situations where the provider is not participating,
Medicare rules may be the best option for billing nonphysician
practitioner services.
Source: “The Ins and Outs of “incident –To
Reimbursement” by Alice Gosfi eld, J.D., Family Practice
Management, November/December 2001.
Source: Joanne Mehmert, CPC, Sep 2005
65
Q
- Drugs and supplies used “incident to” the physician’s
service paid separately or considered bundled into the
CPT code for an injection or nerve block because:
A. All “incident to” items and services should be individually
reported and are separately paid by Medicare
B. All “incident to” items and services are considered paid
for in the payment for only one CPT code, nothing
should be separately reported
C. “Incident to” only refers to non-physician practitioners
and “global” refers to supplies, radiology services and
drugs
D. Drugs and supplies are considered “incident to” costs.
E. If Medicare does not pay “Incident to” items and services
must be collected from the patient.
A
- Answer: D
Explanation:
The term “incident to” is primarily a CMS description for
items and services that are furnished as a part of the
patient’s normal course of treatment and are incidental
(contributory or ancillary) to a patient’s care. Drugs that
cannot be self administered (other than local anesthetics)
are reported and paid separately, most supplies are
included in the global payment.
Source: Medicare Carriers Manual, 100-4, Chapter 12;
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
66
Q
- Dr. Bob is on vacation and his patient Mrs. Smith, a
Medicare benefi ciary, will be seen in the offi ce today by
the NP. Dr. Bob evaluated Mrs. Smith and initiated Mrs.
Smith’s treatment plan 3 weeks ago. Dr. Jim, another
member of the group is seeing patients in the offi ce
during Mrs. Smith’s visit. Mrs. Smith does not have any
new complaints; the NP evaluates her and advises Mrs.
Smith to continue treatment plan that Dr. Bob initiated.
How is the service reported to Medicare?
A. Report the service using the NP’s own name and PIN
number
B. Report the service as an “incident to” service, using Dr.
Bob’s name and PIN number
C. Report the service as an “incident to” service, using Dr.
Jim’s name and number
D. Report as an “incident to” service with Dr. Jim’s PIN and
name. List Dr. Bob’s name and UPIN number as the
“referring doctor (Boxes 17 & 17a) on a paper form
or in the corresponding fi eld when the claim is fi led
electronically.
E. Report as an “Incident to” service using Dr. Bob’s PIN
and name.
A
- Answer: D
Explanation:
Effective May 24, 2004, CMS implemented its clarifi cation
of the Preamble of the Proposed Rule for the Medicate
Physician Fee Schedule on November 1, 2001 (66 Fed Reg
55267) which stated, “The billing number of the ordering
physician (or other practitioner) should not be used ifthat
person did not directly supervise the auxiliary personnel.”
In Question VII above, the doctor that established the
plan of care (Dr. Bob) is the “ordering provider” and Dr.
Jim is the “supervising provider”.
CMS sent Change Request #3138, dated April 23, 2004 to
Medicare Carriers that further clarifi es where physician’s
Provider Information Numbers and names should be
reported when both an ordering provider and a
supervising provider are involved in a service.
Source: Medicare Carriers Manual 100-04, Medicare
Claims Processing; Transmittal 148, April 23, 2004, CMS
website, Medlearn Matters #MM3138
67
Q
- When a pain specialist performs a 3 level lumbar
discogram in an outpatient hospital place of service
(POS) 22, films are taken, and a report is issued what
radiology code(s) should be reported:
A. 72295-26 x 3
B. 72295-26 x 1
C. 76003-26, 72295-26
D. 76005, 72295 x 3
E. 76003 X3, 72295X1
A
- Answer: A
Explanation:
It is appropriate to report code 72295-26, the and interpretation code, for each level for which a
diagnostic study is performed, fi lms taken and a report is
written. The fl uoroscopic guidance code, 76005 is not
separately reported since fl uoroscopic guidance is
included in the supervision and interpretation codes
Source: CPT Assistant: Code and Guideline Changes, A
Comprehensive Review November 1999; CPT Assistant
Coding Consultation Questions and Answers, April 2003.
Source: Joanne Mehmert, CPC, Sep 2005
68
Q
- When a physician loans a C-Arm to an ambulatory
surgical center, place of service (POS), 24 where h/she
performs procedures, the correct code to report for
fl uoroscopic guidance for a facet injection is:
A. 76005-26
B. 76003-26
C. 76005
D. 76000-26
E. 76005-TC
A
- Answer: A
Explanation:
Medicare (and many non-Medicare insurers) pays a global
facility fee to an ASC that includes fl uoroscopic guidance;
it would be a duplicate payment if the physician were paid
a global fee for the fl uoroscopic guidance. When a
procedure is performed in a facility setting, modifi er -26,
the professional component, is appended to the
radiological codes. The physician should lease the
equipment to the ASC.
Source: Medicare Contractors Manual, 100-04, Chapter
14, §10.2
Source: Joanne Mehmert, CPC, Sep 2005
69
Q
1979. When an epidurogram is performed in the offi ce, place of service (POS) 11, images are taken and a formal radiologic report is issued, the physician should report code(s): A. 76005 and 72275 B. 76003 and 72275-26 C. 72275 D. 76005-26 and 72275-TC E. 72275 and 76003 TC
A
- Answer: C
Explanation:
Code 72275, is a supervision and interpretation code that
includes code 76005. The use of fl uoroscopy (76005) is
included in the supervision and interpretation codes and
should not be separately reported
Source: CPT coding Manual; Manchikanti L, Principles
and Practice of Documentation, Billing, Coding, and
Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
70
Q
- Which of the following is a properly designed control
procedure for internal control of accounts receivables?
A. Lag time on billing charges should be closely watched
B. Protocol for authorizing write-offs and discounts should
be established
C. Prior authorizations should be obtained before services
rendered if you think they won’t be paid
D. Patient statements are mailed on a monthly basis
E. Insurance requests for medical records should be logged
and dated
A
- Answer: B
Explanation:
Management of contractual discounts and bad-debt
write-offs ensure that they are legitimate and maintain the
integrity in AR reports.
Source: Marsha Thiel, RN, MA, Sep 2005
71
Q
- Which of the following may report a physician to the
National Practitioner Data Bank?
A. A plaintiff ’s attorney after fi ling a successful claim.
B. A professional society.
C. A judge imposing sanctions.
D. A state licensing board, that receives an allegation.
E. A professional society that conducts formal peer review.
A
- Answer: E
Explanation:
The National Practitioner Data Bank (NPDB) was
established under Title IV-B and B of Public Law 99-660,
42 U.S.C. Section 11101-11152, “The Health Care Quality
Improvement Act of 1986.” The NPDB, which is
maintained by the Department of Health and Human
Services (DHHS), contains a record of adverse clinical
privileging, licensure, and professional society
membership actions taken primarily against physicians
and dentists, and medical malpractice payments made on
behalf of all health care practitioners who hold a license or
other certifi cation of competency. Groups that have access
to the NPDB include hospitals, other health care entities
that conduct peer review and provide or arrange for care, state boards of medical or dental examiners, and other
health care practitioner state boards. Individual
practitioners are also able to self-query the NPDB. The
reporting of information to the NPDB is restricted to
medical malpractice payers, state licensing medical boards
and dental examiners, professional societies that conduct
formal peer review, and hospitals and health care entities.
Source: Gurpreet Singh Padda MD MBA
72
Q
1982.There are currently how many levels of appeal/review
available when a provider and/or Medicare benefi ciary
disagrees with Medicare’s initial determination of claim
payment/denial?
A. There is no opportunity to ask for a review, the Carrier
or Fiscal Intermediary determination is fi nal
B. Three levels of appeal all at the Carrier level
C. Five levels of appeal; the fi nal level is a judicial review in
U.S. District Court
D. Four levels of appeal, the fi nal level is the Administrative
Law Judge (ALJ)
E. Six levels, the fi nal level is the review by secretary of
HHS.
A
- Answer: C
Explanation:
The fi ve levels of review are: 1) appeal to the Medicare
contractor for a re-consideration of the initial
determination, 2) Qualifi ed Independent Contractor
(“QIC”) or Hearing Offi cer employed by the Carrier, 3)
ALJ hearing which can be held by videoconference where
the technology is available, 4)Departmental Appeals Board
review (“DAB”), and 5) Judicial review in U.S. District
Court.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. Federal Register March 25, 2005 and
June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
73
Q
- While waiting to operate, a surgeon asks a physician
colleague what the best antibiotic to use for surgical
implants. The colleague states she always uses Antibiotic
G. The patient is prescribed Antibiotic G by her surgeon
and is found to be allergic two days later, but suffers no
injury. Who is negligent?
A. The colleague
B. The surgeon
C. The pharmacist
D. No one.
E. The patient
A
- Answer: D
Explanation:
The legal criteria for determining negligence require all of
the following: - the professional must have a duty to the affected party
- the professional must breach that duty
- the affected party must experience a harm; and
- the harm must be caused by the breach of duty.
Curbside consultation creates no physician patient
relationship.
Source: Gurpreet Singh Padda MD MBA
74
Q
- A patient undergoes an intrathecal pump implantation
procedure, and develops a deep tissue infection because
the instrument pack was not sterilized. Negligence
occurred in the following circumstance?
A. The operating room nurse failed to notify the surgeon
that the instrument pack was not appropriately sterilized.
B. The operating surgeon did not verify that the instrument
pack was appropriately sterilized.
C. The pump manufacturer failed to obtain a consent for
the implanted device.
D. The patient’s alienated spouse was not contacted by the
physician after the infection was discovered.
E. The wrong antibiotic was prescribed by the operative
physician.
A
- Answer: A
Explanation:
In common language, we consider it negligence if one
imposes a careless or unreasonable risk of harm upon
another. The legal criteria for determining negligence are
as follows: - the professional must have a duty to the affected party
- the professional must breach that duty
- the affected party must experience a harm; and
- the harm must be caused by the breach of duty.
This principle affi rms the need for medical competence. It
is clear that medical mistakes occur, however, this
principle articulates a fundamental commitment on the
part of health care professionals to protect their patients
from harm.
Source: Gurpreet Singh Padda MD MBA
75
Q
1985. All of the following are major principles of medical ethics, except? A. the principle of respect for autonomy B. the principle of nonmalefi cence C. the principle of benefi cence D. the principle of justice E. the principle of egalitarianism
A
- Answer: E
Explanation:
A. Respect for Autonomy means that the patient has the
capacity to act intentionally, with understanding, and
without controlling infl uences that would mitigate against
a free and voluntary act. This principle is the basis for the
practice of “informed consent” in the physician/patient
transaction regarding health care
B. The Principle of Nonmalefi cence requires of us that we
not intentionally create a needless harm or injury to the
patient, either through acts of commission or omission.
C. The Principle of Benefi cence is the duty of health care
providers to be of a benefi t to the patient, as well as to take
positive steps to prevent and to remove harm from the
patient.
D. The Principle of Justice is usually defi ned as a form of
fairness, or as Aristotle once said, “giving to each that
which is his due.” This implies the fair distribution of
goods in society and requires that we look at the role of
entitlement. The question of distributive justice also seems
to hinge on the fact that some goods and services are in
short supply, there is not enough to go around, thus some
fair means of allocating scarce resources must be
determined.
E. Egalitarianism is the basis of the French Constitution.
Source: Gurpreet Singh Padda MD MBA
76
Q
- A study involving a new pain medication is being
proposed. Which of the following is not required in the
informed consent?
A. The names of the Insitutional Review Board board members
who approved the study
B. The aims of the study
C. The anticipated benefi ts of the study
D. The potential hazards of the study
E. The discomforts of participating in the study
A
- Answer: A
Explanation:
In any research on human beings, each potential subject
must be adequately informed of the aims, methods,
anticipated benefi ts and potential hazards of the study and
the discomfort it may entail. He or she should be informed
that he or she is at liberty to abstain from participation in
the study and that he or she is free to withdraw his or her
consent to participation at any time. The physician should
then obtain the subject’s freely-given informed consent,
preferably in writing.
Source: Gurpreet Singh Padda MD MBA
77
Q
- In human subject research, who is required to obtain
consent?
A. The nurse checking the patient in.
B. The primary investigator.
C. A designated properly trained person who is knowledgeable
about the study and able to answer questions.
D. The patient should read the consent independent of any
third party and have a witness sign the consent before
discussing the research procedure.
E. The competent patient’s family members should obtain
the consent and sign as witnesses.
A
- Answer: C
Explanation:
The person who conducts the consent interview should be
knowledgeable about the study and able to answer
questions. FDA does not specify who this individual
should be. Some sponsors and some IRBs require the
clinical investigator to personally conduct the consent
interview. However, if someone other than the clinical
investigator conducts the interview and obtains consent,
this responsibility should be formally delegated by the
clinical investigator and the person so delegated should
have received appropriate training to perform this activity.
Source: Gurpreet Singh Padda MD MBA
78
Q
- Research informed consent may not be obtained?
A. In person from a competent subject
B. By telephone only from a legally authorized representative
C. In person from a competent subject, who cannot write
his full name
D. In a language other than English with an approved
translation.
E. A member of the research team, other than the primary
investigator
A
- Answer: C
Explanation:
A verbal approval does not satisfy the 21 CFR 56.109(c)
requirement for a signed consent document, as outlined in
21 CFR 50.27(a). However, it is acceptable to send the
informed consent document to the legally authorized
representative (LAR) by facsimile and conduct the consent
interview by telephone when the LAR can read the consent
as it is discussed. If the LAR agrees, he/she can sign the
consent and return the signed document to the clinical
investigator by facsimile.
Source: Gurpreet Singh Padda MD MBA
79
Q
- Presumed or implied consent for a chest tube after
pneumothorax is valid in which of the following
circumstances?
A. The patient is transported to the Emergency Room in
shock and obtunded.
B. The patient is transported to the Emergency Room, is
short of breath but competent and does not want a
procedure.
C. The patient is in the ICU, is short of breath but competent competent
and does not want a procedure.
D. The patient is in the ICU and has made his decision
against interventional treatment abundantly clear previously,
signing a DNR, but is now obtunded.
E. The patient’s legal guardian is in the ICU, with the obtunded
patient, indicating that the patient would never
consent to a chest tube and has signed a DNR, which is
not taped to the front of the chart.
A
- Answer: A
Explanation:
Is there such a thing as presumed/implied consent?
The patient’s consent should only be “presumed”, rather
than obtained, in emergency situations when the patient is
unconscious or incompetent and no surrogate decision
maker is available. In general, the patient’s presence in the
hospital ward, ICU or clinic does not represent implied
consent to all treatment and procedures. The patient’s
wishes and values may be quite different than the values of
the physician’s. While the principle of respect for person
obligates you to do your best to include the patient in the
health care decisions that affect his life and body, the
principle of benefi cence may require you to act on the
patient’s behalf when his life is at stake.
Source: Gurpreet Singh Padda MD MBA
80
Q
- In obtaining clinical informed consent how much
information is considered “adequate”?
A. The currently available literature regarding the specifi c
procedure.
B. The same information that a fellow physician would
expect.
C. What this specifi c patient needs to know and understand
in order to make an informed decision.
D. The top fi ve risks associated with this procedure.
E. What a reasonable physician would tell her patient
A
- Answer: C
Explanation:
How do you know when you have said enough about a
certain decision? Most of the literature and law in this area
suggest one of three approaches:
* reasonable physician standard: what would a typical
physician say about this intervention? This standard allows
the physician to determine what information is
appropriate to disclose. However, it is probably not
enough, since most research in this area shows that the
typical physician tells the patient very little. This standard
is also generally considered inconsistent with the goals of
informed consent as the focus is on the physician rather
than on what the patient needs to know.
* reasonable patient standard: what would the average
patient need to know in order to be an informed
participant in the decision? This standard focuses on
considering what a patient would need to know in order to
understand the decision at hand.
* subjective standard: what would this patient need to
know and understand in order to make an informed
decision? This standard is the most challenging to
incorporate into practice, since it requires tailoring
information to each patient.
Most states have legislation or legal cases that determine
the required standard for informed consent. The best
approach to the question of how much information is
enough is one that meets both your professional obligation to provide the best care and respects the patient as a
person with the right to a voice in health care decisions.
Source: Laxmaiah Manchikanti, MD
81
Q
- What are the elements of full informed consent?
A. The name of the procedure, written in lay language
B. Written list of alternative treatments
C. Signature of patient documenting consent
D. A witness signature
E. The patient have an opportunity to be an informed participant
in his health care.
A
- Answer: E
Explanation:
The most important goal of informed consent is that the
patient have an opportunity to be an informed participant
in his health care decisions. It is generally accepted that
complete informed consent includes a discussion of the
following elements:
* the nature of the decision/procedure
* reasonable alternatives to the proposed intervention
* the relevant risks, benefi ts, and uncertainties related to
each alternative
* assessment of patient understanding
* the acceptance of the intervention by the patient
Source: Gurpreet Singh Padda MD MBA
82
Q
- What is informed consent?
A. Telling the patient he needs to have done.
B. Letting the patient ask what needs to be done.
C. Telling the patient about the options of treatment, which
may include no treatment.
D. An ongoing interactive process by which a patient understands
his choices regarding healthcare, not necessarily
written.
E. A comprehensive list of written risks associated with
a specifi c procedure, provided to the patient prior to
initiating the procedure.
A
- Answer: D
Explanation:
Explanation: Informed consent is the process by which a
fully informed patient can participate in choices about his
health care.It originates from the legal and ethical right the
patient has to direct what happens to his body and from
the ethical duty of the physician to involve the patient
in his health care.Although written consent in a clinical
situation is recommended, it is not required.For example:
consent to examine by taking a patient history.
Source: Gurpreet Singh Padda MD MBA
83
Q
- Identify accurate statements: When a health care
provider fails to honor a patient’s written request for an
itemized statement of items or services within 30 days,
what penalties may the provider face from the HHS Offi ce
of Inspector General (OIG)?
A. Exclusion from Medicare program
B. Civil monetary penalty of $5,000
C. Civil monetary penalty and exclusion
D. Civil monetary penalty of $100 for each unfi lled request
E. Criminal penalty with 6 month prison time.
A
- Answer: D
Explanation:
D. Under the Social Security Act (SSA) Medicare patients
have the right to submit a written request for an itemized
statement to any physician, provider, supplier, or any other
health care provider for any item or service provided to the
patient by the provider.
After receiving a request, the provider has 30 days to
furnish an itemized statement describing each item or
service provided to the patient. Providers that fail to
honor a request may be subject to a civil monetary penalty
of $100 for each unfulfi lled request. In addition, the
provider may not charge the benefi ciary for the itemized
statements.
Source: Laxmaiah Manchikanti, MD
84
Q
1994.What are the accurate statements about billing and
compliance?
A. A physician may mark up durable medical equipment
items under the Stark Physician Self-referral in-offi ce
ancillary services exception.
B. If a practice which does not have a compliance plan discovers
a billing error, it is not necessary for this practice
to make a voluntary disclosure and a refund of the
overpayment.
C. When a provider receives a payment from Medicare that should have gone to the patient, the provider should
keep the payment.
D. Direct supervision is defined as “The physician is responsible
overall, but is not necessarily present at the
time of procedure.”
E. If an employee files a qui tam (whistleblower) suit against
his or her employer, the employer may ask the employee
to stay out of the work place and refrain from speaking
to his or her co-workers until a full investigation has
taken plan.
A
- Answer: A
Explanation:
A. The DME must meet six requirements in order to be
billed as in-offi ce ancillary services: - It is needed by the patient to move or leave the
doctor’s offi ce, or is a blood glucose monitor. - It is provided to treat the condition that brought the
patient to the physician and in the “same building” - It is given by the physician or another physician or
employee in a group practice. - The physician or group practice meets all DME supplier standards
- The arrangement doesn’t violate any billing laws or
the Anti-Kickback Statute. - All other in-offi ce ancillary requirements are met.
B. Providers only need to self disclose to OIG in certain
situations. They do not need to self disclose every time
they receive an overpayment from Medicare. However,
every provider must learn when OIG views an
overpayment as a deliberate attempt to defraud Medicare
instead of the result of a harmless error.
If the circumstances surrounding the billing error
resemble any of the situations described below, consider
voluntary disclosure and return of the over payment.
Otherwise, a refund may be suffi cient.
* The situation is the result of a willful disregard for fraud
and abuse laws.
* The situation is a systematic problem that occurred over
a long period of time.
* The provider has not such mechanisms as a compliance
plan in place.
* The provider took no action once the problem was
discovered.
C. Once a provider realized that he or she has received an
overpayment, the provider is statutorily obligated to
return it to Medicare. This includes instances where the
provider receives an overpayment due to an unintended
mistake on their part.
D. According to the Centers for Medicare & Medicaid
Services (CMS), there are three levels of supervision.
General supervision means the procedure is furnished
under the physician’s overall direction and control, but the
doctor’s presence is not required during the procedure.
(The physician remains responsible for training nonphysician
personnel and for maintaining all necessary
equipment and supplies.)
Direct supervision means the physician must be present in
the offi ce suite and immediately available to furnish
assistance and direction throughout the performance of a
procedure. It does not mean that the physician must be
present in the room when the procedure is performed.
Personal supervision means a physician must be in
attendance in the room during the performance of the
procedure.
E. Whistleblowers who are discharged, demoted,
suspended with or without pay, threatened, harassed or in
any other manner discriminated against by their
employers in the terms and conditions of employment are
entitled to relief. That includes reinstatement with the
same seniority,two times the amount of back pay, interest
on the back pay and compensation for any damages,
including attorney’s
fees.
Source: Laxmaiah Manchikanti, MD
85
Q
- When a physician performs a facet joint nerve injection
using fluoroscopic guidance in an office setting, place of
service (POS) 11, he/she should report what code(s):
A. 76000-26
B. 76005
C. 76005-26-TC
D. 76003
E. 76003-26
A
- Answer: B
Explanation:
In the provider’s offi ce (POS 11), h/she owns/leases the
radiological equipment and is entitled to the global
payment (professional and technical components). The
CPT code is submitted without a modifi er to indicate that
the provider is entitled to the global reimbursement.
Source: CPT Coding Manual, CPT Coding Conventions;
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
86
Q
- A patient is admitted to the hospital by a general surgeon.
The pain physician is requested to see the patient for
the purpose of providing whatever pain treatment was
necessary during the hospital stay. Regarding the pain
physician’s initial visit, made for the purpose of assessing
a course of treatment, that visit should be coded as
follows:
A. An inpatient initial hospital care code
B. A subsequent hospital care code
C. An inpatient consult
D. An outpatient consult
E. A confi rmatory consult
A
- Answer: B
Explanation:
Many physicians incorrectly bill an initial hospital care
code for the fi rst time they see the patient during ahospital
stay. However, only the admitting physician, in this case
the surgeon, can bill an initial hospital care code. If the
pain physician is not the admitting physician,he must bill
a subsequent hospital care code, unless he can bill an
inpatient consult. In the above scenario, an inpatient
consult is not billable because the factual scenario
stipulates that the surgeon referred the patient for
treatment, not for an opinion from the pain physician. A
consult cannot be billed unless the patient is referred for
an opinion.
CPT 2005, p. 12, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
87
Q
1997.The senior physician notices that a new physician
routinely fails to code all required diagnoses and
procedures for a patient encounter. This indicates that
there is a problem with:
A. Accuracy
B. Validity
C. Billing and coding
D. Timeliness
E. Reliability
A
- Answer: C
88
Q
1998.True statements about IDET coding include all of the
following, EXCEPT:
A. A new code was established in 2005
B. IDET codes are 0062T (0063T is add’l level)
C. Both are temporary, Category III codes
D. Fluoro is not bundled
E. If a temporary code is available, you must use it instead
of unlisted Category I code
A
- Answer: D
Explanation:
IDET
* New code for 2005
* 0062T (0063T is add’l level)
* Temporary, Category III codes
* Fluoro bundled
* CPT Code says that if a temporary code is available, you
must use it instead of unlisted Category I code
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
89
Q
1999.The Institute of Medicine defi ned core features in the
electronic medical record (EMR) .These include:
A. Patient notifi cation of abnormal laboratory data
B. Decision support
C. Alert reminders and practice tools
D. Allowing payer sources to have access to the medical record,
and payer sources’ attorneys and interested third
parties’ access to the medical record
E. Reporting electronic data storage using uniform data
standards, allowing physician’s offi ces to comply with
federal, state and private reporting requirements.
A
- Answer: C
Explanation:
The electronic medical record is a secure record that does
not allow access to unregistered or unnecessary personnel,
payor sources, or other entities that could disturb a HIPAA
compliant environment. Policy and procedures should be in place with each electronic medical record to assure that
no breach of confi dentiality is realized.
Source: Hans C. Hansen, MD
90
Q
- A pain physician receives a referral from an orthopedic
surgeon who has recently performed back surgery on a
patient whom the pain physician has never seen. The
orthopedic surgeon has done all he can do for this
particular patient. The pain physician performs the
requirements for a level 4 patient encounter, but decides
during the encounter that the patient would benefi t
from a lumbar epidural steroid injection. The physician
dictates a report to the referring surgeon and mails it to
him. This patient encounter should be coded as:
A. 62311 – Bill only the procedure code because the E&M
service is bundled
B. 62311 and 99244-25 – Bill the procedure and a level 4
consult. A consult is billable even when treatment is
administered
C. 62311 and 99204-25 – Bill both the procedure and a level
4 new patient code. You can’t bill a consult because the
referring physician has done all he can for the patient,
so he is referring the patient for treatment and hasn’t
requested an opinion.
D. 62311 or 99204-25 – Bill either the procedure or the
new patient code because you can’t bill both on the
same date of service
E. 62311 or 99244-25 – Bill either the procedure or the consult
code because you can’t bill both on the same date of
service
A
- Answer: C
Explanation:
The general rule is that a physician can bill both a
procedure and either a new patient visit or a consult on
the same date of service. In this case, the issue is whether
the E&M code is a consult or a new patient visit. Because
the referring physician had done all he could for the
patient, he really isn’t interested in the pain physician’s
opinion; he just wants the pain physician to treat the
patient. Therefore, the hallmark of a consult, i.e., a
request for an opinion, is not present. Thus, a new patient
visit must be coded.
Medicare Claims Processing Manual, Chapter 12, Section
30.6.10.A.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
91
Q
- A pain physician sees a Medicare pain patient in the
offi ce for the pre-procedure visit relating to a scheduled
epidural that day. The patient has been complaining of
radicular back pain. On the date of the procedure, the
patient also complains of headaches that have become
unmanageable by over-the-counter medications. The
physician performs a level 3 E&M service for the headache.
The physician also performs a brief E&M service for the
back to insure that the clinical indications still warrant
the epidural. The physician prepares one dictation, in
which he includes the patient’s headaches, the low back
pain, and the lumbar epidural injection for that day. The
physician prescribes narcotics for the headaches. This
patient encounter should be coded as:
A. 62311 – Bill only the procedure code because the E&M
services are bundled
B. 99215 – Combine the two E&M services into the highest
E&M code because 99215 pays more than a lumbar
epidural in the offi ce
C. 62311 and 99213-25 – Bill both the procedure and the
E&M code for the headaches, provided that the level of
the E&M code relates solely to the headaches and not
the back
D. 62311 and 99215-25 – There are two separate E&M services,
one for the headaches and one for the low back;
combine the two E&M services (levels 3 and 2) to bill
one level 5 E&M code.
E. 62311 and 99211-25 – The failure of the physician to dictate
a separate note on a separate piece of paper for the headaches reduces the work value of the level 3 E&M
code to level 1.
A
- Answer: C
Explanation:
The 25 modifi er is defi ned as a signifi cant and separately
identifi able E&M service above and beyond or separate
and distinct from the usual pre-procedure visit that is
related to the procedure. In this case, the headaches
are different from the low back procedure.
While we encourage the physician to dictate a separate
note for the separate E&M service for the headaches - so
as to differentiate it from the low back complaint that is
bundled into the procedure - there is no requirement for a
separate dictation. The E&M code would have a headache
diagnosis, not a low back diagnosis.
Source: CPT 2005, p. 401, Professional Edition
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
92
Q
- A pain physician performs a procedure on a non-
Medicare inpatient for the implantation of a femoral
nerve catheter for continuous infusion. As is typical of
indwelling catheters, the pain physician rounds on the
patient for 3 days and then discontinues the catheter. The
daily pain rounds should be coded as:
A. 99231 – A level 1 subsequent hospital care code
B. 01996 – Catheter management is coded with 01996
C. No code – This service is bundled into payment for the
placement of the catheter
D. 99231-58 – The 58 modifi er is for staged procedures or
services, and it is contemplated that catheter management
constitutes a different stage of the service from
the procedure.
E. 01996-59 – The 59 modifi er indicates that the post-op
rounds were a distinct and separate service from the
insertion of the catheter. Since this is not a Medicare
patient, the usual bundling rules do not apply.
A
- Answer: C
Explanation:
The CPT Code, which is applicable to all payers, defi nes
code 64447 as “including daily management for anesthetic
agent administration.” Therefore, when billing 64447, you
are already billing for the post-op rounds,and no separate
code can be billed. Medicare’s Physician’s Fee Schedule
contains a 10 day global for this and all other continuous
catheter codes, other than a continuous epidural catheter,
which does not have global period.
CPT 2005, p. 250, Professional Edition; Medicare’s
Physician’s Fee Schedule, 2005
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
93
Q
- A pain physician performs surgery on a Medicare patient
for the percutaneous implantation of neurostimulator
electrodes. Thirty days later, the patient is complaining
of pain in the area of the electrode implantation. The
physician sees the patient to rule out infection or other
complications. The physician takes an expanded problem
focused history, performs an expanded problem focused
exam, and engages in low medical decision making. This
patient encounter should be coded as:
A. 99213 – An expanded problem focused history and
exam, together with low medical decision making are
exactly the requirements for 99213.
B. 99212 – Inspection of a surgical site which does not result
in any surgical revision is coded as a level 2.
C. No code – The physician cannot bill this code because
it relates to a complication for which a return to the
operating room is not necessary, and occurs within the
90-day Medicare global for electrode implants.
D. 99213-25 – Use the 25 modifi er to indicate the visit is
separately billable.
E. 63660-52 – Bill the code for the revision of the electrodes
with the 52 modifi er for reduced services since the
E&M is not billable.
A
- Answer: C
Explanation:
The Medicare Global Surgical Package bundles E&M
services relating to a complication that does not result in return to the operating room, if those services occur
during the global period for that code. The code for
percutaneous implantation of electrodes, 63650, has a 90-
day global, so a visit for complications from the surgery is
bundled into the surgical payment and is not billable.
Medicare Claims Processing Manual, Chapter 12, Section
40.1.A.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
94
Q
- A pain physician sees an established patient who speaks
very poor English. The patient brings his wife, but her
English isn’t much better. The patient’s neck pain has
recently gotten worse, but there hasn’t been any new
incident to cause it. The physician takes a expanded
problem focused interval history, and performs an
expanded problem focused exam. Medical decision
making is low. There was no time spent counseling.
Nevertheless, the physician spends 45 minutes face to face
with the patient due to communication problems with
the patient and his wife. This patient encounter should
be coded as:
A. 99213 – An expanded problem focused history and
exam, together with low medical decision making are exactly the requirements for 99213. The physician cannot
bill for the extra interpretation time.
B. 99214 – The physician increases the normal level of
99213 by 1 level to accommodate for the increased
interpretation time.
C. 99215 – The physician spent 45 minutes with the patient,
and a level 5 typically involves 40 minutes, so the physician
can code a level 5.
D. 99213 and 99354 – The physician bills the correct E&M
code for the services performed, and then captures the
additional 30 minutes with the prolonged services code,
99354.
E. 99215 and 99211-25 – The physician spent 45 minutes
with the patient; 5 minutes is equivalent to 99211, and
40 minutes is equivalent to 99215.
A
- Answer: B
Explanation:
You don’t code the underlying E&M code with time as the
primary ingredient because there was no counseling. So,
you code the underlying E&M code as per the
documentation requirements. An expanded problem
focused history and exam, together with low medical
decision making is 99213. However, as long as the
additional 30 minutes is spent face to face with the
patient, the CPT Code allows the billing of an “add-on”
E&M code, 99354, provided that the physician spends
at least 30 extra minutes in excess of the time
usually accorded to the underlying E&M code (15 minutes
for 99213). In this case,the physician spent 45 minutes
which equates to 998213 & 99354.
CPT 2005, pp. 27-28, Professional Edition; Medicare
Claims Processing Manual, Chapter 12, Section 30.6.15.1.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
95
Q
2005.
A
.
96
Q
2006.
A
.
97
Q
- A pain physician sees an established patient. The
patient’s complaint is the same as in prior visits, i.e.,
moderate back pain, which is controlled by prescription
medication, which the physician refi lls in the same
dosage and drug type as he had in the past. Nevertheless,
the physician performs a comprehensive history, a
comprehensive exam, and low medical decision making.
There was no time spent counseling. This patient
encounter should be coded as:
A. 99211 – a nurse could have performed this visit, so 99211
is the correct code
B. 99212 – this is a typical medication management visit,
with no change in medication, and there was no medical
necessity for a comprehensive exam, and as such,
one should code only what was medically necessary,
which is a level 2
C. 99213 – A detailed history warrants a level 3 under any
circumstances
D. 99214 – The combination of a comprehensive history
and comprehensive exam, even with low medical decision
making warrants a level 4
E. 99215 – An established patient visit only needs two of
the three elements of an evaluation and management
code, so the comprehensive history and comprehensive
exam are enough to warrant a level 5, regardless of the
low medical decision making
A
- Answer: B
Explanation:
Overriding the technical documentation requirements for
E&M coding is medical necessity. If an established
patient’s complaints are the same as in his prior visits, and
those complaints are controlled with medication,and
there is no change in the medication, which is refi lled with
the same drug and dosage, and there is no counseling, this
is a classic level 2 offi ce visit, which should take no longer
than 10 minutes. If the physician voluntarily, in order to
increase billing, performs an unnecessary comprehensive
exam, the exam will be disregarded on audit. 42 U.S.C.
1395y excludes from Medicare coverage services which
“are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member.”
42 U.S.C. 1395y.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
98
Q
- A pain physician receives a request from a referring
surgeon to perform a series of 3 epidural steroid
injections on a patient the pain physician has not seen
before. In order to ascertain whether the referring
surgeon’s ordered treatment is the correct treatment, the
pain physician performs a level 4 H&P. After performing
the H&P, the physician performs a lumbar epidural
injection. This patient encounter should be coded as:
A. 62311 – the visit is not billable because it is bundled into
the procedure
B. 62311and 99244 – the procedure and a level 4 consult are
both billable
C. 62311 and 99204 – the procedure and a level 4 new patient
visit are both billable
D. 99204 – a level 4 new patient visit only because the procedure
is bundled into the visit
E. 99244 – a level 4 outpatient consult only because the procedure is bundled into the visit
A
- Answer: C
Explanation:
Although a procedure and a consult can be billed on the
same date, a consult is not billable in this case because the
referring physician did not request the pain physician’s
opinion, rather, he referred the patient for treatment.
Therefore, the new patient visit and the epidural are both
billed. They can both be billed because a new patient visit
can be billed in addition to a procedure on the same date.
CPT 2005, pp. 12, 16, 18, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
99
Q
- What is the primary purpose of the National Correct
Coding Initiative? (NCC)
A. For every third party payer to use in claims processing
B. To control improper coding (unbundling of CPT codes)
that leads to inappropriate payment in Part B claims.
C. To ensure that medical providers adhere to appropriate
coding standards of specialty societies
D. For use by Local Medicare Carriers when paying claims
if they don’t have their own program to identify improper
code submission by providers, i.e., bundled
codes
E. To facilitate up coding by physicians to third party payers
other than Medicare to make up for loss of income.
A
- Answer: B
Explanation:
The NCCI was fi rst published in 1996 and is updated by
AdminiStar Federal every quarter. The purpose of the
NCCI is to identify and isolate inappropriate coding,
unbundling and other improper coding. Carriers must
incorporate the NCCI into their claims processing; they do
not have discretion to pay services that the NCCI
identifi es as “bundled” unless an applicable modifi er is
appended.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
100
Q
- A pain physician receives a consult request from a
referring orthopedic surgeon requesting the pain
physician’s opinion as to what course of treatment is
preferable for an inpatient. Upon entering the room, the
pain physician realizes that he has seen the patient in his
own practice during the past year. The pain physician
documents a consult and puts it in the medical chart.
This service should be coded as follows:
A. An initial hospital care code because this is the fi rst time
the physician has seen the patient during this hospital
stay
B. A subsequent hospital care code because this is an established
patient, thereby precluding either an initial
hospital care code or a consult
C. An inpatient consult
D. An outpatient consult
E. A confi rmatory consult
A
- Answer: C
Explanation:
An inpatient consult code can be billed even if the
physician has previously seen the patient in his own
practice. A consult, whether inpatient or outpatient is not
dependent on whether the patient is a new or established
patient. A consult is dependent on a referring physician
requesting an opinion from the consulting physician.
CPT 2005, p. 14, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
101
Q
- How does a physician practice determine that a private
payer is bundling its claims?
A. When the practice manager reports that the revenue is
lower during the first quarter of the current year than it
was last year during the fi rst quarter
B. When the monthly charges increase and the income
from insurance payers remains the same
C. When the staff that analyzes the explanation of benefi ts
(EOB) by comparing the claims to the original claims
submission and reports that there are consistent denials
for a specifi c type of service
D. When a patient calls to advise that his/her insurance
company denied a claim because the physician billed
too many services in one day
E. When patient complains that practice is over charging.
A
- Answer: C
Explanation:
Private payers’ bundling of claims will have a negative
effect on the practice revenue stream over a period of time;
however, it is often so subtle that it is unlikely to be
recognized until the bundling has been going on for a long
time. The only effective means to stay tuned to payer
payment/bundling patterns is by continuous monitoring
of the reason for claim denials. Billing personnel should
look for an ambiguous reason for non-payment such as
“when you report multiple related services on the same
day for a patient, insurer bases benefi t payments on the
primary service”.
Source: American Medical Association Model Managed
Contract: Supplement 6, “Downcoding and Bundling of
Claims: What Physicians Need to Know About These
Payment Problems
Source: Joanne Mehmert, CPC, Sep 2005
102
Q
- A physician receives a call to the emergency room at
11:30 p.m. to see a Medicare patient whom he admits
to the hospital at 12:30 a.m. The physician performs an
emergency H&P and then documents an inpatient H&P.
These services are coded as follows:
A. An inpatient initial hospital care code only
B. Both an inpatient initial hospital care code and an emergency
department visit code
C. An inpatient consult only
D. An outpatient consult only
E. Both an emergency department visit and a subsequent
hospital care code
A
- Answer: B
Explanation:
Two E&M services may be billed on different dates of service, even if less than 24 hours have transpired between
the services. The initial inpatient hospital care code is
used,rather than the subsequent hospital care code,
because the emergency room is an outpatient setting, so
the admit to the hospital is the initial inpatient service.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.9.1.B.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
103
Q
- A physician receives a call to the emergency room to
see a Medicare patient whom he admits to the hospital
that same date of service. The physician performs an
emergency H&P and then documents an inpatient H&P.
These services are coded as follows:
A. An inpatient initial hospital care code only
B. Both an inpatient initial hospital care code and an emergency
department visit code
C. A hospital inpatient consult only
D. A hospital outpatient consult only
E. Both an emergency department visit and a subsequent
hospital care code
A
- Answer: A
Explanation:
All E&M services on a date of admission of a patient to
inpatient status are billed as part of the inpatient admit
service, including a prior emergency room visit that leads
to the admission of the patient to inpatient status.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.9.1.A.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
104
Q
- An established patient last seen in January 2002,
presents for a visit in June 2005. Based on the length of
time between visits, the physician performs a complete
H&P, including a detailed history, a comprehensive exam,
accompanied by moderate medical decision making. On
the same visit, the physician decides to perform a lumbar
epidural steroid injection since a prior set of injections
had worked in 2002. These services are coded as follows:
A. 99204 – level 4 comprehensive new patient visit
B. 99214 – level 4 established patient visit
C. 62311 – epidural only; the visit is not billable since the
visit is related to the procedure
D. 62311 and 99204 -25 – due to the length of time between
visits, the visit qualifi es as a new patient visit, which is
billable with a procedure because a new patient visit is
typically above and beyond the usual pre-procedure
visit bundled into the procedue
E. 62311 and 99214-25 – Once an established patient,
always an established patient, but since the visit was a
complete H&P, it is billable in addition to the procedure.
A
- Answer: D
Explanation:
A new patient visit occurs if the patient has not been seen
in 3 years by the physician or anyone in his group. A
complete H&P is separately billable since it was above and
beyond the usual pre-procedure visit that is bundled into
the procedure.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.7.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
105
Q
- Do all of the NCCI bundling edits correspond with
CPT coding conventions and the instructions in the CPT
Manual?
A. Administar Federal, the contractor that develops the
edits coordinates with the CPT Editorial staff before
quarterly updates are published
B. There is not always an NCCI edit t that corresponds
precisely to CPT coding conventions and instructions;
however AMA/CPT coding conventions do have a prevailing
infl uence on coding edits
C. CMS local carrier decisions are the only policies that
Administar Federal considers when revising the edits
D. Administar Federal relies solely on specialty society
manuals and communication from physicians to update
the edits
E. NCCI edits are solely determined by CMD of Administer
Federal.
A
- Answer: B
Explanation:
CCI edits are developed around CPT/AMA coding
conventions and instructions; however not all of the CPT
instructions and/or coding conventions are set forth in
NCCI. Administar Federal looks at several factors when
updating the NCCI.
Source: National Correct Coding Initiative,current update
effective July 1, 2005-September 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
106
Q
- What advantage does pre-approval or pre-authorization
by “other” third party payers, meaning payers other than
Federal programs, i.e., Medicare and Medicaid give a
provider?
A. Pre approval means that when a provider is told that
a specifi c item or service is “authorized” payment is
guaranteed
B. Payers always give pre-approval in writing and this will
guarantee payment
C. Obtaining pre-approval offers providers a “safety-net”, it
does not guarantee payment
D. Pre approval is not effective unless the physician personally
makes the request
E. Pre approval must be always obtained by the patient.
A
- Answer: C
Explanation:
Generally, once a claim is pre-authorized/pre-approved,
especially when the pre-approval is obtained in writing, a
physician has an effective argument if the insurer changes
its mind. Payers seldom, if ever, guarantee payment when
they authorize treatment.
Source:Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
107
Q
- What are the accurate statements of the Medicaid review
process compared to Medicare?
A. Yes, the Medicaid review process is mandated by CMS
and it has the same steps
B. No, the Medicaid process has only four steps where
Medicare claims have fi ve
C. It is similar with the exception of the amount of time a
provider is allowed to fi le a claim
D. Medicaid has no established federal review process, it is
State specifi c
E. Medicaid will lose Federal Grants if they do not follow
Medicare review process.
A
- Answer: D
Explanation:
Medicaid may deny a service stating that it is not medically
necessary and where Medicare has a statutory appeals
process that a provider can follow step by step, Medicaid is
State specifi c. There is no “standard” Medicaid review
process.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. Federal Register March 25, 2005 and
June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
108
Q
- The timely fi ling limits for each level of appeal are?
A. The provider has 120 days to fi le an initial appeal and
60 days to fi le an appeal following each level where an
unfavorable decision is rendered
B. All appeals must be resolved within 120 days
C. There are no timely fi ling limits relative to request for
appeal of a Medicare claim denial
D. The provider has 120 days to appeal a denial at each
level
E. The Provider appeal may fi le at any time after one year.
A
- Answer: A
Explanation:
When the Carrier sends its initial determination, a
provider or benefi ciary has 120 days to fi le a request for
reconsideration. After each subsequent unfavorable
determination is received, the provider has 60 days to
request a review at the next level.
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005. Federal
Register March 25, 2005 and June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
109
Q
- Which of the following would be most likely to
precipitate an inaccurate decrease in accounts receivable
aging numbers?
A. Contractual discounts on payments not being made in a
timely manner
B. Uncollectible debts not being written off
C. Delays in claim submissions
D. Delays in refunding overpayments
E. Delayed patient collections
A
- Answer: D
Explanation:
Delays in processing refunds will artifi cially increase the
payments recorded and in turn cause aging numbers to
remain steady or even decrease.
Source: Marsha Thiel, RN, MA, Sep 2005
110
Q
- A pain physician receives a consult request from a
referring surgeon for an inpatient. After the initial
consult, the pain physician continues to make additional
visits to the patient to monitor the course of treatment.
These additional visits should be coded as:
A. Subsequent hospital care visits
B. Inpatient consults
C. Follow-up inpatient consults
D. Confi rmatory consults
E. Outpatient consults
A
- Answer: A
Explanation:
While a physician can bill a follow-up inpatient consult, in
order to do so, the physician must be requested to provide
another consult by the referring physician. Unless the
physician receives a second consult request, follow-up
visits for inpatients are coded as subsequent hospital care
codes. A confi rmatory consult is generally for second
opinions.
CPT 2005, pp. 12, 16, 18, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
111
Q
2026. PRO is a term used to describe: A. Performance Reporting Organization B. Peer Research Organization C. Peer Review Organization D. Professional Review Operations E. Professional Review Organization
A
- Answer: C
112
Q
- A 32-year-old female was seen in interventional pain
management for persistent phantom sensations after
traumatic amputation. The physician evaluates the
patient and advises with regards to appropriate treatment
and communicates with the referring physician. What is
the proper coding for this evaluation and management
service?
A. 99241, new or established patient initial offi ce consultation,
with a problem focused history and focused examination
with straightforward medical decision making
B. 99242, new or established patient offi ce consultation,
with expanded problem focused history and examination
with straightforward medical decision making
C. 99243, new or established patient offi ce consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient offi ce consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient offi ce consultation,
with comprehensive history and examination with high
complexity medical decision making
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
113
Q
- In the pain management facility, labeling is required
for contained regulated waste. Labels are not required
when:
A. Red bags with biohazard labeling are used.
B. On refrigerators that contain labeled blood components.
C. If less than 15 cc of blood 5 g of tissue is placed in a
sealed plastic bag to be transported to a dumpster.
D. When an authorized biohazard transport company will
be handling the waste
E. If policy defi nes the biohazard as benign
A
- Answer: A
Explanation:
Labeling requires fl uorescent orange and red warning
labels are attached to waste, or other containers that may
contain potentially infectious materials and includes
blood,blood products, tissue, serum, or body fl uids.
Universal/standard precautions implies that all blood is
infected with HIV or HBV and requires proper labeling.
Labels are not required when,
Blood components are labeled with their contents, and
specifi ed for transfusion
Blood or infectious materials are placed in a labeled
container for transport and disposal.
When biohazard bags are used. The bags should not leak,
and they are free of sharps and the bag is sealed.
Placing materials of an infectious nature in a facility or
disposal container, such as a dumpster, without labeling
should not be done.
Source: Hans C. Hansen, MD
114
Q
2029.Record keeping in the pain management facility is
required for proper OSHA documentation. After a
needle stick injury, the length a record must be retained
for retrieval:
A. 5 years
B. 10 years
C. 15 years
D. 20 years
E. 30 years
A
- Answer: E
Source: Hans C. Hansen, MD
115
Q
- When a physician is uncomfortable treating a patient
due to religious or sexual nature, it is best to:
A. Openly discuss with the patient as to why the relationship
will not continue.
B. Allow for orderly transfer to another physician.
C. State to the patient that lifestyle preference will not yield
a solid patient-physician relationship.
D. Follow specifi c policy as to types of patients that the physician
will follow, and defi ne them with the staff.
E. Avoid charges of discrimination by treating the patient as
any other, irrespective of lifestyle or religious activity
A
- Answer: E
Explanation:
This is a somewhat diffi cult area for a physician to grasp.
A patient who expresses a lifestyle contradictory to what
the physician would consider conducive to a patientphysician
relationship, does not necessarily mean that the
physician is allowed to drop the patient. Antidiscrimination
suits have been settled against the practice
based on personal views of the physician, irrespective of
the fact that the physician had given names of other
physicians that would treat the patient. The ACLU Chief
Council Michael Small states “discrimination, whether it
in the workplace or in the doctor’s offi ce, can never be
tolerated”. All businesses open to the public must treat
their clients/patients equally without regard to race, sexual
orientation, or gender.
Source: Hans C. Hansen, MD
116
Q
- A 62-year-old patient of yours has refused to pay on a
$427.00 balance. You have researched your compliance
plan, and your auditor’s recommendations. You have
offered the patient multiple choices to pay over time,
and the patient refuses because you are “not doing
anything”. The patient continually asks for narcotics in
a higher dose, and you have refused, placing the patient
on a pharmacokinetically long-acting drug which is
unsatisfactory to the patient’s demands. The patient
expects to be seen monthly for her medication, but states
that she is not going to pay you. Your next step is to:
A. Discontinue the patient/physician relationship due to
noncompliance of payment.
B. State to the patient that you will refer her to another provider
who may be more amenable to her wishes.
C. Send the patient to collections, and discharge the patient,
after informing her of your intention in writing.
D. Do nothing, continue to see the patient as you are
concerned about abandonment, and you write off the
balance.
E. You inform the patient, both verbally and in writing, that
you are unable to continue to treat her without a demonstration
of her responsibility to pay some or all of her
bill.
A
- Answer: E
Explanation:
When a patient becomes noncompliant, care must be
exercised to avoid abandonment. At no time should the
patient feel that care will be withdrawn inappropriately or
that they are going to have an inadequate period of time to
fi nd another treating physician, typically 30-days. It might
be wise to use a third party, such as a business manager to
sit in a non-confrontational environment with the patient
discussing more than one option, avoiding
embarrassment. Another strategy might be to give the
patient time to contemplate options and availability of
other treatment physicians. It might be that you are the
best choice, which would suggest payment compliance is a
better option than no treatment whatsoever.
Finally,when controlled substances are involved, abrupt
discontinuation in an age group that could be considered
at risk for adverse event or poor outcome should be
avoided.Consider the appearances to referral sources or
the community of an older or elderly individual, refused
access to medications, which resulted in an adverse event
Perceptions are sometimes far more costly than a few
dollars on a bill, particularly if this bill can be negotiated.
The caveat would of course be a managed care plan, or a
compliance violation when lack of collection could come
back with frequent write-offs, or lack of collection
resulting in a professional sanction. If good will is the
theme of the day, this is unlikely.
Source: Hans C. Hansen, MD
117
Q
- A patient who comes to you on a regular basis for
controlled substance management has been found to be
doctor shopping. This information was relayed to you
by a reliable pharmacist, stating the patient is known in
the community to divert medications. If you decide to
terminate the relationship, and the patient declares that
he is going to sue you for abandonment, he has done it
before and he will win again. Your next step would be:
A. Negotiate a reasonable termination plan, with a medication
taper and assistance in fi nding another physician.
B. Immediate termination, irrespective of the threat.
C. Developing an immediate referral so there is no interruption
in treatment.
D. Consider the threat incredulous and avoid confrontation,
informing the patient that 30-days of medication
will be prescribed and then you are done with him.
E. Inform the patient of your policy to continue emergency
care for 30-days, and offer detoxifi cation, then assure
continuity, both verbally and in writing.
A
- Answer: E
Explanation:
Patients threatening lawsuit should not alter appropriate
medical care,and judgment should not be impaired by
fear.Proper medical care supersedes baseless threats,
particularly when legitimate prescribing practices are
followed. When a patient / physician relationship must be
terminated, appropriate cautions and policies are in place
to avoid being accused of abandonment. Abandonment is
when a patient might result in injury or has been injured
by a physician’s refusal to treat, defi ned. Usually by 30-
days, a patient must be given a reasonable amount of time
to fi nd a substitute to care provide her; otherwise, there is
a breachof duty, which is the foundation of medical
malpractice.
The duty of treatment is defi ned by community standard,
and that of the profession and not at the physician’s
discretion. The patient’s overall health status should be
addressed, and alternatives to care, appropriate to a
treatment course for best outcome must to be
acknowledged. This is where offering detoxifi cation may
be this patient’s only choice.
Prescribing medications for any length of time in a patient
that is suspected or known of a diversion is an
inappropriate patient for a controlled substance.
Providing a controlled substance to a person known to
divert his contributory to traffi cking, and places the
physician at risk.
Source: Hans C. Hansen, MD
118
Q
- A 47-year-old patient complaining of low back pain is an
established patient with the clinic. It becomes apparent,
however, that her brother who was recently treated by
you is fi ling a lawsuit against you because he allegedly
returned to work prematurely from a Workman’s
Compensation injury, re-injuring himself.The proper
approach to dealing with the sister of the plaintiff is to:
A. Withdraw care and discharge from the clinic.
B. State to the sister that your partner will continue to treat
her, but you will not be treating her due to confl ict of
interest.
C. Continue to treat the sister as every other patient, because
the lawsuit does not involve her or action against you personally.
D. Consider it wise to discontinue treatment and provide
orderly transfer to another physician of equal competence
informing the patient, both verbally and by
registered letter.
E. Transfer care to a university based system that is immune
from liability concerns.
A
- Answer: D
Explanation:
There is really nothing legally that would prohibit a
physician from treating a family member of a plaintiff, but
it is a risky decision. Comments might be made that could
be misconstrued or constructed to be deleterious to the
physician during the upcoming action. Furthermore, it
may be possible that the family member legitimately or
illegitimately develops a complication in attempts to
establish a pattern. Collusion cannot be ruled out, which
places the physician in an awkward position of constantly
second guessing each visit. Furthermore, the family
member could testify about offi ce policy procedure,
experiences, and behavior patterns of the physician.
Universities are not immune from lawsuits and patient
dumping can be considered abandonment.
It is best to probably severe ties with the patient that has a
family member involved in litigation with you or a partner.
Source: Hans C. Hansen, MD
119
Q
- A non-Medicare inpatient underwent extensive knee
surgery. The anesthesiologist placed a femoral catheter
for continuous infusion to control her pain. Another
anesthesiologist, who is the pain specialist in the group
rounds on the patient for 3 days. The fi rst day the
patient had increased pain and the doctor performed an
expanded problem focused interval history and exam and
made some adjustments in the medication. The patient’s
pain improved and visits on the 2nd and 3rd days were
problem focused. The daily visits are reported using what
codes:
A. 99232x1 and 99231 x 2 - Subsequent care codes;
B. 01996-52 - Daily hospital management of an epidural
or subarachnoid continuous drug administration with
a modifi er -52 since the catheter is not in the epidural
or subarachnoid space;
C. 99232-25 x 1 and 99231-25 x 2 - The daily visits require a
modifi er -25 to indicate that the care is over and above
placement of the catheter after surgery;
D. No follow up days are billed because the code 64448
specifi cally “includes daily management”
A
- Answer: D
Explanation:
CPT instructions specifi cally preclude the reporting of any
daily care when code 64448 is reported. The descriptions
and instructions in the CPT Manual for this code and the
other continuous catheters for pain control are clearly
stated.
Source: CPT Coding Manual
Source: Joanne Mehmert, CPC
120
Q
- A new Medicare patient comes in to an interventional
pain specialist’s offi ce for the fi rst time complaining of
low back pain which started when she bent over to lift a
box 2 days ago. The physician proceeds to examine the
patient to determine a course of treatment. Based on
the history & exam which takes about 15 minutes, the
doctor decides to perform an ESI. The physician recently
converted to an electronic medical record (EMR) that
operates on a palm pilot. He has found that with the
use of this palm and the EMR’s E&M templates he can
perform a comprehensive visit and exam in 15 minutes.
After completing the exam, he performs the lumbar ESI.
The encounter is coded:
A. 99202 and 62311-25 - It was medically necessary to
perform a history and exam to determine the course of
treatment and a modifi er -25 should be appended to
the ESI code to bypass Medicare’s bundling edit;
B. 99202 and 62311 - The new patient history and exam resulted
in the doctor’s decision to perform the injection.
It is appropriate to report both codes, modifi er –25 is
usually not required for a new patient and a minor
procedure;
C. 99204 and 62311 - Since the EMR provided the physician
with the information that he needed to document
a higher level of service, the level documented should be
reported regardless of the time he spent;
D. 99203-25 and 62311 -The use of the EMR resulted
in a comprehensive visit and exam, the decision was
straightforward.Based on the time and medical decision
making, the doctor compromised between a level 3 and level 4 and added modifier -25
A
- Answer: B
Explanation:
Explanation: The government has prosecuted physicians
for routinely coding double the typical time for the level of
E&M service. Medical necessity is the overriding
consideration. Regardless of the amount of documentation
an EMR generates, if the need isn’t there and the physician
spent half of the usual time,it is not appropriate to report
a higher level of service. Modifi er 25 should not be
required for a Medicare claim for a new patient visit when
a procedure is performed. In December 2005, the Offi ce of
Inspector General (OIG) released a report that indicated
that modifi er –25 was used (in 2002) unnecessarily on a
large number of claims where it did not result in improper
payments; however, it did not meet program
requirements. There may be exceptions to this principle
since Part B Carriers do not always program the same
claim edits.
Source: Code of Federal Regulations 42 U.S.C., 1395y;U.S.
v Mayer (U.S. District TN 2000)
Source: Joanne Mehmert, CPC
121
Q
- An established Medicare patient who is on opioids
comes in for a prescription refi ll. The physician has
an interactive patient questionnaire that takes about
10 minutes to complete which he reviews with patients
on narcotic management to comply with his strict
controlled substance policy. The patient is stable and
is taking the medication as prescribed. No change in
dosage is necessary. The doctor also uses electronic
records complete with E&M templates. The doctor
uses the E&M template to perform and document the
necessary elements to complete a comprehensive history
which took him another 10 minutes, for a total time of 20
minutes with the patient. The visit is reported as:
A. 99211 - A level one visit because the offi ce nurse could
have asked the patient the questions and fi lled out the
questionnaire;
B. 99212 - No change in the patient’s status does not warrant
a comprehensive history, this is a problem focused
history and straightforward medical decision making;
C. 99213 - A detailed history is reported since the visit was
not 25 minutes which is the threshold time for a level
4;
D. 99214 - Management of a patient taking opioids is high
risk and regardless of the time spent, always warrants
a level 4;
E. 99212-22 - The visit should be modifi ed to show the
payer that the physician is entitled to more than level 2
reimbursement for opioid management
A
- Answer: B
Explanation:
The overriding principle is medical necessity. The patient
is described is stable, with his pain well controlled, and is
taking the medication as prescribed. The doctor did not
change dosage, the patient had no complaints, and the
doctor did not spend time counseling. The comprehensive
history was not medically necessary for this patient at this
time; the physician used the template to increase the level
of service.
Source: Code of Federal Regulations 42 U.S.C. 1395y
excludes from Medicare coverage services which “are not
reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a
malformed body member”.
Source: Joanne Mehmert, CPC
122
Q
- A 42-year-old female patient presents with intractable
chest wall pain following a radical mastectomy
performed 8 months ago for carcinoma of the breast. A
comprehensive history and examination was performed.
Physician communicates with referring physician and
provides medical decision making which was of moderate
complexity. How would you code this visit?
A. 99241, new or established patient initial offi ce consultation,
with a problem focused history and focused examination
with straightforward medical decision making
B. 99242, new or established patient offi ce consultation,
with expanded problem focused history and examination
with straightforward medical decision making
C. 99243, new or established patient offi ce consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient offi ce consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient offi ce consultation,
with comprehensive history and examination with high
complexity medical decision making
A
- Answer: D
Source: Laxmaiah Manchikanti, MD
123
Q
- Mr. Spencer, a Medicare patient, has been treated for
back pain radiating down his legs over the past 5 years.
During that time he has undergone injections, lysis of
epidural adhesions, physician therapy, bio-feedback,
and medication management, none of which have been
effective. Dr. Jackson who has been treating Mr. Spencer
requests an opinion from Dr. Michael, an Interventional
Specialist that uses spinal cord stimulation for a number
of his own patients. Dr. Michael talked with Dr. Jackson
at length about the patient and spends 20 minutes
reading the notes Dr. Jackson sent before he goes into
see Mr. Spencer. Dr. Michael spent 30 minutes taking
an expanded problem focused history and doing an
expanded problem focused examination; however Mr.
Spencer was very apprehensive and wanted to know in
great detail how SCS works, what he could expect, etc. Dr.
Michael spent another 45 minutes explaining SCS. Dr.
Michael documented all elements of the visit including
his discussion and the time he spent explaining SCS to
Mr. Spencer. The visit should be reported as:
A. 99244 - A level 4 consultation requires a comprehensive
history, exam and medical decision of moderate complexity
and the typical time is 60 minutes;
B. 99243 - A level 3 consultation requires a detailed history,
detailed exam, medical decision making of low complexity
and the typical time is 40 minutes
C. 99245 - Counting the time that Dr. Michael spent reviewing
the notes before he went into see Mr. Spencer,
he spent the typical time for a level 5 consult, 80 minutes;
D. 99242 - A level 2 consultation requires an expanded
problem focused history, an expanded problem focused
exam and straightforward medical decision making; the
typical time is 30 minutes
A
- Answer: A
Explanation:
Dr. Michael spent over 50% of the typical time for a level 4 consultation explaining the patient’s treatment
option. Regardless of the extent of the history, exam and
medical decision making, when a physician spends (and
documents time and discussion points) over 50% of the
typical time for the visit, time can be the determining
factor in choosing a code. Medicare does not allow time
spent reading the records to be used to determine a code
level. Time must be spent face-to-face with a patient in the
offi ce.
Source: CPT Manual, E&M Coding Guidelines
Source: Joanne Mehmert, CPC
124
Q
- A 34-year-old patient, with post-cervical laminectomy
syndrome, presents with severe neck pain associated with
depression and drug dependency for your consultation.
Physician spends approximately 1½ hours with
comprehensive history and examination. What is the
appropriate coding for this visit?
A. 99241, new or established patient initial offi ce consultation,
with a problem focused history and focused examination
with straightforward medical decision making
B. 99242, new or established patient offi ce consultation,
with expanded problem focused history and examination
with straightforward medical decision making
C. 99243, new or established patient offi ce consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient offi ce consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient offi ce consultation,
with comprehensive history and examination with high
complexity medical decision making
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
125
Q
- A patient that is well known to the clinic because of a
very successful lysis of epidural adhesions procedure
3 years ago, calls for an appointment. The patient
explained that she moved out of the area shortly after her
lysis procedure and has been doing well. She moved back
to the city a week ago and while moving she hurt her back.
She is experiencing signifi cant pain and would like to see
the same physician that treated her 3 years ago. The
physician notes that he called in a prescription for the patient 2 years and 10 months ago, just before she moved
out of the area. When the patient comes in, the physician
performs and documents a Level 3 E&M service. This
visit should be reported as:
A. 99203 - A level 3 new patient visit is the appropriate code
to report for this encounter
B. 99213-22 - An established patient visit should be reported;
however, the physician should append a modifi
er -22 (unusual procedure service) and charge more
than his usual fee since he had not seen the patient in
almost 3 years;
C. 99203-52 - Since the doctor called in a prescription for
the patient 2 years and 10 months ago, a new patient
with a “reduced services” modifi er should be reported;
D. 99215-52-The physician appends the modifi er -52 to
indicate that the services were reduced because the
documentation does not support a level 5 visit.He feels
that he should be paid more than the level 3 established
patient visit
A
- Answer: A
Explanation:
Prior to the year 2000, CPT defi ned a “new patient” as one
that had not had any professional services in the past 3
years. In the 2000 CPT Manual a signifi cant change was
made in the description of a “new patient” and this change
is also refl ected in the Medicare Claims Processing
Manual. CPT 2000-2006, which defi nes: “professional
services” as, “those face-to-face- services rendered by a
physician and reported by a specifi c CPT code”. Since
calling in a prescription is not a service for which a
physician reports a CPT code, a new patient visit is
reported.
Source: Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Non-physician Practitioners
§30.6.7A and CPT Coding Manual E&M Services
Guidelines Page 1.
Source: Joanne Mehmert, CPC
126
Q
- An established Medicare patient comes to the offi ce
to have the second in a planned series of three lumbar
epidural steroid injections.The physician takes a focused
interval history asking the patient about the effect of the
fi rst epidural and to ensure that she discontinued her
daily aspirin as instructed. Based on his interview with
the patient, he proceeds with the injection. The physician
dictates a meticulous note. The encounter should be
reported as:
A. 99213-25, 62311-The epidural and the visit were medically
necessary and both should be billed using the
modifi er -25 to ensure that the claim passes the payer’s
bundling edit;
B. 62311 - A procedure includes a reasonable amount of
pre and post procedure work which is bundled into the
payment for the injection;
C. 99215 - The physician has a choice of reporting a procedure
or an E&M visit and chooses to report a level 5
E&M service;
D. 99213, 62311 - The physician realizes that the offi ce
visit is not above and beyond the usual work that he
performs when he does a procedure; however, he still
wants to bill an offi ce visit just in case the Carrier will
reimburse without the -25 modifi er.
A
- Answer: B
Explanation:
The visit is not above and beyond the usual pre operative
work. The physician’s note is good medical practice and
documents the medical necessity of performing the second
injection with the primary benefi t that it provides a high
qualify medical record for his patient. The answer
described in “C” bears no resemblance to a true statement
and “D” is a deliberate attempt to obtain payment to
which one is not entitled.
Source: CPT Coding Guidelines
Source: Joanne Mehmert, CPC
127
Q
- A patient comes into the offi ce to pick up a prescription
for medication refi ll. The new receptionist takes the
patient’s chart into the doctor and the doctor looks at
the medication record, writes a prescription and gives it
to the receptionist to give to the patient. The receptionist
hands the patient the prescription and tells the patient to
have a nice day. This encounter should be reported to the
insurance company as:
A. 99211 - An incident to service because the receptionist is
employed by the physician and the doctor looked at the
chart and wrote the prescription;
B. 99212 - The physician should report a level two office
visit because the physician looked at the patient’s medication
record and made a medical decision to write the
prescription;
C. No charge should be submitted because the receptionist
is not qualifi ed to perform, and did not perform an offi
ce visit and the doctor did not see the patient;
D. 99213 - Anytime a physician writes a prescription, it is
considered a management decision that justifi es a level
3 offi ce visit.
A
- Answer: C
Explanation:
The receptionist did not perform an offi ce visit and the
physician did not have any contact with her patient. The
CPT codes assume that a qualifi ed person will perform
and document a service and while an employee does not
necessarily have to be a nurse or clinician to report a 5
minute offi ce visit, the employee should have enough
training to perform and document a minimal service. In
the circumstance described above, an office visit was not performed by the doctor.
Source: CPT Coding Instructions
Source: Joanne Mehmert, CPC
128
Q
- A hospital in-patient in the advanced stages of lung
cancer is suffering from intractable pain and a pain
specialist has been asked to consult for pain control.
The consultant begins his interview and exam of the
patient which takes 50 minutes and fi nds it necessary
to review radiology fi lms that are at the nursing station.
Additionally, he spends 45 minutes at the nursing station
discussing the patient’s hospital course to date with the
charge nurse, reviewing the patient’s electronic record,
and talking with the patient’s oncologist and surgeon. By
the time he has completed his consultation, he performed
a level 2 history and examination (99252) and spent an
additional 45 minutes reviewing records, consulting
with other professionals and coordinating the patient’s
care. The physician’s total time was 95 minutes. The
appropriate code is:
A. 99254 because the time spent is the threshold for a level
4 consult even though the doctor only performed and
documented an H&P to qualify for a level 2 consultation,
he can add the extra time to report a higher level;
B. 99252 and 99356, prolonged care, requiring direct (faceto-
face) patient contact beyond the usual service, fi rst
hour, because the doctor spent a total of 95 minutes on
the patient consult;
C. 99252, 99356, 99357, since the threshold time for the
consult (40 minutes) and the fi rst prolonged care time
(1st hour) were both exceeded, the physician should
report an additional 30 minutes of prolonged care
D. 99252, A level two consultation code, prolonged care can
not be reported because the physician was not at the
patient’s bedside for the entire 95 minutes.
A
- Answer: B
Explanation:
In the hospital, unlike in the offi ce, time spent on the
fl oor/unit reviewing records and coordinating the care can
be considered as long as it is spent exclusively on the
patient. At least 15 minutes must be spent in addition to
the fi rst hour of prolonged care to report the second 30
minutes, 99357.
Source: Joanne Mehmert, CPC
129
Q
- An inpatient is 4 days post knee surgery and the surgeon
has been managing his pain control with injections and
oral medication. Since the pain is not being satisfactorily
controlled with the surgeon’s current regimen, he asks a
pain management specialist to perform a femoral nerve
block. The specialist spends a few minutes talking to the
patient and agrees that the femoral nerve block is likely
to be the best course of treatment at this time. The pain
specialist reports:
A. CPT codes 99255-25 and 64447 Level 5 consultation
with modifi er -25 to show a service above and beyond
the usual pre/post operative work and a femoral nerve
block, single
B. CPT code 64447
C. CPT codes 99231-25 and 64447 Level 1 subsequent care
hospital visit
D. CPT codes 99231-57 and 64447 Modifi er 57 should be
appended to the hospital visit since a procedure was
performed
A
- Answer: B
Explanation:
The surgeon did not request an evaluation or ask for the
pain specialist’s opinion or advice. He simply requested
that the pain physician perform a femoral nerve block. The
only appropriate code to report in this circumstance is the
injection code.
Source: Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Nonphysician Practitioners -
Consultations
Source: Joanne Mehmert, CPC
130
Q
- A Medicare benefi ciary underwent an epidural lysis of adhesions (10 day global) on February 1, and returns to
the offi ce for a follow-up visit on February 8, the doctor
noted that the patient has a slight redness around the
site where the catheter had been inserted and applied
antibiotic ointment. He recommended that the patient
apply antibiotic ointment for the next 3-4 days to prevent
infection. During the visit, the patient also complains of
a dull, aching pain in her left knee that started when she
twisted her knee while going downstairs to do laundry 2
days ago. After a visit that included a problem focused
exam and straightforward medical decision making
(Level 2), the physician should:
A. Report code 99212-24 (E&M for an unrelated condition
during the global period)
B. Report code 99212(No modifi er is necessary since the
ICD-9 code will be different than the code for the procedure
performed on February )
C. The doctor can’t report any services during the 10-day
global period
D. Report code 99213-24(The doctor treated the small
wound to prevent infection and took care of a new
complaint which adds up to a higher level of service)
A
- Answer: A
Explanation:
All additional medical or surgical services required of the
surgeon during the postoperative period of the surgery
room are included in the global fee for the surgery. Thus,
the treatment of the surgical wound to prevent infection is
included in the global fee. It is appropriate to report an
E&M code for a condition that is not related to the
condition for which the surgery was performed. Modifi er
-24 is required to bypass the global surgery edit.
Source: Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Nonphysician Practitioners §40.1A
Source: Joanne Mehmert, CPC
131
Q
- Dr. Harris, a specialist in the treatment of cancer pain,
provided a consultation service on March 5, for a patient
who is in the hospital for treatment of Chondrosarcoma
in her pelvis. Dr. Harris wrote a consultation note
and recommended a treatment plan to the referring
oncologist; however, he did not assume care of the pain
condition. On March 8, the patient’s oncologist asked
Dr. Harris to provide a follow-up consultation since
the treatment that Dr. Harris recommended was not
providing adequate pain control and the patient was
experiencing a signifi cant amount of breakthrough pain.
Dr. Harris saw the patient performed a visit that would
qualify for a level 2 service. Dr. Harris should report the
March 8 visit as:
A. 99252-76 (Level 2 initial consultation and 76 to indicate
repeat procedure by same physician)
B. 99252-32 (Modifi er for mandated services)
C. 99232 (Subsequent hospital care, level 2)
D. 99232-32
A
- Answer: C
Explanation:
Only one initial consultation code should be reported per
a patient’s hospital stay. The AMA instructs providers to
report subsequent care hospital visit codes when a followup
consultation is performed since the follow-up
consultation codes were deleted effective 1/1/06.
Source: CPT Changes 2006
Source: Joanne Mehmert, CPC
132
Q
- After unsatisfactory pain control has been achieved
with injections, physical therapy and oral medication,
a patient that is covered by Health Plus has been told
by his pain management specialist that a spinal cord
stimulator (SCS) is the next option. Before Health Plus
will approve a trial and subsequent permanent SCS
stimulator, it requires a confirmatory consultation from
another chronic pain specialist. The consultant performs
a level 4 consultation service and sends a report to Health
Plus. CPT guidelines instruct the provider to report this
service:
A. 99204-25 (New patient visit & Modifi er -25, separately
identifi able E&M service)
B. 99244-32 (Consultation & Mandated services)
C. 99204-32
D. 99244-25
A
- Answer: B
Explanation:
CPT Changes 2006: An Insider’s View (pg. 4), states:
“When a consultation is mandated by a third-party payer,
modifi er -32 should be appended to the level of
consultation code reported.” Medicare does not recognize modifi er -32 as a payment modifi er or cover a second
opinion evaluation visit required by a third party payer.
Source: Joanne Mehmert, CPC
133
Q
- Dr. Cruise wrote a letter to his Part B Medicare carrier
asking for the correct method to report bilateral intraarticular
facet blocks. His carrier was paying the correct
amount for the fi rst level; however, when he reported one
or two additional, bilateral levels [using modifi er -50] his
claims were either denied or paid incorrectly. In his letter,
he provided accurate and complete information along
with examples showing CPT coding instructions and his
exact charges. A year after receiving [and implementing]
the Carrier’s written instructions, the Carrier determined
that Dr. Cruise had been overpaid due to his billing
method and asked for a refund. The Carrier also added
interest and penalty to its demand. Dr. Cruise refunded
the overpayment; however, after Dr. Cruise presented
more information, the Carrier waived the penalty. The
reason the Carrier waived the penalty is:
A. Dr. Cruise received and followed erroneous written guidance
from a representative acting within the scope of
the contractor’s Medicare contract authority
B. Dr. Cruise was a very infl uential physician in the community
and the Carrier Medical Director did not want
to risk any backlash from other physicians
C. Dr. Cruise did not have any other negative audit outcomes
D. None of the above
A
- Answer: A
Explanation:
CMS published Transmittal 731, [61 pages] dated 11/1/05
which addresses only the penalty provision.
CMS published §903(c) of the Medicare Prescription
Drug, Improvement and Modernization Act of 2003
(MMA), which amended §1871(e) of the Social Security
Act (the Act), establishes a basis for waiving the penalty in
certain circumstances. Specifi cally, §903(c) establishes
that, subject to certain conditions, a provider or supplier
shall not be subject to any penalty under an authority of
Title XVIII of the Act or under an authority of Title XI of
the Act (that relates to Title XVIII) if the basis for the
penalty that would have otherwise been applicable was
that the provider or supplier acted in accordance with
erroneous guidance from the Medicare program.
This statutory amendment also provides for waiving
interest if the overpayment that is the basis for assessing
such interest resulted from the provider or supplier acting
in accordance with erroneous guidance from the Medicare
program.
Source: Joanne Mehmert, CPC
134
Q
- An MSDS is:
A. Mandatory manual of current OSHA affairs
B. A medical waste discharge plan
C. The materials list of ingredients, and chemical composition
D. Documentation procedures of blood borne pathogens
E. A component of the hazardous waste spill kit.
A
- Answer: C
Explanation:
The materials list of ingredients, and chemical
composition.
The Material Safety Data Sheets, MSDS, are mandatory for
medical offi ces and should be displayed, or found by
employees on demand, usually kept in a binder. These lists
are frequently printed by the company, and labeled on the
device or container for quick reference. An example might
be a cleaning solvent, or a container with potentially
dangerous organic content, such as insecticide.
Source: Hans C. Hansen, MD
135
Q
- An electronic medical record vendor approaches you
stating that the electronic medical record will increase
productivity, and allow the physician to capture an
elevated evaluation and management code by enhanced
documentation. The vendor goes on to relate that the
electronic medical record efficiently documents a higher
code and can increase the practice bottom line. Your
correct response is:
A. Ask the vendor to show you the vendor support for the
electronic medical record.
B. Demonstrate an amortization schedule to justify cost of
the unit.
C. Ask for a demonstration of workfl ow and enhanced operational
components to justify a higher E/M.
D. Ignore the vendor, but ask for a demonstration.
E. Consider the vendor as relating a common sales pitch,
and examine the input output effi ciency of the electronic
medical record independently.
A
- Answer: E
Explanation:
Vendors, have a fi nancial motive to demonstrate a benefi t
to the practice. It is easy for a vendor to show templated
output documents, that may justify a CPT Level 4, and
entice the physician to consider up-coding the work
performed. It is incumbent upon the physician, that only
work performed is documented. Templates are met with a
high level of scrutiny during an audit. Do all of the
templates appear the same? Were you sold a system that
effi ciently up-codes, and hence a revenue generating tool,
as opposed to a work fl ow tool? The physician will in time
meet salespeople who really have nothing to lose but
everything to gain, and the digital sales industry has no
regulation. The physician, however, is in one of the most
regulated environments in business, and has everything to
lose. The best approach with any vendor is to listen,
review the system, but verify, and apply principals of a valid compliance program to assess the fl exibility of the
electronic medical record. The medical record should be
fl exible enough to offer many templates, refl ecting only the
work performed, and not a standard, regurgitated
document, which will fall into question should an audit
occur.
Source: Hans C. Hansen, MD
136
Q
- “Incident To” billing for physician extenders under CMS
guidelines Statute S2050 is used to defi ne services of midlevel
practitioners such as physician assistants and nurse
practitioners. The supervising physician, immediately
available by phone is consulted by the nurse practitioner
regarding a patient. The electronic medical record will support:
A. 100% of charged capture because the physician is immediately
available
B. 85% charge capture of the physician’s fee
C. Defi ned by the electronic medical record, if CPT guidelines
are met, 100% capture defi ned by complexity, and
medical decision-making.
D. The practice is unable to bill for the nurse practitioner’s
services.
E. The nurse practitioner may bill under his or her provider
number 100% of the fee, irrespective of conversation
with the physician.
A
- Answer: B
Explanation:
The nurse practitioner may work independently and bill
under his or her provider number, but obtain only 85% of
the fee. The electronic medical record is irrelevant. If the
physician is immediately available, onsite, and the nurse
practitioner is present examining the patient in a
collaborative environment with the physician, then the
physician’s services may be billed at 100% “Incident To” .
If the physician is not immediately available to the site,
irrespective of telephone conversations, the practice may
bill 85% of the physician’s fee. The electronic medical
record will (or should) account for incident to,
documenting when the physician is present and when not
in the presence when a physician extender is utilized.
Source: Hans C. Hansen, MD
137
Q
- An interventional pain specialist is called by an internist
to consult on an in-patient that is complaining of severe
neck pain. When the specialist goes into the patient’s
room, she realizes that she has treated the patient in
her offi ce for low back pain a year ago. The specialist
performs a consultation, and dictates a note along with
her recommendations. The correct coding for this
encounter is:
A. An initial hospital care code because this is the fi rst time
the specialist has seen the patient during this hospital
stay;
B. A subsequent hospital care code because the specialist
treated this patient in her offi ce within the past 3 years;
C. An inpatient consultation
D. An outpatient consultation
A
- Answer: C
Explanation:
A consult does not depend on whether the patient is a new
or established patient. A consult depends on whether the
doctor is currently treating the patient for the condition
and whether the referring doctor requests an opinion or
advice from the specialist. There is no “initial hospital
visit” code.
Source: Source: Medicare Claims Processing Manual,
100-04 Chapter 12 Physicians/Non-physician
Practitioners §30.6.7 and 1995 or 1997 E&M Coding
Guidelines.
Source: Joanne Mehmert, CPC
138
Q
- True statements about Chief Compliance Offi cer include
the following:
A. Totally independent position
B. Access to all staff, but not to C.E.O.
C. Assign the compliance plan to supervisor in reception
department
D. Generally a compliance committee will assist
E. Operates independently and confi dentially without informing
board of directors
A
2053. Answer: D Explanation: Chief Compliance Offi cer *Access to the top *Oversee and monitor the compliance plan *Generally a compliance committee to assist
139
Q
- Which of the following is not a work practice control
required by the regulation governing occupational
exposure to bloodborne pathogens?
A. Not eating or drinking in work areas
B. Not smoking in work areas
C. Not storing food in the same refrigerator as blood is
stored
D. Recapping needles using both hands.
E. Washing hands after removing gloves
A
- Answer: D
Explanation:
Source: 29 CFR 1910.1030(d)(2).
Source: Erin Brisbay McMahon, JD
140
Q
- Which one of the following is not a major component
of the regulation governing occupational exposure to
bloodborne pathogens?
A. Exposure Control Plan
B. Hepatitis B Vaccinations
C. Testing Employees for Infectious Diseases
D. Post-Exposure Evaluation and Follow-Up
E. Recordkeeping
A
- Answer: C
Explanation:
Source:29 CFR 1910.1030.
Source: Erin Brisbay McMahon, JD
141
Q
2056. Which of the following is a designated health service subject to the Stark law? A. Ambulatory surgery B. Outpatient prescription drugs C. Services paid at a composite rate D. Sleep lab services E. Cardiac catheterization
A
- Answer: B
Explanation:
Source:42 USC §1395nn(h)(6)
Source: Erin Brisbay McMahon, JD
142
Q
- The Level II (national) codes of the Healthcare Common
Procedure Coding System (HCPCS) coding system are
maintained by the
A. American Medical Association
B. CPT Editorial Panel
C. Local fi scal intermediary
D. Centers for Medicare and Medicaid Services
E. International Classifi cation of Diseases, Ninth Revision
(ICD-9 CM)
A
- Answer: D
143
Q
- A physician performed an outpatient surgical procedure
on the disc of a Medicare patient. Upon searching the
CPT codes and consulting with the physician, the coder is
unable to fi nd a code for the procedure. The coder should
assign:
A. An unlisted Evaluation and Management code from the
E & M section
B. A HCPCS Level Two (alphanumeric) code
C. An anesthesia treatment service code
D. A code which is closest to the description
E. An unlisted procedure code located in the nervous system
section
A
- Answer: E
144
Q
- Multiple functions of a medical record include all
EXCEPT:
A. Support “medical necessity”
B. Reduce medical errors & professional liability exposure
C. Reduce audit exposure
D. Facilitate claims review
E. Facilitate upcoding
A
2059. Answer: E Explanation: Medical records function to: keep the practitioner out of the slammer support “medical necessity” reduce medical errors & professional liability exposure reduce audit exposure facilitate claim review support insurance billing provide clinical data for education provide clinical data for research promote continuity of care among physicians indicate quality of care
145
Q
2060. What are state laws affecting medical practices? A. Balanced Budget Act B. Medical records confi dentiality laws C. OSHA D. Needle stick safety E. Privacy
A
2060. Answer: B Explanation: State Laws * Medical records confi dentiality laws * Medical records access laws * HIV/AIDs * Mental health * Genetic testing/anti-discrimination
146
Q
- What are the ramifi cations of anti-kickback statute on
your practice?
A. It is a felony - 10 years imprisonment
B. It is a crime to offer, solicit, pay, or receive remuneration,
in cash or in kind, directly or indirectly, for referrals
under a federally-funded health care program
C. Civil penalties - $500,000 per violation
D. “Multipurpose” Rule
E. No safe harbors
A
- Answer: B
Explanation:
Anti-Kickback Statute
* A crime to offer, solicit, pay, or receive remuneration, in
cash or in kind, directly or indirectly, for referrals under a
federally-funded health care program
- Felony - 5 years imprisonment
- Civil Penalties - $50,000 per violation
- “One Purpose” Rule
- Safe Harbors
Source: Laxmaiah Manchikanti, MD
147
Q
- Administrator of a pain center identifi ed some risks of
non-compliance. Which one of these is legitimate?
A. An increase in the cost of an investigation and audit
B. No risk of exclusion from government health care programs.
C. Criminal and civil penalties
D. No risk of termination of private managed care and
insurance contracts
E. Reduction in fee schedule
A
- Answer: C
Explanation:
RISKS OF NON-COMPLIANCE:
Criminal and civil penalties
The cost of an investigation and audit
Exclusion from government health care programs
including Medicare, Medicaid, and Tricare
Possible termination of private managed care and
insurance contracts
148
Q
- What are true statements about regular and effective
compliance training?
A. Includes all department heads
B. Includes all employees and vendors
C. Initial training is provided only if employee wants to
learn
D. Regular ongoing training is expensive and not an essential
component
E. In response to identifi ed problem to the particular employee
A
2063. Answer: B Explanation: Regular and Effective Training Who? All employees and vendors What? Initial training Regular ongoing training In response to identifi ed problem
149
Q
- The training requirements of needle stick safety include
all of the following EXCEPT:
A. Work hours
B. 90 days after initial assignment
C. At a cost to employee
D. Within 365 days after effective date of standard
E. Within 10 years of previous training.
A
2064. Answer: C Explanation: Training * No cost to employee * During work hours * At time of initial assignment * Within 90 days after effective date of standard * Within 1 year of previous training * Shift in occupational exposure Source: Laxmaiah Manchikanti, MD
150
Q
- You were requested to provide a consultation on a 38-
year-old male with low back pain with radiation into
lower extremity. MRI fi ndings were unequivocal. Physical
examination was normal. Nerve conduction studies were
negative. You advise the patient with regards to future
treatment and communicate with the referring physician.
In this evaluation a detailed history and examination was
carried out. Medical decision making included advice
to refer the patient to physical therapy. What is the
appropriate coding for this evaluation and management
service?
A. 99241, new or established patient initial offi ce consultation,
with a problem focused history and focused examination
with straightforward medical decision making
B. 99242, new or established patient offi ce consultation,
with expanded problem focused history and examination
with straightforward medical decision making
C. 99243, new or established patient offi ce consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient offi ce consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient offi ce consultation,
with comprehensive history and examination with high
complexity medical decision making
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
151
Q
- Accurate examples of abuse are identifi ed as follows:
A. Occasionally submitting duplicate claims
B. Intentional upcoding
C. Unbundling using appropriate modifi ers
D. Using modifi er-25 to charge for separate, identifi able
E/M service, on the same day as procedure
E. Collecting approved amount from the patient
A
2066. Answer: B Explanation: Examples of Abuse are: Collecting more from the patient than you should Routinely submitting duplicate claims Upcoding Unbundling Wrong modifi ers Modifi er 59
152
Q
- The Electronic Medical Record defi nes critical areas of
development. These include:
A. System back offi ce management
B. Document management
C. HIPAA control constraints
D. Data input, decision support, system data and development
of new protocol
A
- Answer: C
Source: Hans C. Hansen, MD
153
Q
2068. For a service to be reasonable and necessary it must be: A. Safe B. Experimental C. Investigational D. Patient can afford to pay E. Furnished only in an hospital
A
- Answer: A
Explanation:
Service must be:
Safe and effective
Not experimental or investigational
Appropriate, including the duration and frequency that is
considered appropriate for the service, in terms of whether
it is:
- Furnished in accordance with accepted standards of
medical practice for the diagnosis or treatment of the
patient’s condition or to improve the function
- Furnished in a setting appropriate to the patient’s
medical needs and condition
- Ordered and/or furnished by qualifi ed personnel
- One that meets, but does not exceed, the patient’s
medical need.
Source: Laxmaiah Manchikanti, MD
154
Q
- An established patient for neck pain and headaches
returns with a new onset low back pain which started
following motor vehicle injury. Pain also radiates
into lower extremity associated with numbness and
tingling. Patient is evaluated with a detailed history,
and physical examination. Appropriate management
included evaluation with an MRI, physical therapy and
nonsteroidal anti-infl ammatory drug therapy. How
would you code this visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: D
Source: Laxmaiah Manchikanti, MD
155
Q
- An established, 43-year-old female patient, with
frequent intermittent, moderate to severe episodes of
low back pain, requiring transforaminal epidural steroid
injections, hydrocodone therapy, presents with continued
low back and lower extremity pain requiring her to miss
work, presents for a follow-up visit,. Physician takes
history, performs a detailed examination, and changes
medical therapy. At this time it was also decided that
patient will be referred for a neurosurgical consultation.
How would you code this visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: D
Source: Laxmaiah Manchikanti, MD
156
Q
- A 46-year-old female, established patient, who is
experiencing increased symptoms while in a pain
management treatment program involving interventional
techniques and medication management with exercise
program, presents for reassessment and counseling.
Interventional pain physician takes a detailed history, conducts an examination and provides the patient with
counseling, instructing in an exercise program and
refers the patient to physical therapy and psychology.
Identify the appropriate coding for this evaluation and
management visit.
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: D
Source: Laxmaiah Manchikanti, MD
157
Q
- A 44-year-old male, established patient, with chronic
myofascial pain syndrome, effectively managed by
desipramine, gabapentin, and oxycodone 10/325 three
times daily presents with new onset of urinary hesitancy.
Physician performs a problem focused history with low
complexity of medical decision making. Physician refers
the patient to an urologist. What is the appropriate EM
code for this visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
158
Q
- A patient with established diagnosis of refl ex sympathetic
dystrophy, with signifi cant improvement after
sympathetic blocks, presently maintained on medical
therapy with gabapentin and desipramine, presents for
an offi ce visit. Physician spends approximately 5 minutes
with the patient with focused history and straight forward
medical decision making. What is the appropriate coding
for this evaluation and management visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
159
Q
- A 44-year-old white female, an established patient
experienced reoccurrence of knee pain after she
discontinued Naprosyn for gastric irritation. She presents
for alternate therapy. Physician provides a 6 minute
visit with problem focused history and examination
and prescribes Mobic® 7.5 mg twice daily. What is the
appropriate coding for this visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
160
Q
- As part of interventional pain management, you are
providing a patient with quarterly testosterone injections.
Patient returns for a testosterone injection and was seen
by an RN and the injection was provided. How would you
code this evaluation and management visit?
A. 99211, established patient, offi ce or other outpatient visit
(time 5 minutes), no physician presence is required
B. 99212, established patient, offi ce or other outpatient
visit, problem focused
C. 99213, established patient, offi ce or other outpatient
visit, expanded problem focused
D. 99214, established patient, offi ce or other outpatient
visit, detailed visit
E. 99215, established patient, offi ce or other outpatient
visit, comprehensive
A
- Answer: A
Source: Laxmaiah Manchikanti, MD
161
Q
- A 68-year-old male presents with severe neck and
bilateral shoulder pain. His complaints included stress
incontinence. His physical examination was with brisk
deep tendon refl exes. The physician evaluation included
comprehensive history, comprehensive examination and
medical decision making of moderate complexity. Select
the appropriate coding for this initial offi ce visit?
A. 99201, new patient offi ce or other outpatient visit, problem
focused history and examination with straightforward
medical decision making
B. 99202, new patient offi ce or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient offi ce or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient offi ce or other outpatient visit, with
comprehensive history and examination with moderate
complexity medical decision making
E. 99205, new patient offi ce or other outpatient visit, with
comprehensive history, examination and high complexity
medical decision making
A
- Answer: D
Source: Laxmaiah Manchikanti, MD
162
Q
- A 21-year-old football player presents with fi ve day old
injury complaining of severe low back pain and right
knee pain. The right knee is associated with swelling and
discoloration. What is the appropriate code for this initial
offi ce visit?
A. 99201, new patient offi ce or other outpatient visit, problem
focused history and examination with straightforward
medical decision making
B. 99202, new patient offi ce or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient offi ce or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient offi ce or other outpatient visit, with
comprehensive history and examination with moderate
complexity medical decision making
E. 99205, new patient offi ce or other outpatient visit, with
comprehensive history, examination and high complexity
medical decision making
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
163
Q
- A long-term patient of yours brings her 12-year-old
daughter with progressive scoliosis. You take a detailed
history and conduct a detailed examination, advise the
patient with regards to further management. What is the
appropriate coding for this visit?
A. 99201, new patient offi ce or other outpatient visit, problem
focused history and examination with straightforward
medical decision making
B. 99202, new patient offi ce or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient offi ce or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient offi ce or other outpatient visit, with
comprehensive history and examination with moderate
complexity medical decision making
E. 99205, new patient offi ce or other outpatient visit, with
comprehensive history, examination and high complexity
medical decision making
A
- Answer: C
Source: Laxmaiah Manchikanti, MD
164
Q
- A 42-year-old male patient presents with localized low
back pain which started a week ago following strain.
There was no history of any medical problems. There
were no radicular symptoms. Patient had only local
tenderness without alteration of refl exes or sensation,
etc. What is the appropriate coding for this evaluation
and management service visit?
A. 99201, new patient offi ce or other outpatient visit, problem
focused history and examination with straightforward
medical decision making
B. 99202, new patient offi ce or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient offi ce or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient offi ce or other outpatient visit, with
comprehensive history and examination with moderate
complexity medical decision making
E. 99205, new patient offi ce or other outpatient visit, with
comprehensive history, examination and high complexity
medical decision making
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
165
Q
2080.What are the accurate statements about federal
regulations?
A. They are promulgated by Congress, CMS, and OIG.
B. They are promulgated by the Department of Justice
(DOJ), Federal Bureau of Investigations (FBI) and Offi
ce of Inspector General (OIG).
C. Courts may not promulgate any regulations, as it is the
duty of Congress and Administration.
D. They are enforced by Congress.
E. They are enforced by local Medicare Carriers
A
- Answer: A
166
Q
2081.A compliance offi cer should report credible evidence
of violation of criminal, civil or administrative law to
appropriate federal and state authorities under OIG
Compliance Guidance:
A. Immediately
B. Within 30 days
C. Within 45 days
D. Within 60 days
E. Never
A
- Answer: D
Explanation:
If a compliance offi cer, compliance committee or other
management offi cial discovers credible evidence of
misconduct from any source and, after a reasonable
inquiry, has reason to believe that the misconduct may
violate criminal, civil or administrative law, the provider
promptly should report the existence of misconduct to the
appropriate federal or state authorities within a reasonable
period, but not more than 60 days after determining that
there is credible evidence of violation to appropriate
federal and state authorities.
A. OIG states that some violations may be serious that they
warrant immediate notifi cation to government authorities
prior to, or simultaneous with, commencing an internal
investigation. Examples include the following:
¨A clear violation of criminal law.
¨Has a signifi cant adverse effect on the quality of care
provided to program benefi ciaries (in addition to any
other legal obligations regarding quality of care).
¨Indicates evidence of a systemic failure to comply with
applicable laws, rules or program instructions or an
existing corporate integrity agreement regardless of the
fi nancial impact on federal health care programs.
OIG states that all providers, regardless of size, should
ensure that they are reporting the results of any
overpayments or violations to the appropriate entity.
B. Violations need to be reported in 60 days.
C. Violations need to be reported in 60 days.
D. Violations need to be reported in 60 days.
E. Violations need to be reported in 60 days.
167
Q
- A provider should make the same effort to collect the
amount owed by a non-Medicare patient as s/he does
from a Medicare patient because
A. All non-Medicare payers have a stipulation in the Agreement
that the provider signs that stipulates as stated
above
B. The doctor’s name is likely to wind up in a newspaper
article or “Letter to the Editor” if he doesn’t make equal
collection efforts for all patients
C. Medicare wants parity in the treatment of Medicare and
non-Medicare patients
D. The AMA published a mandate that collection efforts are
to be the same for all patients, regardless of insurance
coverage
A
- Answer: C
Explanation:
While it is possible that a patient may fi nd out if a doctor
doesn’t make equal collection efforts and write to the
newspaper. A primary reason to make equal collection
effort for all patients is that, according to Herb Kuhn,
Director Center for Medicare Management Centers for
Medicare and Medicaid Services, “Medicare wants parity
to protect the program and all patients, not just our
benefi ciaries”.
The above quote is an excerpt from Mr. Kuhn’s testimony
before the House Energy & Commerce Subcommittee on
Oversight & Investigations June 24, 2004,
Source: Joanne Mehmert, CPC
168
Q
2083.Two of the most frequently and improperly used
modifi ers that providers use to bypass National Correct
Coding (NCCI) code edits are:
A. Modifi er 57 (Decision to do surgery) and modifi er 24
(Unrelated E&M by the same physician during a postoperative
period
B. Modifi er 58 (Staged or related procedure/service by the
same physician during the postoperative period and
modifi er 24
C. Modifi er 25 (Signifi cant, separately identifi able E&M by
the same physician on the same day of the procedure
or other service) and modifi er 59 (Distinct procedural
service such as different anatomic sites or different patient
encounter)
D. Modifi er 76 (Repeat procedure by the same physician)
and modifi er 25
A
- Answer: C
Explanation:
A recently released Offi ce of the Inspector General (OIG)
inspection report found that 40 percent of code pairsbilled
with modifi er 59 in fi scal year 2003 did not meet program
requirements, resulting in an estimated $59 million in
improper payments.
The report also said that 35 percent of claims for E/M
services allowed by Medicare in 2002 did not meet
program requirements, resulting in $538 million in
improper payments. Modifi er 25 was also used
unnecessarily on a large number of claims, and while such
use may not lead to improper payments, it fails to meet
program requirements.
Source: News Release issued by the Inspector General
December 12, 2005
Source: Joanne Mehmert, CPC
169
Q
- Dr. Smith has a contractual agreement with United
Health Care (UHC) and wants to perform an occipital
nerve block (ONB) for a patient who suffers from cluster
headaches. After he performed an ONB for a UHC
patient 3 months ago, he discovered that UHC considers
ONB’s investigational and does not cover the service. The patient is willing to pay for the injection.
A. Dr. Smith can have the patient sign an ABN form and
substitute UHC for the word ‘Medicare” in the form
B. Collect cash from the patient without a written notice
since the patient said she was willing to pay for the
service
C. He knows that his contract requires that he provide
his patient with a written notice before he provides a
non-covered service.He has a form for UHC patients
explaining that it doesn’t cover occipital nerve block
and asks his patient to pay for procedure
D. Dr. Smith cannot collect from the patient since he is a
contracted provider. He can perform the ONB for free
or send the patient to someone else
A
- Answer: C
Explanation:
ABN’s are designed for use with Medicare benefi ciaries
only, including those who are dually-eligible Medicare and
Medicaid. ABN’s are not for use with patients who are not
Medicare benefi ciaries. A provider should be familiar
with the terms of his/her contractual agreements relative to charging a patient for a non-covered service. Just as a
patient is “allowed” to pay and receive a cosmetic
procedure, they should also be able to pay for and receive a
non-covered therapeutic procedure. Usually this
provision is in the provider’s contractual agreement.
Source: Medicare Transmittal AB-02-114, July 31, 2002
Source: Joanne Mehmert, CPC
170
Q
- What item(s) listed below does Medicare consider
“incident to” a physician’s service and may be reported
and paid separately when services are provided in an
offi ce setting, POS 11?
A. Needles and syringes used to perform an injection/nerve
block
B. A substance such as Depo Medrol that is injected when a
lumbar epidural steroid injection is performed
C. Lidocaine that is used to anesthetize the area
D. Pulse oximetry
A
- Answer: B
Explanation:
Needles, syringes, and local anesthetic (lidocaine), are
supplies that are bundled into the majority of the surgical
procedure codes. Supplies are considered to be included in
the payment for the procedure, i.e., the “global surgical
fee”.
Pulse oximetry is pre, intra, and post operative care that is
bundled into the procedure, i.e., paid in the global fee.
A drug or substance (Depo Medrol) that a patient cannot
self administer is separately paid and is considered
“incident to” the physician’s service.
Source: Medicare Carrier Manual, 100-4, Chapter 12
Source: Joanne Mehmert, CPC
171
Q
- Working in his offi ce, Dr. Ledger is going to inject 2500
units of Myobloc (J0587, per 100 units) in a patient’s
cervical spinal muscles. He used needle EMG guidance
to obtain the precise muscle and injection location (CPT
95874). The procedure included injections into the right
sternocleidomastoid, splenius capitis, posterior scalene,
and oblique capitis inferioris muscle. An injection was
also made in the left semispinalis capitis. In addition to
CPT code 64613 for the injection procedure, what codes
should Dr. submit?
A. 95874 x 5, J0587 x 1
B. 95874 x 1, J0587 x 25
C. 95874 x 1, J0587 x 1
D. 95874-50, J0587 x 2500
A
- Answer: B
Explanation:
Needle EMG localization is reported one time per session
according to CPT coding conventions. Likewise the
injection code 64613 is reported one time per session
regardless of the number of injections or number of
muscles injected. J0587 is listed per 100 mg, to determine
the number of units to report, divide the amount injected
by the listed dosage: 2500/100 = 25
Source: Joanne Mehmert, CPC
172
Q
2089. Steps that a practice can take to minimize theft and fraud include: A. Internal audits B. External audits C. Segregation of duties D. Competitive bidding for purchases E. All of the above
A
- Answer: E
Explanation:
It is essential to have controls and then audit to make sure
that the controls are working. Segregation of duties allows
a “check and balance”to be implemented to minimize
theft and fraud. Competitive bidding will eliminate the
opportunity for “kick back”and allow the best price to be
obtained.
Source: Trent Roark,MBA
173
Q
2090. Ways to build revenue include: A. Recall and no show contact B. Mine charts, screenings, seminars C. Pay for referrals D. A and B only E. A, B and C only
A
- Answer: D
Explanation:
recall and no show patients need to be contacted to
reschedule the appointment. Going through charts to
contact patients who have not returned for some time is
another opportunity. Screenings and seminars allow for
the introduction of the practice to the community. Having
these programs in your practice allows the participant to
fi nd your location and be impressed by your practice
environment. Paying for referrals is illegal and carries
civil and criminal penalties.
Source: Trent Roark,MBA
174
Q
- Three keys of success have been identifi ed.These are:
A. Staffi ng, fi nancial and profi tability
B. Staffi ng, measuring and patient satisfaction
C. Physician, fi nancial and practice growth
D. Number of procedures, profi tability and staffi ng
E. Marketing, physician and profi tability
A
- Answer: B
Explanation:
Having the right trained staff and number of staff,
including physicians will help you meet the patient
demand. Measuring the effi ciency, growth, and fi nancial
results is essential to determining if changes need to be
made. Patient satisfaction is essential to grow a practice.
Word of mouth is the number one referral source of
patients.
Source: Trent Roark,MBA
175
Q
- Modern organization structure requires input and
output between:
A. CEO/Administrator, physicians, patients, clinic and
fi nance
B. CEO/Administrator, Board, and physicians.
C. Physicians to the CEO/Administrator.
D. Physician to CEO/Administrator, clinic and fi nance.
E. Finance to the Physician and CEO/Administrator.
A
- Answer: A
Explanation:
Open communication to and from all areas of the practice
allow for more accurate information, shared responsibility
and better decision making. One group pushing their own
agenda down to another group will result in resentment,
less motivation, less openness, and worse decision making.
Source: Trent Roark,MBA
176
Q
- An offi ce billing employee reports to the physician that
a template has been developed for each of the separate
providers to expedite billing processing and reporting.
The template is compliant, and ensures a Level 3 new,
consultative, and return patient, as determined by the
American Medical Association 1997 CPT guidelines. The
content will be placed in the electronic medical record
and accessed by keystroke. The physician’s response is
to:
A. Accept the template as an important time conserving
element in the practice.
B. Consider the templates as an important component of
effi ciency and compliance.
C. Review the template to determine a true Level 3 reporting,
CPT guidelines.
D. Discard the template.
E. Ask the other members of the tier team to provide input
and favored dialogue to the template.
A
- Answer: D
Explanation:
It is incumbent upon the physician’s practice to be
compliant. A troubling feature of the electronic medical
record is the ease of standard templates to emerge as a one
and only approach to billing and coding. Just as the billing
sheet contains all levels of code, and not pre-selected 2, 3,
or 4, for example, a template created by a non-physician,
applicable to all patients, and all providers, has no validity
in a true compliance plan. A physician is only allowed to
bill for elements that they are personally involved in, and a
template does not always refl ect true work performed.
Unfortunate up-coding or down-coding may occurplacing
the practice at risk.
Source: Hans C. Hansen, MD
177
Q
- The correct defi nition of CPT-4 is:
A. Inpatient and outpatient diagnosis classifi cation system
and an inpatient procedure classifi cation system
B. Systematic listing of procedures and services performed
by physicians
C. Uniform method for healthcare providers and medical
suppliers to code professional services and procedures
D. Inpatient coding system for tracking time and supplies
consumed per procedure
E. Classifi cation system developed by CMS for providers to
code services and procedures for billing purposes
A
2094. Answer: B Explanation: A.Incorrect. Description of ICD-9 B.Correct. C.Incorrect. Description of HCPCS D.Incorrect E.Incorrect. CPT-4 was not developed by CMS. Source: Marsha Thiel, RN, MA
178
Q
- You just went to a seminar that extolled the virtues of
having an employee handbook to minimize the risk of
employment suits and claims. If you want to minimize
your liability, which of the following is the best way to
proceed?
A. Delegate the task of drafting and implementing a handbook
to your offi ce staff, and appoint your offi ce manager
as chairman of the committee
B. Instruct your offi ce manager to download a handbook
from an internet site and distribute it to the staff
C. Your divorce attorney owes you money so just ask him to
draft something for you
D. Disregard the advice you heard in the seminar handbooks
can cause more problems than they solve, and
implementing one will cause morale problems– the less said, the better
E. None of the above
A
- Answer: E
Explanation:
Handbooks are a very valuable part of a well-run offi ce,
and can help you minimize liability and maximize
employee morale. But having a poorly drafted handbook is
worse than not having one at all. Don’t download a
generic handbook from the internet it may not comply
with applicable laws. Use an experienced employment
lawyer to draft a handbook appropriate to your offi ce, your
practice, and your state laws
Source: Judith Holmes
179
Q
- A local clinical laboratory provides a phlebotomist
free of charge to a doctor’s offi ce. The phlebotomist
takes specimens from the physician’s offi ce to the lab.
When the phlebotomist is not busy drawing blood, the
phlebotomist assists the doctor/s offi ce personnel with
fi ling of records and other clerical duties. What aspects of
this scenario, if any, implicate the anti-kickback laws?
A. Provision by the clinical lab of a phlebotomist free of
charge to the physician.
B. Performance by the phlebotomist of clerical duties in the
physician’s offi ce.
C. Phlebotomist taking specimens from physician’s offi ce
to the lab
D. All of the above.
E. None
A
- Answer: B
Explanation
Don’t accept anything from a clinical lab that you didn’t
pay fair market value for.
OIG indicated it was aware of a number of deals between
clinical labs and providers that could implicate the antikickback
statute. When a lab offers or gives a referral
source anything of value without receiving fair market
value it can be viewed as an inducement to refer. It’s also
true when a potential referral source receives anything of
value from the lab.
When permitted by state law, a lab can make available to a
physician’s offi ce a phlebotomist who collects specimens
from patients for testing by the outside lab. Although the
simple placement of a lab employee in the physician’s
offi ce isn’t by itself necessarily an inducement forbidden
by the Anti Kickback Statute, the statute does come into
play whenthe phlebotomist performs additional tasks that
are normally the responsibility of the physician’s offi ce
staff. These tasks can include taking vital signs or other
nursing functions, testing for the physician’s offi ce lab, or
performing clerical services.
When the phlebotomist performs clerical or medical
functions that aren’t directly related to the collection or
processing of lab specimens,OIG makes the deduction that
the phlebotomist is providing a benefi t in return for the
physician’s referrals to the lab. In this case, the physician,
the phlebotomist and the lab may have exposure under the
Anti-kickback Statute. This analysis also applies to the
placement of phlebotomists in other health care settings,
including nursing homes, clinics and hospitals.
OIG also points out that the mere existence of a contract
between a lab and a health care provider that prohibits the
phlebotomist from performing services unrelated to
specimen collection does not eliminate the concern over
possible abuse, particularly if it’s a situation where the
phlebotomist is not closely monitored by his or her
employer or where the contractual prohibition is not
rigorously enforced.
Source: Laxmaiah Manchikanti, MD
180
Q
- A hospital wishes to lease space in its building to a group
of Interventionalists. Choose the correct statement.
A. The hospital may charge the physicians less than the
property’s general market value if they agree not to
refer patients elsewhere.
B. Hospital may provide bonus of $100 for each interventional
procedure.
C. Hospital may share 50% of gross revenues from physical
therapy services, with physicians
D. Hospital may provide administrative and nursing services
at no cost to physicians, and physicians get reimbursed
for these services.
E. Hospital wants to lease the space for the value paid in
their market for like property.
A
.2097. Answer: E
Explanation:
According to the fi nal stark II regulations, fair market
value is the price that an asset would bring by bona fi de
bargaining between well-informed buyers and sellers who
are not in a position to generate business for the other
party in an arms-length transaction, consistent with the
price the asset would bring on the general market. Fair
market price is the price paid in a particular market for
assets of like type, quality and quantity at the time of the
acquisition For rentals and leases, fair market value is the value of
rental property without taking into account the property’s
intended use. This means the space’s general market value,
unadjusted for the additional value of the space’s
convenience or proximity to the renter if the landlord is a
potential source of referrals to the renter
181
Q
2098. A patient can appoint all of the following as their surrogate decision-maker EXCEPT: A. Spouse B. Friend C. Their physician D. Non-traditional signifi cant other E. Relative
A
- Answer: C
Source: Weinberg M, Board Review 2004
182
Q
2099.Developing Quality Assurance and clinical practice
affects outcome driven mechanisms by which of the
following :
A. Reassuring patients of high level of expectation.
B. Considering outcome management an institutional issue
and outside of the reasonable accountability of a private
clinical practice.
C. Excluding the patient from medical decision-making
relying on objective interpretation of the physician.
D. Developing questionnaires, mechanisms to address complaints,
and adhering to necessary compliance plan for
best treatment management.
E. Holding staff meetings to improve collections
A
- Answer: D
Source: Hans C. Hansen, MD
183
Q
- An anesthesiologist performs a caudal epidural and
two lumbar interlaminar epidural steroid injections at
different levels in a patient with chronic non-specifi c low
back pain. The accurate coding for these procedures is
A. CPT 62311 – lumbar /caudal epidural steroid injection
B. CPT 62310 – cervical/thoracic epidural steroid injection
C. CPT 62311 x 3 – lumbar/caudal epidural steroid injections
D. CPT 62311 and 62311 x 2 – lumbar or caudal epidural
steroid injections
E. CPT 62311 and 64483 & 64484 – caudal or lumbar
epidural and lumbar transforaminal epidural steroid
injections
A
- Answer: A
Explanation:
Administration of multiple epidural injections during the
same session is not only unusual but also is considered as
abuse. As a general rule, a physician is not reimbursed for
more than one epidural steroid injection for the region
(i.e., lumbar/sacral).
Source: Laxmaiah Manchikanti, MD
184
Q
- A surgery center is surveyed for accreditation by:
A. Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
B. American Cancer Society
C. Commission on Accreditation of Rehabilitation Facilities
(CARF)
D. Offi ce of Inspector General (OIG)
E. American Hospital Association
A
- Answer: A
Source: Laxmaiah Manchikanti, MD
185
Q
- A direction to “Code fi rst underlying disease” should be
considered
A. Mandatory dependent upon the code selection
B. A mandatory instruction
C. Only when coding inpatient records
D. A suggestion only
E. Applies only for worker’s compensation patients
A
- Answer: B
186
Q
- A patient had lumbar disc decompression with 90-
day global period and presents one month later for an
unrelated Evaluation and Management (E/M) service.
Indicate the modifi er that should be attached to the E/M
code for the service provided.
A. -24 unrelated evaluation and management service by the
same physician during a postoperative period
B. -79 unrelated procedure or service by the same physician
during the postoperative period
C. -59 distinct procedural service
D. -25 signifi cant, separately identifi able evaluation and
management service by the same physician on the same
day of the procedure or other service
E. -58 staged or related procedure or service by the same
physician during the postoperative period
A
- Answer: A
187
Q
2104.In evaluating quality and compliance with coding,
the degree to which the same results (same codes) are
obtained by different coders or on multiple attempts by
the same coder generally refers to:
A. Validity
B. Completeness
C. Timeliness
D. Reliability
E. Accuracy
A
- Answer: D
188
Q
2105.The Correct Coding Initiative (CCI) edits contain a
listing of codes under two columns titled “comprehensive
codes” and “component codes.” According to the CCI
edits, a provider must bill Medicare for a procedure with
the following:
A. Only the component code
B. Only the comprehensive code
C. Both the comprehensive code and the component code
D. Comprehensive code and component code with modifi
er -59
E. Comprehensive code and component code with modifi er
-51
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
189
Q
2106. Tachycardia after taking a correct dosage of prescribed oxycodone would be reported as (an): A. Drug interaction B. Adverse reaction to a drug C. Poisoning D. Late effect of an adverse reaction E. Late effect of a poisoning
A
- Answer: B
190
Q
2107. Dizziness and blurred vision following ingestion of prescribed hydrocodone and three glasses of wine at dinner would be reported as a: A. Poisoning B. Adverse reaction to a drug C. Late effect of a poisoning D. Late effect of an adverse reaction E. Drug interaction
A
- Answer: A
191
Q
2108. Practice patterns and medical protocol should be the responsibility of: A. The CEO/Administrator. B. Committee of employees. C. The Medical Director. D. The clinical staff. E. Each physician.
A
- Answer: C
Explanation:
the Medical Director. It is important to have a peer who
can address productivity issues and protocols with the
medical staff. Anyone else does not have a medical license.
All medical issues should be addressed by the Medical
Director once input is received from the medical staff,
clinical staff (if appropriate) and administration.
Source: Trent Roark,MBA
192
Q
- Your clinic is placing an advertisement for a new
receptionist. You want to make sure the offi ce projects
a professional, cool-with-it-now image so you place
an ad that states: Help Wanted: Female, age 25-35, for
receptionist position. Must have front offi ce appearance,
and must speak English without accent. Great job
security. Send photo with resume. Which of the following
is true?
A. An unsuccessful applicant may fi le an EEOC charge
against the clinic for discrimination based on age
B. An unsuccessful applicant may fi le an EEOC charge
against the clinic for discrimination based on race or
national origin
C. An unsuccessful applicant may fi le an EEOC charge
based on disability discrimination
D. A successful applicant who is later terminated may have
a breach of implied contract
E. All of the above
A
- Answer: E
Explanation:
The ad discriminates on the basis of age and the
requirement to speak without accent discriminates against
race and national origin. The words front offi ce
appearance have been held to discriminate against those
with visible disabilities. The ad also promises job
security, allowing a terminated employee to have a claim
against the clinic for breach of implied contract of
continued employment. Employers are at a decided disadvantage
Source: Judith Holmes
193
Q
- Which of the following is not something a physician
practice’s policies and procedures concerning OIG
compliance needs to address?
A. Medical directorships
B. Offi ce and equipment leases
C. Gift-giving
D. Publishing
E. Financial arrangements with outside entities to whom
the practice may refer federal health care program business
A
2110. Answer: D Explanation: Explanation: Publishing is not an issue addressed in the OIG compliance materials. Source: 65 Fed. Reg. at 59,440-41. Source: Erin Brisbay McMahon, JD
194
Q
- It is recommended that the Sharps container be emptied
when it is:
A. Full
B. 3/4 full
C. Half full
D. Monthly
E. When you are no longer able to close the lid
A
- Answer: B
Source: Hans C. Hansen, MD
195
Q
2112. The Quick Ratio is a measurement of: A. Current Assets to Current Liabilities B. Current Liabilities to Current Assets C. Profi tability D. Assets E. Owners Equity
A
- Answer: A
Explanation:
ratio of Current Assets to Current Liabilities. This ratio
will tell you if you have enough current assets to cover
your current liabilities. Current means that the asset or
liability can be sold or paid within a year.
Source: Trent Roark,MBA
196
Q
2113. Data to evaluate for each doctor monthly includes: A. new patients and no charge patients B. established patients C. procedures D. A and C only E. A, B and C
A
- Answer: E
Explanation:
tracking the physician productivity is essential to compare
the productivity of one physician to another. Once done, a
decision needs to be made as to whether a physician is
under-producing compared to the other physicians so that
correction can be made.If a physician has a high rate of
no-charge patients, the physician is not covering their
overhead. Again, correction can then be taken.
Source: Trent Roark,MBA
197
Q
2114. Medicare can pay a “clean” claim no sooner than: A. 10 days of receipt B. 5 days of receipt C. 30 days of receipt D. 15 days of receipt E. 2 days of receipt
A
- Answer: A
Explanation:
under law, Medicare cannot pay a “clean” claim within 10
days of receipt. This means that it is essential to fi le the
claim as soon as possible to start the pay clock running. If
it takes a practice 2 days to fi le a claim, that meanspayment
will not be received, at best, until 12 days after service. The
goal should be to fi le the claim the next morning to
improve cash fl ow.
Source: Trent Roark,MBA
198
Q
2115. Aged Accounts Receivable report should be run monthly. The goal is to have 90 days and less balance be greater than: A. 90% B. 60% C. 80% D. 95% E. 50%
A
- Answer: C
Explanation:
management of the accounts receivable is essential to
maintain good cash fl ow. In keeping the total balance of
accounts greater than 80% means that the accounts are
being managed and properly worked. Any lower
percentage would indicate that the accounts receivable are
not being managed.
Source: Trent Roark,MBA
199
Q
- The OIG does not have to exclude an individual from
participation in federal healthcare programs in cases
where:
A. The individual is convicted of a criminal offense related
to the delivery of an item or service under Medicare or
Medicaid.
B. The individual is convicted of a criminal offense related
to the neglect or abuse of a patient in connection with
the delivery of a health care item or service.
C. The individual is convicted of any misdemeanor under
federal or state law relating to the unlawful manufacture,
distribution, prescription, or dispensing of a controlled
substance.
D. The individual is convicted of any felony relating to
fraud, theft, embezzlement, breach of fi duciary responsibility,
or other fi nancial misconduct under federal or
state law relating to health care fraud.
E. The individual is convicted of any felony under federal
or state law relating to the unlawful manufacture, distribution,
prescription, or dispensing of a controlled
substance.
A
- Answer: C
Explanation:
The OIG’s mandatory exclusionary authority does not
extend to misdemeanors relating to controlled substances
crimes.
Source: 42 U.S.C. § 1320a-7(a).
Source: Erin Brisbay McMahon, JD
200
Q
2117.OIG must exclude providers from Medicare and
Medicaid participation if they have been convicted of
certain criminal offenses. Which of the following is not
considered a conviction for the purposes of deciding
whether to exclude a provider from participation in
Medicare and Medicaid?
A. judgments entered by a court.
B. pleas of guilty accepted by a court.
C. pleas of nolo contendre or no contest accepted by a
court.
D. participation in a fi rst offender program where judgment
has been withheld pending completion of the
program.
E. a hung jury.
A
- Answer: E
Explanation:
A hung jury does not result in a conviction under the
exclusionary statute; all of the other answers listed above
are considered a conviction under that statute.
Source:42 U.S.C. § 1320a-7(i).
Source: Erin Brisbay McMahon, JD
201
Q
- Under Stark Law, what is acceptable from medical
representatives?
A. Golf balls and sports bag
B. Free meal of more than modest value and is not accompanied
by exchange of information
C. Free stethoscope
D. Lunch for staff not connected to an information presentation
E. Gift certifi cate from a bookstore
A
- Answer: C
Explanation:
WHAT’S ACCEPTABLE
- Free stethoscope
- Free meal, if it is “modest by local standards,” and
accompanied by educational or scientifi c exchange
- Lunch for staff, if provided during an information
presentation
- Free medical books, provided the cost is not substantial
- Modest buffet meal accompanying scientifi c or
educational meeting
WHAT’S NOT
- Golf balls and sports bag
- Free meal, if it’s of more than modest value and is not
accompanied by exchange of information
- Lunch for staff, if not connected to an information
presentation
- Gift certifi cate from a bookstore
- Scientifi c or educational meeting held before an athletic
event or entertainment performance
- Reimbursement for gasoline expenses
202
Q
- What is Medicare’s defi nition of reasonable and
necessary medical services?
A. Services necessary to improve the health of a patient
B. Services for the diagnosis or treatment of an illness or
injury or to improve the functioning of a malformed
body member
C. Services for the diagnosis or treatment of an illness or
injury.
D. Services to improve the functioning of a malformed
body member
E. Services for the treatment of a patient or to improve the
functioning of a malformed body member
A
- Answer: B
Explanation:
Source:42 USC § 1395y(a)(1)(A).
Source: Erin Brisbay McMahon, JD
203
Q
- Which of the following is not a required administrative
safeguard under the HIPAA Security Rule?
A. The appointment of a security offi cer.
B. A risk analysis.
C. The development of policies and procedures
D. Password management
E. Data backup plan
A
- Answer: D
Explanation:
Password management is an addressable administrative
safeguard under 45 CFR 164.308; all of the rest of these are
required administrative safeguards under that rule.
Source: 45 CFR 164.308
Source: Erin Brisbay McMahon, JD
204
Q
2121.Which one of the following is not an electronic
transaction governed by the HIPAA Transactions and
Codes Sets Rule?
A. sending a patient’s electronic health record
B. health care claims
C. checking on a patient’s eligibility for health plan
D. coordination of benefi ts
E. requesting a preauthorization
A
- Answer: A
205
Q
- Do all of the National Correct Coding Initiative (CCI)
bundling edits correspond with CPT coding conventions
and the instructions in the CPT Manual?
A. Yes, Administar Federal, the contractor that develops the edits coordinates with the CPT Editorial staff before
quarterly updates are published
B. There is not always an NCCI edit t that corresponds
precisely to CPT coding conventions and instructions;
however AMA/CPT coding conventions do have a prevailing
infl uence on coding edits
C. No, CMS local carrier decisions are the only policies that
Administar Federal considers when revising the edits
D. Administar Federal relies solely on specialty society
manuals and communication from physicians to update
the edits
A
- Answer: B
206
Q
- One of your nurse practitioners just told you that the
new physician you hired last month is already known
as the offi ce super-fl irt and that he has declared he will
conquer every nurse in the offi ce by year’s end. The most
appropriate course of action you can take is:
A. Don’t get involved. It’s not any of your business and it
would be an invasion of your staff ’s privacy to inquire
further
B. You have an obligation to go to your nurse practitioner
and warn her not to spread rumors, and to refrain from
discussing issues relating to co-workers
C. You should institute an internal investigation to determine
whether or not the allegations have merit
D. You should talk privately to your new physician and
remind him of your offi ce policies prohibiting inappropriate
conduct in the offi ce. You should then make
sure he has signed your anti-harassment policy, and you
should then keep a very close eye on him
E. Fire him he’s bad news and you are just buying trouble
keeping him around
A
- Answer: D
207
Q
- True statement applicable to a patient request for a copy
of his or her record :
A. The physician is not required to give the patient any
records that were not created or generated by the practice.
B. The provider is required to give a copy of all the records.
C. Designated records set includes only the medical records
generated by the provider
D. Medical records may be released only after patient has
paid his bill in full.
E. Patient’s access is limited to only certain areas of medical
record
A
- Answer: B
208
Q
- A nurse practitioner employed by your clinic has fi led a
harassment claim against your clinic, claiming a hostile
work environment has been created because the male
physicians and staff members regularly tell off color
jokes. Which of the following are viable defenses:
A. The jokes did not affect the work environment and were
not offensive to a reasonable person
B. The jokes were not offensive to the nurse practitioner
because she laughed too and she told similar jokes
C. The conduct was not harassment because no one else
minded
D. All of the above may be raised as defenses but they may
not work
E. None of the above2125. A nurse practitioner employed by your clinic has fi led a
harassment claim against your clinic, claiming a hostile
work environment has been created because the male
physicians and staff members regularly tell off color
jokes. Which of the following are viable defenses:
A. The jokes did not affect the work environment and were
not offensive to a reasonable person
B. The jokes were not offensive to the nurse practitioner
because she laughed too and she told similar jokes
C. The conduct was not harassment because no one else
minded
D. All of the above may be raised as defenses but they may
not work
E. None of the above
A
- Answer: D
Explanation:
209
Q
- You are the sole owner of your medical clinic. Your
transcriptionst has fi led a sexual harassment claim against
your clinic, claiming a hostile work environment because
one of your male employees made a lewd comment as he
touched her inappropriately when she was in the break
room. The incident occurred fi ve months before she fi le
her claim with the EEOC, but she made no mention of it
to anyone at your clinic prior to her claim. Which of the
following is true?
A. Your clinic has a defense because you have adopted a
comprehensive policy prohibiting harassment and all
of your employees have signed the policy agreeing to
abide by it. You have also provided comprehensive offi
ce training on discrimination and harassment
B. Your clinic has a defense because you have a policy requiring
employees to act in compliance with the clinic’s
written complaint procedure and the transcriptionist
failed to make a complaint in accordance with that offi
ce policy
C. Your clinic has a defense because the incident was an
isolated incident and was not severe or pervasive
D. All of the above
E. None of the above. Your clinic is strictly liable for all
harassment occurring at your clinic
A
- Answer: D
210
Q
- You are the sole owner of your medical clinic. One
of your employees is Dr. West, a female physician. For
several months, she dated your offi ce manager, a male,
one of the employees she supervised. Immediately after
the offi ce manager broke off the relationship, Dr. West
demoted him to receptionist and cut his pay in half. She
is also threatening to fi re him if he does not resume the
relationship with her. Your offi ce manager has fi led sexual
harassment and retaliation claims against your clinic
because of Dr. West’s conduct. Which of the following
is true?
A. Your clinic is safe a male cannot fi le harassment and retaliation
claims against a femaleand that her wheelchair
may be a downer for some patients
B. Your clinic is safe the offi ce manager cannot fi le a claim
if the relationship had been voluntary and he is not a
minor
C. Your clinic is safe you were not aware that they had been
dating and you were not aware that Dr. West reduced
his pay and position
D. Your clinic is safe you have a policy against harassment
and retaliation and Dr. West signed an agreement to be
bound by that agreement.
E. Your clinic is in trouble
A
- Answer: E
Explanation:
This is a classic example of economic harassment. Dr
West is the offi ce manager’s supervisor. She reduced the
offi ce manager’s pay and demoted him as a result of his
refusal to continue a personal relationship. It only takes
one incident to create liability and it the clinic is strictly
liable even if there is a policy in place and even if the clinic
owner does not know it has occurred. It does not matter
that the supervisor is a female
Source: Judith Holmes
211
Q
- Your file clerk, a hispanic woman in her 50’s has been
with you for a year, but during that year she has been a terrible employee. There have been several significant problems that have been caused by her misfiling of records, she is chronically late, and several patients have
complained about her abrupt manner of speaking to
them. You have never warned her about her behavior,
and you have never noted any performance defects in her
employment fi le. Your new offi ce manager has decided
he wants to get rid of her. He devises a plan to make
her employment life unbearable by ignoring her, giving
her weekend assignments, and giving her the dreaded
telephone duty. After several weeks of this treatment,
your nurse quits. Which of the following statements are
correct:
A. Your offi ce manager’s plan worked like a charm so you
give him a raise and vow to use the technique in the
future
B. You breathe a sigh of relief because you know the clerk
can’t sue you because she quit and was not fi red
C. The clerk can sue for constructive discharge based on
race and/or age if she can establish that the employer
made conditions so intolerable that any reasonable person
would have been forced to quit
D. The clerk can sue for constructive discharge based on
race or age only if she can demonstrate that her replacement
was less qualifi ed to perform the job duties.
E. You are immune from suit because she was a bad employee
A
- Answer: C
Explanation:
Assuming she can establish the elements of a racial and/or
age discrimination claim, the clerk could also allege
constructive discharge based upon the facts presented. A
constructive discharge claim exists:
a)when an employer makes conditions so intolerable that
it would force a reasonable employee to resign her
employment and
b)the employer either created the conditions or knew
about them and permitted them to continue.
Important note: You would have a better defense to a
potential lawsuit if you could produce documentation of
not only her performance defi ciencies, but also your
repeated warnings to her that she must improve.
Testimony of poor performance withoutcontemporaneous
documentation is often not effective.
Americans with Disabilities Act (ADA)
Overall learning points:
Although the ADA is a federal Act that applies only to
employers with 50 or more employees, physicians
practicing in groups of all sizes must know the general
ADA requirements for two reasons. First, most states have
laws very similar to the ADA and apply to employers with
far fewer employees. Second, the actions of physicians in a
clinic or hospital setting may subject that facility to
liability based on the physician’s conduct - DEFINITELY a
CLM (Career Limiting Move).
Source: Judith Holmes
212
Q
2129.Which of the following are guidelines for good
evaluations?
A. Be familiar with company policies and procedures.
B. Avoid generalities, ambiguities, and sarcasm.
C. Make the time necessary to compose the evaluation.
Avoid poor English and typographical errors.
D. Ensure that there are no surprises, by providing the
employee with effective feedback during the entire
evaluation period
E. All of the above
A
- Answer: E
Explanation:
All of those elements convey to the employee the
importance you place on the evaluation process and on the
information and direction you are imparting.
Source: Judith Holmes
213
Q
- Which of the following are components of an effective
performance evaluation narrative?
A. Include your own subjective feelings regarding the employee’s
performance. It is only fair that he/she receive
some insight into the effects that his/her performance
has had on you.
B. Be willing to consider and memorialize mitigating circumstances
that excuse defi ciencies in the employee’s
performance, and provide suggestions for improvement
C. Include all information available from any source that
is in any way related to the employee’s performance.
You have no way of knowing what information will be
pertinent later in the defense of a grievance, claim or
lawsuit
D. All of the above
E. None of the above
A
- Answer: E
Explanation:
In fact, the possible answers given are exactly how NOT to
write a performance evaluation. You should document
facts, not conclusions. Avoid judgments. You should be
able to establish a written pattern of performance. Avoid argumentative statements, excuses, and directions that fail
to direct.
Source: Judith Holmes
214
Q
- Which of the following promotes effective evaluation
meetings?
A. Have an agenda, encourage feedback, and listen.
B. Include a third-party witness in your meeting.
C. Be hospitable: offer coffee and doughnuts before the
meeting to break the ice.
D. A and B.
E. All of the above.
A
- Answer: A
Explanation:
There is generally no need for a witness in an evaluation
meeting unless you anticipate the employee to become
confrontational. In general, the manager should have been
providing feedback during the entire evaluation period
andso the employee should have no surprises during the
evaluation meeting. (Coffee and doughnuts are a nice
touch but optional).
Source: Judith Holmes
215
Q
- What is the most important element of an employee evaluation?
A. A statement from the employee expressing his or her
opinions
B. A description of available resources at the disposal of
the employee in attempting to meet the performance
requirements
C. A narrative summary of the employee’s work history,
clearly setting forth past performance defi ciencies
D. A clear and unambiguous description of the disciplinary
or corrective action to be taken if performance requirements
are not met within the mandated time period
E. Specifi cation of exact tasks to be performed and reasonable
time frames, in clear, unambiguous language
A
- Answer: E
Explanation:
Use clear unambiguous language so that you and the
employee have objective standards by which to measure
successful performance
Source: Judith Holmes
216
Q
- Which of the following statements is true?
A. As of 2004, nearly every employer in the United States
has mandatory employment law training obligations
B. Failure to provide adequate employment law training on
harassment, discrimination and safety issues exposes
the employer to signifi cant risk of lawsuits, as well as
government charges and penalties
C. Training pays for itself
D. It is important to have a written record of what was covered
in the training sessions, and who attended
E. All of the above.
A
- Answer: E
Explanation:
Physician employers are required to comply with many
state and federal safety and employment-related laws.
Effective compliance requires adequate staff training.
Failure to do so, in the words of one court, is an
extraordinary mistake. In fact, the U.S. Supreme Court has
recently held that failure to conduct staff training on
harassment and discrimination may expose the employer
to punitive damages in addition to compensatory
damages. Because training is so important, it is also
important to be able to produce evidence that your
training programs are adequate and that your staff
members have actually attended the training sessions
Source: Judith Holmes
217
Q
2134…
A
.
218
Q
2135…
A
.
