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
.
219
Q
2136…
A
.
220
Q
- As a physician operating an offi ce practice, you should
avoid basing decisions on personal romantic relationships
outside the offi ce setting, as such allegation would give
rise to a claim of invasion of policy. However, you have an
obligation to assure that the offi ce is free from harassment
by co-workers, including your new physician. If you
believe the physician may be responsible for creating
an adverse effect on the offi ce atmosphere, you should
investigate, and, as with every thing related to medicine,
document, document, document, you investigation.
A. Immediately reporting violations to the Department of
Health and Human Services
B. Training employees regarding the rules and the practices’
policies and procedures, and documenting training and
attendance
C. Responding to patient complaints of violations of the
rules within ninety days from the receipt of the complaint
D. Amending the patient record upon the patient’s request
E. Maintaining maintenance records for the practice’s
physical facility
A
- Answer: B
Explanation:
a)Reporting violations to the Department of Health and
Human Services is not required.
b)Proof of proper training of employees regarding the
HIPAA Administrative Simplifi cation Rules will
minimize the risk of liability for a physician practice if it
has not committed a HIPAA violation but an employee of
the practice has.
c)There is no time limit on responding to patient
complaints.
d)Amending the patient record upon the patient’s request
is not required.
e)Maintaining maintenance records for the practice’s
physical facility is an addressable safeguard under the
HIPAA Security Rule. Source:45 CFR 164.530(c).
Source: Erin Brisbay McMahon, JD
221
Q
- A 72-year-old female with a long history of anxiety
treated with diazepam decides to triple her dose because
of increasing fearfulness about “environmental noises.”
Several days after her attempt at self-prescribing,
her neighbor fi nds her to be extremely lethargic and
nonresponsive. On examination, she is found to be
stuporous and have diminished reaction to pain and
decreased refl exes. Her respiratory rate is 8 breaths per
minute (BPM), and she has shallow respirations. Which
antidote could be given to reverse these fi ndings?
A. Naltrexone
B. Physostigmine
C. Pralidoxime
D. Flumazenil
E. Naloxone
A
- Answer: D
Explanation:
Reference: Hardman, p 564. Katzung, pp 370, 1013.
A. Naltrexone is an antagonist therapy for heroin addiction
B. Physostigmine is used to treat glaucoma
C. Pralidoxime is used together with another medicine
called atropine to treat poisoning caused by organic
phosphorus pesticides
D. Flumazenil is a competitive antagonist of
benzodiazepines at the GABA receptor.
Repeated administration is necessary because of its
short half-life relative to that of most benzodiazepines.
E. Naloxone is an opioid antagonist.
Source: Stern - 2004
222
Q
- In a patient with bilateral chest wall pain, a physician
performed bilateral intercostal nerve blocks at 7th, 8th,
and 9th intercostal nerves under fl uoroscopy. What is the
correct coding for these procedures?
A. CPT 64420 – single intercostal nerve block and CPT
64421 – multiple intercostal nerve blocks
B. CPT 64421-50 multiple intercostal nerve blocks and CPT
76003 – fl uoroscopic visualization
C. CPT 64420 x 6 – single intercostal nerve blocks and CPT
76003 x 6- fl uoroscopic visualization
D. CPT 64421-50 – multiple intercostal nerve blocks, CPT
76005-50 - fl uoroscopic visualization
E. CPT 64421 – multiple intercostal nerve blocks, CPT
76003 fl uoroscopic visualization
A
- Answer: E
Explanation:
Intercostal nerve blocks are not covered by bilateral
coding. CPT 64421 describes multiple intercostal nerve
blocks. Consequently, no modifi ers are required. CPT
76003 describes the fl uoroscopic visualization of nonspinal
procedures. CPT 76005 is limited to the spine area.
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
223
Q
- Choose the accurate statements about coding.
A. Physicians are the best coders as they are trained during
residency.
B. Physicians do not need to learn and use CPT language
C. An informed MD coder is always better than a non-MD
coder
D. Physician may not be involved in coding
E. Coding is black and white without any gray areas
A
2140. Answer: C Explanation: Coding Complex Requires Skill and effort Medical knowledge “Physician is the best coder” Physician must be involved in Coding Physicians are the only one who know what was done Learn and use CPT language An informed MD coder is always better than a non-MD coder Coding is not black and white May be several ways to code procedures Source: Laxmaiah Manchikanti, MD
224
Q
2141.A 65-year old man with cancer and multiple bony
metastasis complains of increasing requirement of
intrathecal morphine. However, he also complains of
increased nausea associated with increased dose. All
the workup with regards to carcinomatous spread failed
to show any progression of the disease. The following
explanation is accurate.
A. The catheter is no longer in the intrathecal space and he
is not receiving appropriate dosages.
B. He is addicted to the drugs and requesting higher doses
C. He is physically dependent on the drug and is nauseated
due to withdrawal symptoms.
D. He developed tolerance to the analgesics effects of intrathecal
morphine.
E. There is significant progression of the disease, which was
unidentified by the evaluation.
A
- Answer: D
Explanation:
Source: Source: Manchikanti L, Principles of
Documentation, Billing, Coding & Practice Management
2004
The patient is most likely developing tolerance to the
analgesic effects of the intrathecal morphine while
continuing to complain of the adverse side effect of nausea
as the intrathecal dose is increased. The mechanism by
which tolerance develops is not known. The development
of tolerance can be minimized by selecting the lowest
effective narcotic dose; placing the catheter as close as
possible to the cord level of the painful areas; giving
multiple, small, divided doses rather than one or two large,
daily boluses; and using low-dose continuous infusions
whenever possible.
Source: Manchikanti L, Board Review 2005
225
Q
- The “rules” that, in many cases, defi ne which physician
referrals are legal and which are not, are found in the
following regulations:
A. Stark regulations
B. Anti-Kickback Statute
C. Stark regulations and Anti-Kickback Statute
D. Stark regulations, Anti-Kickback Statute, and Omnibus
Budget Reconciliation Act of 1993
E. Stark regulations, HIPAA, and Balanced Budget Act
A
- Answer: C
Explanation:
A. The “Stark I” regulations were published in the Federal
Register on August 15, 1995.
The “Stark II” law that was part of the Omnibus Budget
Reconciliation Act of 1993, which expanded that
application of Stark I rules to additional types of health
care providers and to Medicaid.
Note that regulations for this law are issued in two
phases: Phase I, released Jan. 4, 2001, is
fi nal. Phase II, released March 26, 2004, is effective July
26, 2004.
B. The Anti-Kickback Statute also addresses physician
referrals.
C. Physician self referrals are governed by Stark
regulations and Anti-kickback statute.
D. OBRA of 1993 includes Stark
E. HIPAA and BBA do not govern physician self referrals
Source: Manchikanti L, Board Review 2005
226
Q
- Each of the following statements about muscle rigidity
induced by opioids is true EXCEPT:
A. The degree of rigidity is related to the rate of opioid
administration
B. It is more apparent during the administration of nitrous oxide
C. Muscles of the trunk are affected more than muscles of
the extremities
D. It results from a direct effect of the opioid on skeletal
muscles
E. It can be produced by large doses of morphine
A
- Answer: D
Source: American Board of Anesthesilogy, In-trainnig
examination
227
Q
2144.A postoperative patient after total hip replacement
receiving continuous intravenous morphine sulfate
develops confusion four days later. The treatment of
choice for this patient is:
A. Switch patient to patient-controlled analgesia
B. Start him on methylphenidate
C. Stop morphine and start on hydromorphone
D. Reduce the dose of morphine by 80%
E. Start on a fentanyl patch
A
- Answer: C
228
Q
- An outpatient consultation, new patient requires which
one of the following:
A. A self-referral who has seen his primary care physician
and is consulting you for your opinion.
B. Service provided by the physician whose opinion or advice
regarding the evaluation and/or management of a
problem is requested by another physician.
C. A patient of the same specialty in the same group
practice who consults you for your opinion after his
consultation.
D. A worker’s comp. case manager, not a physician, requesting
epidural steroid injection.
E. A consultation with the patient and generation of carbon
copy to referring physician.
A
- Answer: B
229
Q
2146.Which of the following is not an example of hostile
environment sexual harassment?
A. A physician asks a nurse out on a date and she refuses.
B. A female coworker repeatedly touches a male coworker
on his shoulders, hugs him goodnight, and makes numerous
comments about his “tight little butt.” He tearfully
asks her to stop.
C. The staff posts sexually explicit jokes and cartoons on the
offi ce kitchen bulletin board.
D. A male coworker repeatedly touches another male
coworker on his shoulders, hugs him goodnight, and
makes numerous comments about his “tight little
butt.”
E. All of the above are examples of hostile environment
sexual harassment.
A
- Answer: A
Explanation:
Explanation: Although it is not advisable, asking an
employee out for a date and getting turned down ONCE is
not harassing. The big caveat is that if the physician has
authority over the employee, and he later takes any adverse
action against him or her (fi res her, doesn’t promote her,
switches her to an undesirable work schedule, etc.) there is
a great danger of the physician being accused of “quid pro quo” or economic harassment. This is very serious
because it only takes one adverse employment action to
expose a physician and/or the clinic to liability for sexual
harassment.
Source: Judith Homes, Sep 2005
230
Q
- What do the physician self-referral Stark rules prohibit?
A. They prohibit physicians from referring patients to hospitals
where the physicians work
B. They prohibit physicians from referring patients for
designated health services to entities in which the physicians
have fi nancial relationships, unless an exception
applies.
C. They prohibit health care providers from billing for services
of patients they refer to other providers.
D. They prohibit health care providers from receiving
money from their services for any referrals to physical
therapy.
E. The prohibit physicians performing cases in ambulatory surgery centers with physician ownership of 50% or
more.
A
- Answer: B
Explanation:
Source: Manchikanti L, Principles of Documentation,
Billing, Coding & Practice Management 2004
Stark prohibits physicians from referring to an entity with
which they or their immediate family members have a
fi nancial relationship for the furnishing of any of 11
designated Medicare-reimbursable health services if
claims for those services are submitted to Medicare or
Medicaid. Also, physicians may not bill Medicare or
Medicare for such referred services.
The 11 designated health services are as follows:
Clinical laboratory services.
Physical therapy services (including speech-language
pathology services)
Occupational therapy.
Radiology and certain other imaging services
Radiation therapy services and supplies.
Durable medical equipment and supplies
Parenteral and enteral nutrients, equipment and supplies.
Prosthetics, orthotics, prosthetic devices and supplies.
Home health services.
Outpatient prescription drugs
Inpatient and outpatient hospital services (with
exceptions).
A designated health service remains a designated service
under Stark even when it’s billed as something else or
bundled with other services.
CMS has released an
appendix to the Stark regulations detailing, by CPT and
HCPCS code, those services that are subject to the
prohibition.
Source: Manchikanti L, Board Review 2005
231
Q
- Choose the accurate statement with regards to NMDA
receptors.
A. Experimental evidence has shown that NMDA can induce
seizure activity in animals.
B. NMDA has shown no capability of inducing seizures in
animals.
C. Combined with alcohol, NMDA receptors abolish the
susceptibility to seizures.
D. NMDA antagonist MK-801 increases the severity of the
seizures during withdrawal.
E. Chronic exposure to alcohol reduces the density of MK-
801 binding sites.
A
- Answer: A
Explanation:
A. NMDA itself can induce seizure activity in animals.
B. NMDA itself can induce seizure activity in animals.
C. In animal experiments, it is suggested that alcohol
behaves as an NMDA antagonist in the intact animal.
NMDA receptors are altered during chronic exposure to
alcohol and appear to be important in mediating some of
the signs of alcohol withdrawal.
Increasing numbers of NMDA receptors after chronic
alcohol exposure may underlie the increase
susceptibility of animals and humans to seizures during
abrupt withdrawal from alcohol.
D. Experiments with mice show that NMDA-induced
seizure activity was elevated in mice made dependent on
alcohol and that the NMDA antagonist
MK-801 could reduce the severity of these seizures.
E. It has been demonstrated in culture neurons that
chronic exposure to alcohol increases the densityof
MK-801 binding sites, suggesting that neurons may
compensate for the acute inhibitory actions of alcohol
on NMDAreceptor function by increasing the density of
these receptors.
This up-regulation of receptor density is a common
resposne of many cell and tissue types to theprolonged
presence of receptor antagonists.
232
Q
- You interview a fabulous candidate for your part-time
business manager. After you hire him and before he starts
work, he submits to your standard drug test and physical
exam. You fi nd out he is epileptic, that he can’t lift over
20 pounds because of a genetic condition, and that he has
ingested cocaine in the past 24 hours. What can you do?
A. You can fi re him for having epilepsy.
B. You can fi re him for not being able to lift over 20
pounds.
C. You can fi re him for current illegal drug use.
D. All of the above.
E. None of the above.
A
- Answer: C
Explanation:
Explanation : Epilepsy is a condition that is protected by
the ADA, so you cannot fi re him on that basis alone. You
may terminate him only if he cannot perform the essential
functions of the job of being a part-time businessmanager.
Although you may have a legitimate concern about the
effect of his condition on your staff and patients, you have
the duty to make reasonable accommodations to your new
employee. You probably cannot terminate your new
employee simply for not being able to lift 20 pounds,
because it would be diffi cult to demonstrate an “essential
function of the job” of business manager includes heavy
lifting. Because current use of illegal drugs is not
protected by the ADA, he may be terminated on those
grounds alone.
Practically speaking, however, even if you fi re him for
cocaine use, he will claim that is a pretense, and that you
really fi red him for the impermissible reasons. As with all
other aspects of running a medical practice, keep good
documentation and its sometimes your best defense.
Source: Judith Homes, Sep 2005
233
Q
2150. A characteristic manifestation of hallucinogen use is: A. Bruxism B. Agoraphobia C. Neologisms D. Synesthesia E. Anomie
A
- Answer: D
Explanation:
There are two groups of hallucinogens based on chemical
structure: - Indolealkylamines (resembles 5HT);
includes LSD, Democrat (methyltryptamine), psilocin,
psilocybin. - Phenylethylamines; includes mescaline
(from peyote cactus), 2,5-dimethoxyamphetamine (DMS),
3,4-methylenedioxyamphetamine (MDA), and 3,4-
methylenedioxymethamphetamine
(MDMA).
Symptoms of hallucinogenic drugs use
include dilated pupils, blurring of vision, sweating,
incoordination, increased blood pressure, tachycardia,
tremors, hyperrefl exia, and mood changes ranging from
euphoria to anxious as well as visual illusion an dperceptual changes (i.e., micropsia, synesthesias).
Tolerance and cross-tolerance can develop. There are no
withdrawal phenomena, and they are not reinforcers to
other drugs.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
234
Q
- The true statement with regards to disability includes
the following:
A. It is a term that can be used interchangeably with the
term handicap.
B. It is a condition that relates to the effects of a disease
process or injury.
C. It is a condition that requires the use of an assistive device
to perform activities of daily living.
D. It is expressed as a percentage of the body as a whole.
E. It is a condition that relates to function relative to work
or other obligations.
A
- Answer: E
Explanation:
Source: AMA Guides to the Evaluation of Permanent
Impairment, 2001.
Disability is the limiting, loss, or absence of the capacity of
a person to meet personal, social, oroccupational demands,
or to meet statutory or regulatory requirements.
Disability relates to function relative to work or other
obligations and activities of daily living. It may be
characterized as temporary, permanent partial, or total.
Methods of assessing functional performance include
measurement of range of motion, strength, endurance,and
work simulation. Disability is not synonymous with
handicap. When an impairment is associated with an
obstacle to useful activity, a handicap may exist; assistive
devices or modifi cations of the environment are often
required to accomplish life’s basic activities.
Source: Manchikanti L, Board Review 2005
235
Q
- True statements in granting a patient’s request for a
confi dential communication:
A. A physician may may require a patient to give an explanation
for making the request.
B. A physician may require patient to request confi dential
communication in writing.
C. A health plan may not require a patietn to give an explanation
for making the request.
D. None of the above.
E. All of the above.
A
- Answer: B
236
Q
- What is the true statement about global fee policy?
A. Global fee policy describes packaging or inclusion of certain
services in allowance for a surgical procedure
B. Global fee policy describes unbundling or combining
multiple services into a single charge
C. Global package includes preoperative and postoperative
services for 120 days
D. Global package includes initial evaluation if performed
on the same day
E. Global package includes all diagnostic tests
A
2153. Answer: A Explanation: Global Fee Policy Packaged or certain services are included in allowance for a surgical procedure. Bundling: Combining multiple services into a single charge. Global Package Includes: Pre-operative Procedure Post-operative Does Not Include: Initial evaluation Unrelated visits Diagnostic test(s) Return trips to OR Staged procedures Global Period Major day prior, day of, and 90 days after Minor day of or day of and ten days after Source: Laxmaiah Manchikanti, MD
237
Q
- Employers are required to provide training to all
employees with occupational exposure that . . . Which
one of the following DOES NOT accurately complete this
sentence?
A. Is provided at no cost to the employees.
B. Is provided at the time of initial employment and as
requested by the employee thereafter.
C. Is appropriate in terms of content and vocabulary
given the employees education level, vocabulary and
language.
D. Is provided during working hours.
E. Discusses the employer’s Exposure Control Plan, bloodborne
diseases and modes of transmission and the use
of personal protective equipment.
A
- Answer: B
Explanation:
Training is to be provided at the time of initial assignment
to tasks where occupational exposure may take place, at
least annually thereafter, and additional training when changes such as modifi cation of tasks or procedures or
institution of new tasks or procedures affect the
employee’s occupational exposure.
Source: 29 CFR 1910.1030(g)(2).
Source: Erin Brisbay McMahon, JD, Sep 2005
238
Q
- Which of the following is NOT required as part of a postexposure
evaluation and follow-up?
A. A confi dential medical evaluation
B. Documentation of the route of exposure and circumstances
under which exposure occurred
C. Identifying and testing source individual’s blood regardless
of consent
D. Providing the employee post-exposure protective treatment
E. Providing the employee counseling
A
- Answer: C
Explanation:
Answer (c) is not correct. The regulations provide that the
source individual’s blood shall be tested as soon as
feasible and after consent is obtained in order to determine
HBV and HIV infectivity. If consent is not obtained, the
employer shall establish that legally required consent
cannot be obtained. However, when the source
individual’s consent is not required by law, the source
individual’s blood, if available, shall be tested and the
results documented.
Source: 29 CFR 1910.1030 (f)(3).
Source: Erin Brisbay McMahon, JD, Sep 2005
239
Q
- A physician performed interlaminar cervical epidural
under fl uoroscopy with documentation of nerve
root fi lling at 4 levels. Identify proper coding for the
procedure.
A. 64479-59, 64480 - C/T transforaminal and C/T transforaminal
additional units
B. 62310, 76005-26 - C/T epidural and fl uoroscopy
C. 62310 x 1, 64479 x 1, 64480 x 3 -C/T epidural, C/T transforaminal
and C/T transforaminal additional units
D. 62310, 72275-59 and 76005-26 -C/T epidural, epidurography,
and fl uoroscopy
E. 64479 x 1, 64480 x 3, 76005-26 x 3 -C/T transforaminal,
C/T transforaminal additional units and fl uoroscopy
A
- Answer: B
Source: Laxmaiah Manchikanti, MD
240
Q
- Your physician partner tells your nurse practitioner that
he will take her to your next medical meeting in Tahiti if
“she makes it worth his while.” She refuses and fi nds
herself being transferred to the night shift in your clinic
located in Omaha. Your nurse practitioner is not happy.
Do you have reason to worry?
A. It was just one incident and just one request for a date so
it isn’t suffi cient to be considered “harassment.”
B. She turned him down and there is no evidence her
employment change had anything to do with his hurt
feelings
C. The actions involve a supervisor taking adverse action
against a subordinate – it only takes one incident to
create liability.
D. Since you, as managing physician of the clinic, did not
know about the situation, the clinic has no responsibility
to prohibit the conduct and therefore has no liability
for the conduct.
E. There is no evidence that the physician acted improperly
by fondling her, making sexually explicit comments, or
otherwise conducting himself in an inappropriate way.
A
- Answer: C
Explanation:
Explanation: With “economic harassment,” it only takes
one incident to fi nd an employer liable. The key points are
that the head of the medical group or clinic does not even
need to know the improper conduct took place – it is
enough that the employee received an adverse employment
action after refusing a supervisors sexually-oriented
request.
Environmental harassment has four elements: 1) The
conduct is unwelcome; 2) The conduct is directed at a
protected category; 3) the conduct is offensive to the
recipient and to a “reasonable person;” and 4) the conduct
is severe OR pervasive.
Source: Judith Homes, Sep 2005
241
Q
- Which of the following is a physician/employer’s best
defense to a sexual harassment claim?
A. The conduct did not cause emotional or psychological
injury to the complaining employee.
B. The conduct did not occur very often and wasn’t very
offensive
C. The conduct between co employees did not occur during
business hours
D. The conduct did not occur at the clinic or in the medical
offi ces.
E. Adoption of comprehensive written policies prohibiting
harassment, conduct of periodic training sessions, well
publicized procedure and prompt thorough investigations
.
A
- Answer: E
Explanation:
Explanation:This is a no brainer but important to teach
the policies that must be implemented by all employers.
The U.S. Supreme Court decisions of Faragher and Ellerth
must be discussed and understood.
Source: Judith Homes, Sep 2005
242
Q
- As described by Beauchamp and Childress, the principles
that are focal to medical practice are:
A. casuistry, communitarianism, benevolence and virtue
B. intellectual, moral, intentional and consequential
C. benefi cence, non-malefi cence, autonomy and justice
D. normative, applied, descriptive and meta-ethical
A
- Answer: C
Explanation:
In their much cited work The Principles of Biomedical
Ethics [Oxford, NY, 2001], Tom Beauchamp and James
Childress defi ne the basic, prima facie principles that are
applicable in medicine as benefi cence, non-malefi cence,
autonomy and justice, and explicate why and how these
principles may be employed in the address and resolution
of ethical issues and problems in the healthcare setting(s).
Casuistry, and communitarianism are ethical approaches. Normative, applied, descriptive and meta-ethical are types
of ethics
Source: Giordano J, Board Review 2006
243
Q
- A physician in your group has just converted to
Scientology. It’s all he can talk about. He hand out fl iers,
talks about Scientology at lunch, and has put up a poster
of Tom Cruise and Katie Holmes on the clinic refrigerator.
As the managing physician, what should you do?
A. Do nothing. His religion is his business, and you could
subject yourself and your clinic to claims of religious
discrimination if you attempt to infl uence what he talks
about in the offi ce.
B. Terminate the offending physician immediately.
C. Make sure you put additional information about several
other mainstream religions in the offi ce to counterbalance
the Scientology infl uence.
D. Encourage other employees to discuss their religions and
provide a forum for discussions.
E. None of the above.
A
- Answer: E
Explanation:
Explanation:Terminating the physician will no doubt
result in claims of religious discrimination. However, the
other three approaches will no doubt result in claims of
religious harassment by other members of your staff who
do not want to be pressured about religion. You should
have a policy prohibiting religious solicitation of
employees or physicians. Make sure the workplace
atmosphere is free from religious infl uences that may
make some employees uncomfortable. (and Tom Cruise
should stick to acting)
Source: Judith Homes, Sep 2005
244
Q
2161.Which of the following behavior is not considered
unlawful harassment?
A. Constantly yelling at your staff over small, inconsequential
mistakes.
B. Use of epithets, slurs, and insults directed at an individual
because of his national origin.
C. Putting up a screen saver on your office computer that
has a sexually explicit picture of two nurses. (It’s in your office and no one has the authority to use it but
you.)
D. Repeatedly calling yourself and others names such as
“old geezer” and “senile” in meetings and during an
informal discussion with your staff.
E. All of the above are examples of unlawful discrimination.
A
- Answer: A
Explanation:
Explanation: Harassment is only unlawful if it is directed
at a protected category. Although yelling at your staff is
obnoxious and unprofessional, it is not unlawful if you yell
at everyone- that is, if you are an “equal opportunity
yeller.” If you treat everyone the same way and do not
discriminate by yelling more often at women or Hispanics
or older workers, etc. then you simply need a lesson in
deportment. With respect to “old geezer” and other ageist
comments, even if you direct the comments toward
yourself, other older workers may use that as evidence of
age discrimination and harassment. With respect to C, if
the computer screen may be viewed by nurses who need to
put fi les on your desk, or if you computer may be seen as
people who walk into or past your offi ce, that may be used
as evidence of the existence of a hostile work environment
Source: Judith Homes, Sep 2005
245
Q
- Select true statements about upcoding:
A. It is the largest risk area outside of unbundling
B. Compliance with documentation guidelines may not be
the most important aspect
C. It is not necessary to meet level of care if computerized
records are used.
D. Medicare will investigate only down coding.
E. Medicare will reward you for upcoding
A
- Answer: A
Explanation:
* Upcoding:
- Largest risk area outside of unbundling.
- Compliance with documentation guidelines is
important.
- Must assure that level of care meets presenting
problem(s) of patient.
* Medicare will investigate up-coding & down-coding.
Source: Laxmaiah Manchikanti, MD
246
Q
- What are the consequences of down coding?
A. Compliance with guidelines may not the most important
aspect.
B. It is not necessary to assure proper coding of the level of
service during downcoding
C. Medicare will eventually reimburse all your down coding
after 5 years.
D. Down coding is largest area of loss of revenue for the
practice
E. Medicare may not investigate down coding.
A
- Answer: D
Explanation:
* Down Coding
- Largest area of loss of revenue outside disbundling.
- Compliance with guidelines is important.
- Must assure proper coding of the level of service.
Source: Laxmaiah Manchikanti, MD
247
Q
- Which of these statements is true”
A. A person accused of harassment must have intended to
harass the coworker. If he or she was merely joking, or
was just being friendly, his or her actions will not be
considered “harassment.”
B. A person is not a victim of harassment if he or she merely
overhears remarks or “off color” jokes that he or she was
not intended to hear.
C. A person claiming to have been harassed must complain
about the harassment in order to bring a claim against
his or her employer.
D. Harassment is not a problem in my offi ce.
E. None of the above.
A
- Answer: E
Explanation:
Explanation: If you think you and your offi ce are “bullet
proof,” think again. You as an employer cannot simply
assume that because you have a “family atmosphere,” no
one on your staff will fi le a claim against you. Have you
ever said “nobody minds the jokes- in fact, they all
participate,” or “I was just joking!” or “she laughed, too”
or “she’s just way too sensitive” or “he was evesdropping!”
or “I didn’t mean to hurt his feelings”? If you have ever
rationalized your behavior by saying any of the above, it’s
only a matter of time before the EEOC comes knocking on
your door.
Source: Judith Homes, Sep 2005
248
Q
- Select true statements about Add-On Codes:
A. They are never used by themselves and the modifi er 51
(additional procedure) is not used.
B. Payment and adjustments are always made with modifi
ed -51
C. Examples include epidurography, fl uoroscopy and discography-
interpretation
D. Facet joint injections and facet neurolysis do not have
add-on codes
E. 64421 - multiple intercostal nerve blocks is an add-on
code to CPT 64420 – single intercostal nerve block
A
2165. Answer: A Explanation: Add-On Codes * Never used by themselves * The modifi er 51 (additional procedure) is not used * No payment adjustments Examples: Facet joint injections Facet neurolysis Transforaminal epidurals Not Add-On Codes: Epidurography Fluoroscopy Discography-interpretation Source: Laxmaiah Manchikanti, MD
249
Q
- Identify true statements about Current Procedural
Technology (CPT) and International Classifi cation of
Diseases (ICD-9) codes?
A. ICD-9 is a systematic listing of procedure or service accurately
defi ning and assisting with simplifi ed reporting
B. CPT is a systematic listing and coding of procedures and
services performed by physicians
C. ICD-9 identifi es each procedure or service with a fi vedigit
code
D. CPT provides systematic listing of disease classifi cation
and provides alphabetic index to diseases
E. CPT and ICD-9 both provide a tabular list of diseases
A
- Answer: B
Explanation:
CPT - Systematic listing and coding of procedures and
services performed by physicians - Procedure or service is accurately defi ned with
simplifi ed reporting - Each procedure or service is identifi ed with a fi ve-digit
code
ICD-9
International Classifi cation of Diseases
Organization
Disease classifi cation: Alphabetic index to diseases
Tabular list of diseases
Source: Laxmaiah Manchikanti, MD
250
Q
- Your nurse practitioner has complained to you on several
occasions that the drug rep that comes every Friday has
repeatedly asked her out, often attempted to kiss her, has
groped her and has made suggestive remarks to her. She
has told the drug rep to leave her alone, but the conduct
continues. What is the appropriate response?
A. Explain to your nurse that you have no right to control
an individual who is not your employee.
B. Suggest to her that she simply make light of the situation
and not be overly sensitive.
C. Talk to the drug rep and insist he immediately cease the
unwanted behavior.
D. Immediately call the drug company, tell the rep’s boss
the drug rep is a “sex maniac”, and demand they send
another rep from now on.
E. The next time the drug rep comes to your offi ce, you deck
him.
A
- Answer: C
Explanation:
Explanation:Most employers believe they can’t control an independent visitor’s conduct while they are at the
workplace. That is not true. In fact, an employer has a duty
to protect employees from unwanted sexual conduct,
including the conduct of third parties. Answer D is not
correct because, unless the employer actually witnesses the
conduct,making accusations and possibly causing the drug
rep to lose his job will subject the employer to
unnecessary liability. Use that approach only as a last ditch
effort. Obviously Answer E is an overreaction, and
Answers A & B are not appropriate reactions, since
ignoring the problem can subject the employer to a claim
that the employer tolerated a hostile work environment.
Source: Judith Homes, Sep 2005
251
Q
2168.True statements regarding causation, apportionment,
and worker’s compensation are:
A. Determining medical causation requires detective work
and witness of the accident.
B. For purposes of the AMA Guides, causation means an
identifiable factor, such as an accident, that results in a
medically identifiable condition.
C. The legal standard for causation in civil litigation and
in worker’s compensation is uniform across the United
States.
D. Apportionment analysis in worker’s compensation represents
assignment of all factors.
E. The role of a physician in worker’s compensation system
is only to provide effective medical care but not be involved
in other aspects of the care.
A
2168. Answer: B Explanation: AMA Guides to the Evaluation of Permanent Impairment, 2001. Source: Manchikanti L, Board Review 2005
252
Q
- You are interviewing an applicant for a receptionist
position in your offi ce. One of the applicants is in a
wheelchair. What should you do?
A. As diplomatically as possible, explain that her appearance
at the front desk may be upsetting to patients and
may make your staff uncomfortable. Try to refer her to
job openings at other facilities.
B. Thank her for applying, but explain to her that she is not
qualifi ed for the job.
C. Don’t shy away from discussing her disability – ask her
about how she became disabled, and how she feels
about being in a wheelchair.
D. Tell her about the job requirements and ask her to show
you how she would perform those duties.
E. None of the above.
A
- Answer: D
Explanation:
Explanation: When interviewing an applicant who is
obviously disabled, the physician/employer should have a
clear understanding of the “essential functions” of the job
(preferably in writing). The employer should explain
those job duties to the applicant and ask: “Can you
perform those duties,with or without an accommodation?”
You may ask her to demonstrate, for example, how she
would operate the equipment, handle the phones, etc. The
ADA prohibits an employer from asking unnecessary
details about the disability, such as the origin of the
disability. An employer may not reject an applicant simply
because of the anticipated reaction of other employees or
patients.
Source: Judith Homes, Sep 2005
253
Q
- Quality Assurance
A. Indicates ongoing vigilance to patient satisfaction indices.
B. Is only necessary during injection techniques to assure medical necessity
C. Is regulated by governmental and civil agencies.
D. Is dependent on physician input, and eliminates the need
for staff input.
E. Is to prevent malpractice cases
A
- Answer: A
Source: Manchikanti L, Board Review 2005
254
Q
- Which of the following is a disability protected by the
ADA?
A. A broken leg requiring a cast and crutches and that
causes signifi cant limitations in mobility.
B. A physical or mental impairment that makes it diffi cult
for the person to obtain employment.
C. Signifi cant scarring from burns that causing facial disfi
gurement.
D. An extreme phobia involving any type of spider, insect,
or snake.
E. None of the above.
A
- Answer: E
Explanation:
Explanation: In order for a mental or physical condition to
be covered by the ADA, the impairment must substantially
limit one or more major life activities on a continuing
basis. Major life activities include hearing, seeing,
breathing, walking, working learning, caring for oneself
on a daily basis, speaking, and performing manual tasks.
Injuries such as a broken leg are temporary and nonchronic
impairments and are not covered. A disfi gurement
is not covered unless it affects a major life activity.
Source: Judith Homes, Sep 2005
255
Q
- Identify the true statement with regards to a physician’s
role in impairment and disability evaluation.
A. Determine impairment, provide medical information to
assist in disability determination.
B. Provide a disability rating which is binding on the
administrative law judge for Social Security and Disability.
C. In state worker’s compensation law, a physician role is
limited to determining disability only, but not impairment.
D. The World Health Organization has specifi cally defi ned
a role of the physician in impairment and disability.
E. Physician role in impairment and disability determination
is independently without input from employer and
without consideration to job duties.
A
- Answer: A
Explanation:
Source: AMA Guides to the evaluation of Permanent
Impairment, 2001.
Physicians’ Role
A. A physician role as per the Guides to the Evaluation of
Permanent Impairment:
Determine impairment, provide medical information to
assist in disability determination.
B. Social Security Administration (SSA):
Determine impairment; may assist with the disability
determination as a consultative examiner.
State Workers’ Compensation Law:
C. Evaluation (rating) of permanent impairment is a
medical appraisal of the nature and extent of the injury or
disease as it affects an injured employee’s personal
effi ciency in the activities of daily living, such as self-care,
communication, normal living postures, ambulation,
elevation, traveling, and nonspecialized activities of bodily
members.
D. World Health Organization (WHO):
Not specifi cally defi ned; assumed to be one of the
decision-makers in determining disability through
impairment assessment.
E. Disability is determined based on job requirements and
needs
Source: Manchikanti L, Board Review 2005
256
Q
- A 38-year old white male with history of low back pain
with radiation into lower extremity with disc herniation
demonstrated at L4/5 with nerve root compression,
and electromyographic evidence of L5 radiculopathy
was referred for consultation. You have examined the
patient and decided to perform transforaminal epidural
steroid injection at L5 nerve root. This encounter is
appropriately considered as follows:
A. It is a consultation as the patient was referred by another
physician for management.
B. It is a consultation as the patient was referred and your
opinion was requested.
C. It is a new offi ce visit since it is a known problem and the
patient was referred to you for the treatment.
D. It is a consultation as you told the patient to return to
the referring physician after completion of course of
epidurals.
E. It is a consultation, as you do not plan on billing for another
consultation within the next 3 years
A
2174. Answer: C Explanation: Source: Manchikanti L, Principles of Documentation, Billing, Coding & Practice Management 2004 Explanation: Consultation An opinion is requested Patient is not referred 3 R’s Request for opinion is received Render the service/Opinion Report back to physician requesting your opinion Source: Manchikanti L, Board Review 2005
257
Q
- True statements regarding quality assurance include the
following:
A. Quality assurance, quality improvement, and quality
management are interchangeable words.
B. Quality assurance is internally driven, follows patient
care, and has no endpoints.
C. Quality improvement is externally driven, focused on
individuals, and works toward endpoints.
D. Total quality of management, quality management and
improvement, and continuous quality improvement
are synonymous with quality assurance.
E. Quality improvement program is different from quality
assurance and it focuses on patient care, process, integrated
analysis
A
- Answer: E
258
Q
2177.True statements with reference to Americans with
Disability Act.
A. The physician’s input is not essential for determining any
of the criteria under Americans with Disabilities Act.
B. Conditions that are temporary and are not considered to
be impairment under the ADA include pregnancy, old
age, sexual orientation, sexual addiction, smoking, or
current illegal drug use
C. To be deemed disabled for purposes of ADA protection,
an individual needs to have only mild physical or mental
impairment that does not limit major life activities.
D. The person may be hypothetically or perceived to be
disabled to be qualifi ed under ADA.
E. It is the physician’s responsibility to identify and determine
if reasonable accommodations are possible to
enable the individual’s performance of essential job
activities in his or her employment.
A
- Answer: B
259
Q
- You are conducting interviews for the position of nurse
practitioner. You need a reliable, stable, hardworking
person in the job. During the job interview, what
questions topics should you cover?
A. A complete history of job injuries, including details of
all past worker’s comp claims she has made. Get a list
of all drugs she is currently taking, and the reasons for
taking the drugs
B. A description of all chronic health care problems of her
husband and children. Include issues such as diabetes,
epilepsy, and other diseases that may require her to be
absent from work to care for her family.
C. Make sure you know if she has ever been treated for
drug addition or alcoholism, and be sure not to ask
only about current problems get a history of past abuse,
including approximate dates she claims she overcame
the addictions.
D. All of the above.
E. None of the above.
A
- Answer: E
Explanation:
Explanation: Stay away from all of those issues!! Under the
ADA, it is unlawful to discriminate against someone
because of alcoholism or past drug use. You may only ask
about current use of illegal drugs – that is not protected.
You may not ask about family medical issues or current
legal drug use because the ADA protects not only disabled
individuals, but those who are perceived as having a
disability and those who are associated with individuals
who have a disability. You also may not refuse to hire
someone who has fi led worker’s comp. claims in the past.
Even if it does not directly violate the ADA, the employer
may be subject to claims of unlawful discrimination for
fi ling a lawful claim.
Source: Judith Homes, Sep 2005
260
Q
- Your receptionist has just received an e-mail from a
coworker. It is the fi fth time the coworker has asked
your receptionist out on a date. Is his conduct sexually
harassing?
A. No. And it’s none of your business. Stop reading your
employees’ e-mails.
B. Yes. You may become liable to the receptionist for the
harassment because you knew about it and did nothing
to stop it.
C. It depends.
D. It is sexually harassing behavior, but because it is a private
e-mail, you may do nothing unless and until she
complains to you. You should act only after she makes a specific complaint to you.
E. You may act only if you have a written policy against dating
coworkers.
A
- Answer: C
Explanation:
Explanation: Whether or not the conduct is sexually
harassing depends on whether the invitations for dates are
unwelcome. We don’t have enough information to
determine that critical element. For example, is the
receptionist married to someone else and has she
repeatedly told him to stop emailing her? Or do they have
an ongoing romantic relationship and she looks forwardto
receiving the invitations? A and D are not correct – an
employer has a right to know what his employees aredoing
during work hours using the employer’s offi ce equipment.
Source: Judith Homes, Sep 2005
261
Q
- An interventional pain program predominantly
managing cancer patients may be accredited by all of the
following EXCEPT:
A. American Cancer Society (ACS)
B. Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)
C. Accreditation Association for Ambulatory Health Care
(AAAHC)
D. Commission on Accreditation of Rehabilitation Facilities
(CARF)
E. State Department of Health for Physical, Occupational,
and Behavioral Components
A
- Answer: A
Source: Laxmaiah Manchikanti, MD
262
Q
2181.Identify accurate statements describing federal
regulations?
A. The fi nal Stark regulations expressly prohibit an organization
from offering free compliance training.
B. To qualify for the in-offi ce ancillary Exception under
Stark, the services must be furnished in only the same
building.
C. A provider may never charge Medicare patients additional
fees for services covered by Medicare.
D. The HHS Offi ce of Inspector General (OIG) may seek
criminal penalties as well as administrative sanctions
and civil penalties against violators of the anti-kickback
statutes.
E. A provider may never charge Medicare patients additional
fees for Medicare’s non-covered services.
A
- Answer: D
Explanation:
A. The Stark rules permit organizations to give physicians,
the physician’s family members or offi ce staff compliance
training – without the training being counted as an illegal
fringe benefi t or perk if:
* The training takes place in the provider’s services area;
* The training is not for continuing medical education.
B. To qualify for the in-offi ce ancillary service Exception,
services must be furnished in one of the following three
locations: - The same building if one of the following conditions
apply:
* The physician or practice has an offi ce that is
normally open at least 35 hours a week and offers services,
including at least some non-DHS, at least 30 hours per
week; or;
* The patient usually receives services from the
referring physician or group at that offi ce. The physician
or group’s offi ce must normally be open at least eight
hours a week and the referring physician must personally
offer service, including some non-DHS, at least six hours a
week; or;
* The referring physician or practice member is
present and orders or provides DHS at that site during a
patient visit. In addition, the physician or group must own
or rent an offi ce in the building that is open at lest eight
hours a week and offer services at least six hours a week. - One or more centralized buildings used by the group
practice to deliver at least some of its clinical lab services.
A centralized building may include a mobile vehicle if it’s
used exclusively by the practice and leased for at least six
months, 24 hours/day, 7 days/week - One or more centralized buildings used by the group
practice to deliver at least some of its designated health services other than clinical lab services.
C & E. Providers may charge Medicare patients extra for
items and services that are not covered by Medicare, but
the providers should think carefully when they offer a
contract for boutique or concierge care to their Medicare
benefi ciaries.
D. Health care providers that violate fraud and abuse laws
risk more than administrative sanctions and civil
penalties. OIG, working alone or with other law
enforcement agencies and state Medicaid Fraud Control
Units, may fi le criminal cases against individuals who
initiate or participate in illegal activities.
Source: Laxmaiah Manchikanti, MD
263
Q
- How should an employer determine if the employer’s
employees have occupational exposures to blood or other
potentially infectious materials?
A. Consult the list common job classifi cations experiencing
occupational exposures maintained by OSHA on
its website.
B. Rely on responses from employees responsible for direct
patient care as to their exposure to blood or other potentially
infectious diseases.
C. Review job classifi cations within the work environment
to determine which job classifi cations have occupational
exposure to blood or other potentially infectious
materials.
D. Schedule for an OSHA representative to visit the work
site and identify individual employees who have occupational
exposures.
E. None of the above
A
- Answer: C
Explanation:
As part of the Exposure Control Plan, an employer is
required to prepare an exposure determination that
contains (1) a list of all job classifi cations in which all
employees in those classifi cations have exposure, (2) a list
of job classifi cations in which some employees have
exposure, and (3) a list of tasks/procedures in which
occupational exposure occurs and that are performed by
the employees in (2) above. The exposure determination
must be made without regard to the use of personal
protective equipment.
Source:29 CFR 1910.1030(c)(2).
Source: Erin Brisbay McMahon, JD, Sep 2005
264
Q
- You are asked to perform diagnostic facet joint nerve
blocks to block L3/4 and L4/5 facet joints on the right
side. What are the correct medial branches needed to
block these two joints?
A. Right L2, L3, and L4 medial branches
B. Right L3 and L4 medial branches and L5 dorsal ramus
C. Right L1, L2 and L3 medial branches
D. Right L3 and L4 medial branches
E. Right L1, L2, and L4 medial branches and L5 dorsal ramus
A
- Answer: A
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
265
Q
- The agency of the pain physician should be focal and
adherent to the defi nable “ends” or distinct ultimate
goal(s) of pain medicine as a practice. These ends may be
defi ned as:
A. Critical decision making so as to recognize when to practice
acquiescent or defensive medicine
B. rendering care that is competent, technically advanced
and consistent with the knowledge relevant to the practice
and circumstance(s)
C. establishing equivalent autonomy of the physician to
exercise the distinct ‘rights’ of medicine as a practice
D. all of the above
A
- Answer: B
Explanation:
Medicine, and pain medicine by extension, may be
philosophically defi ned as the care and treatment of those
made vulnerable by the effects of disease, illness or injury.
This premise establishes the primacy of the good of the
patient,and the ends of medicine to be the rendering of
care that is both technically competent and right, as well as
morally and ethically sound as relevant to the patient as a
person.The physician is an agent of this practice, and must
be consistent and adherent to these ends. For the pain
physician, this means not practicing acquiescent or
defensive medicine, and recognizing the non-trumping,
reciprocal autonomy of patient and physician in theclinical
relationship (Giordano J. Moral agency in pain medicine:
Philosophy, practice and virtue. Pain Physician 2006; 9:
41-46; Giordano J. Moral virtue and the pain physician:
Agency, intentions and actions. Practical PainManagement
2006; 6(4): 76-80. See also: Pellegrino ED.
Professionalism, profession and the virtues of the good
physician. Mt Sinai J. Med. 2002; 69: 378-384)
Source: Giordano J, Board Review 2006
266
Q
- As a public and/or social good, the practice of medicine
should seek to:
A. be effective and effi cient as moral obligations against
wastefulness
B. be instrumental to the context of societies and governmental
agendas
C. be stipulated by explicit contractual affi rmations
D. ascribe to a business ethos of effi ciency as a means toward
maximizing profi table ends
A
- Answer: A
Explanation:
Medicine is a practice, defi ned as an exchange of good as
relevant to the relationship of participant agents. These
agents are part of a public or social structure,and therefore
medicine seeks to maintain and restore health as a
fundamental human good. As such, there is the moral
obligation to provide this good in a way that maximizes its
benefi t, is not wasteful and achieves what it claims to
provide. It is not instrumental and cannot and should not
be commodifi ed and/or subsumed by an ethic and ethos
of the solely contractual market model or be focally
subject to social construction.
(Giordano J. Cassandra’s curse: Interventional pain
management, policy and preserving meaning against a
market mentality. Pain Physician 2006; 9: 167-170)
Source: Giordano J, Board Review 2006
267
Q
- The moral obligation to treat pain is:
A. stipulated in the legal statutes on fair medical
practice(s)
B. inherent to the declarative act of profession of the pain
physician
C. explicit to a maxim of non-harm
D. a sole function of NIH and AMA policy on ethical medical
practice
A
- Answer: B
Explanation:
The moral affi rmation and obligation to treat pain is
explicit to the statement that one is a ‘pain physician’ and
invites patient trust that the physician will act prudently in
the best interest of the patient to cure, heal and/or care for
pain. (Giordano J. Moral agency in pain medicine:
Philosophy, practice and virtue. Pain Physician 2006; 9:
41-46)
Legal statutes do not prescribe moral affi rmations.
The maxim of non-harm exists as constituent to a larger
foundation of moral affi rmations and obligations.
Moral values refl ect community interest; these create
purpose that can be supported and advanced through the
development and implementation of public healthcare
policies
Source: Giordano J, Board Review 2006
268
Q
- Which of the following statements is correct?
A. A patient may request that a provider amend a diagnosis
that was submitted on a billing claim form.
B. A provider must act on a patient’s request for amendment
within 30 days, either deny or amend.
C. A provider does not agree with a patient’s request for
an amendment. However, the provider must make the
amendment but can note disagreement in the amendment
and inform insurer.
D. Provider has to amend diagnosis in 30 days as provider
may not deny the patient request.
E. Provider has no obligation even if the information on the
claim was inaccurate.
A
- Answer: A
Explanation:
The privacy rule allows patients to request amendments of
their records including amendments to billing records.
The provider is not obligated to make the amendment if
the provider believes that the original information (the
diagnosis in this scenario) was accurate as submitted. In
fact, from a billing compliance standpoint, the provider
should not make the amendment if the original
information was accurate and complete.
A provider is given 60 days to act on amendment requests
and providers are always permitted to deny amendment
request when the information is accurate and complete
when originally recorded.
Source:Manchikanti L Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Erin Brisbay McMahon, JD, Sep 2005
269
Q
- Which of the following statements is correct?
A. The HIPAA security rule requires that a criminal background
check be conducted on everyone.
B. Physician practices with less than ten full-time employees
are not subject to HIPAA.
C. A HIPAA-covered physician practice do not need to apply
security rule standards to laptop computers owned
by the practice.
D. If an employee of a HIPAA-covered physician practice
works from home and accesses electronic protected
health information via a remote connection, the practice
has no duty to make sure that its HIPAA security
standards are followed at the employee’s home.
E. If an employee of a HIPAA-covered physician practice
works from home and accesses electronic protected
health information via a remote connection, the practice
has a duty to make sure that its HIPAA security
standards are followed at the employee’s home.
A
- Answer: E
Explanation:
A covered entity’s responsibility to implement security
standards extends to the members of its workforce,
whether they work at home or on-site. Because a covered
entity is responsible for ensuring the security of the
information in its care, the covered entity must include ‘‘at
home’’ functions in its security process.
Source: 68 Fed. Reg. 8339
Source: Erin Brisbay McMahon, JD, Sep 2005
270
Q
- A patient hand delivers a written request for a copy of
his medical record to Smith and Jones, PSC, a physician
practice that is a covered entity under HIPAA. The
record contains information faxed to the PSC from other
physicians and from the local hospital. The PSC should . .
.?Choose the answer that best completes the sentence.
A. Produce only those records the PSC has created and
withhold the records received from other physicians
and from the local hospital.
B. Refuse the request if it is not notarized.
C. Refuse the request if it is not signed by a witness.
D. Produce all the records it has on the patient.
E. Only release the portions of the record that the patient
needs for treatment due to the minimum necessary
rule.
A
- Answer: D
Explanation:
The Privacy Rule permits a provider who is a covered
entity to disclose a complete medical record including
portions that were created by another provider. No
justifi cation for releasing the entire record is needed in
those instances where the minimum necessary standard
does not apply, such as disclosures to or requests by a
health care provider for treatment purposes or disclosures
to the individual who is the subject of the protected health
information.
Source:
http://healthprivacy.answers.hhs.gov/
Source: Erin Brisbay McMahon, JD, Sep 2005
271
Q
2190. Which of the following is NOT an element necessary to prove a Stark law violation? A. A referral by a physician B. For a designated health service; C. Entity has fi nancial relationship with physician or family member D. Billed to Medicare or Medicaid E. Physician has intent to defraud.
A
- Answer: E
Explanation:
Stark is a strict liability statute. No intent to defraud is
required to violate it.
Source: Furrow B et al. Health Law: Cases, Materials, and
Problems 2004 at 1034.
Source: Erin Brisbay McMahon, JD, Sep 2005
272
Q
- Which of the following is not true with respect to an
employer’s duty to communicate hazards to employees?
A. Labels must include the Biohazard legend found in the
regulation.
B. Red bags or containers may be substituted for labels.
C. The labels shall be fl uorescent yellow, orange, or orangered.
D. All regulated waste, containers, refrigerators and freezers
containing blood or other potentially infectious materials
are required to be specifi cally identifi ed.
E. All of the above.
A
- Answer: C
Explanation:
Labels shall be fl uorescent orange or orange-red or
predominately so, with lettering and symbols in
contrasting color.
Source: 29 CFR 1910.1030(g).
Source: Erin Brisbay McMahon, JD, Sep 2005
273
Q
2192.The patient asks for a prescription with the explicit
intent to end their life. This activity is considered as:
A. Voluntary Active Euthanasia
B. Voluntary Passive Euthanasia
C. Involuntary Passive Euthanasia
D. Involuntary Active Euthanasia
E. Physician Assisted Suicide
A
- Answer: E
Source: Weinberg M, Board Review 2005
274
Q
- CMS guidelines in a documentation of evaluation and
management services recommend to use the following:
A. SOAP- subjective, objective, assessment, and plan
B. SOAPER - subjective, objective, assessment, plan, education
and return instructions
C. SOAPIE - subjective, objective, assessment, plan, implementation,
and evaluation
D. SNOCAMP - subjective, nature of presenting problem,
counseling, assessment, medical decision making, and plan
E. Documentation involving elements, bullets, and level of care.
A
- Answer: E
Explanation:
Source: Manchikanti L, Recent developments in evaluation
and management services. Pain Physician 2000; 3:403-421.
Source: Manchikanti L, Board Review 2005
275
Q
- What are the correct statements about standards and
guidelines?
A. Standard is a degree of quality, level of achievement, etc.,
regarded as desirable and necessary for some purpose.
B. Standards are systematically developed statements to
help practitioners and patients make decisions about
appropriate health care for specifi c clinical circumstances.
C. Guidelines are documents demonstrating a degree of
quality, level of achievement, etc., regarded as desirable
and necessary for some purpose.
D. Guidelines are superior to standards
E. Guidelines are the same as standards
A
- Answer: A
Explanation:
Standard
A degree of quality, level of achievement, regarded as
desirable and necessary for some
purpose.
Guidelines
Systematically developed statements to help practitioners
and patients make decisions about
appropriate health care for specifi c clinical circumstances.
Source: Laxmaiah Manchikanti, MD
276
Q
2195. Which of the following is NOT considered an immediate family member for purposes of Stark? A. Stepbrother B. Grandparent C. Stepparent D. Nephew E. Spouse of grandchild
A
- Answer: D
Explanation:
A physician’s “immediate family member” means the
physician’s husband or wife, birth or adoptive parent,
child, or sibling; stepparent, stepchild, stepbrother, or
stepsister; father-in-law, mother-in-law, son-in-law,
daughter-in-law, grandparent or grandchild; and spouse of
a grandparent or grandchild.
Source: Erin Brisbay McMahon, JD, Sep 2005
277
Q
2196.The OIG does not have the discretion to exclude
individuals and entities from participation in federal
healthcare programs in cases where:
A. The individual or entity submitted a claim substantially
in excess of usual charges.
B. The individual or entity provided unnecessary or substandard
services.
C. An individual defaulted on an education loan in connection
with medical school loans made or secured by
HHS.
D. An individual was convicted of driving under the infl uence
of alcohol or substances.
E. An individual was convicted of a criminal misdemeanor
for fi nancial misconduct with respect to a healthcare
program
A
- Answer: D
Explanation:
The OIG has discretionary or permissive authority to
exclude individuals and entities on the basis of all of the
answers above, except for (d).
Source: 42 U.S.C. § 1320a-7(b).
Source: Erin Brisbay McMahon, JD
278
Q
- Morality, ethics and legal parameters are interactive in
many ways. Which statement best describes the ethically
maximized, legally appropriate practice of medicine?
A. good laws are those that are morally sound
B. aws establish limits; ethics establish exceptions
C. moral affi rmations and obligations allow good use of
ethics within the law
D. know thyself and persist beyond mere limits
A
- Answer: C
Explanation:
What is morally ‘good’ or right is not always legal, and vice
versa. Moral affi rmations and obligations guide the sound
practice of medicine. Legal parameters defi ne the scope of
that practice within a society.Thus, moral affi rmations and
obligations guide ethical practice within the scope
afforded by societal law(s) (Giordano J. Moral agency in
pain medicine: Philosophy, practice and virtue. Pain
Physician 2006; 9: 41-46).
Source: Giordano J, Board Review 2006
279
Q
- Choose the answer that includes all the categories of
exceptions under Stark:
A. Ownership and compensation exceptions
B. Compensation exceptions
C. Ownership exceptions
D. Financial exceptions, ownership exceptions, and compensation
exceptions
E. Ownership and compensation exceptions, ownership
exceptions, and compensation exceptions
A
- Answer: E
Explanation:
If a fi nancial relationship exists between the DHS entity
and the referring physician, it must fi t within an exception.
Exceptions are broken down into three broad categories:
ownership and compensation exceptions, ownership
exceptions, and compensation exceptions. An ownership
or investment interest requires an ownership exception. A
compensation arrangement requires a compensation
exception.
Source: 42 CFR 411.354.
Source: Erin Brisbay McMahon, JD, Sep 2005
280
Q
- Which of the following must appear in an accounting of
disclosures to the patient?
A. All disclosures for treatment purposes.
B. All inadvertent disclosures that have been made to a person
who is not the patient.
C. All disclosures made pursuant to an authorization signed
by the patient.
D. All incidental disclosures.
E. All disclosures made for purposes of claims processing
A
- Answer: B
Explanation:
Inadvertent disclosures of protected health information
are required to be included in an accounting of disclosures.
Source: 45 CFR 164.528.
Source: Erin Brisbay McMahon, JD, Sep 2005
281
Q
2201.In pain medicine, the ‘mantle of responsibility’ ultimately
rests upon:
A. the administration of any medical facility as a community
to guide and shape the scope of practice
B. governmental policy that informs and directs medical
practice
C. the patient as an autonomous person to make and dictate
decisions
D. the physician as both a therapeutic and moral agent
A
- Answer: D
282
Q
- Although widely used, and indeed useful, one of the
diffi culties with the sole use of prima facie principles to
ethically guide medical practice is:
A. that they are too restrictive and not ‘applied’ in nature
B. potential collision and/or confl ict between principles
C. problems in deciding which cases and what factors to
focus upon
D. all of the above
A
- Answer: B
Explanation:
Although principles are regarded as a very valuable system
of applied ethics, one of the potential problems with using
principles alone, is that without a grounding base, it may
be diffi cult to ordinally ‘rank’ which principle should be
applied in a given situation (ie.- when using the casuistic
approach), particularly when more than one principle is
viable. Such collisions or confl ict require some intuition
on the part of the involved decision maker as ethical agent,
and require some level of moral affi rmation and/or moral
obligations to uphold the decision. (Giordano J. Moral
agency in pain medicine: Philosophy, practice and virtue.
Pain Physician 2006; 9: 41-46; Giordano J. Moral virtue
and the pain physician: Agency, intentions and actions.
Practical Pain Management 2006; 6(4): 76-80)
Source: Giordano J, Board Review 2006
283
Q
2203.HIPAA mandates that physicians do which of the
following?
A. Obtain written patient consent to obtain a consultation
for services from another physician.
B. De-identify personal health information whenever possible.
C. Secure all medical records and lock the cabinets between
patient visits.
D. Never discuss clinical information with the family of the
patient.
E. Do not provide medical records to the patient when requested
A
- Answer: B
Source: Manchikanti L, Board Review 2005
284
Q
- You are providing multidisciplinary services. You also
have ownership in a physical therapy located outside your
clinic. The patient requires epidural steroid injection,
along with physical therapy. Your obligation in this
situation is as follows:
A. Disclose to the patient at the time of referral
B. Disclose to insurer upon request
C. It is okay not to disclose if income from facility is based
on percent of investment, not based on volume of referrals
D. It is okay if your income from the facility is based on
volume of referrals rather than based on percent of
investment.
E. Do not refer the patient to your facility and refer to another
facility
A
- Answer: E
Source: Manchikanti L, Board Review 2005
285
Q
- Your transcriptionist has been making a signifi cant
number of mistakes, her behavior has been erratic, and
her attendance has been unacceptable. You suspect drug
use. You decide to investigate by searching her desk and
looking in her locker. When should you conduct the
search?
A. Randomly, without warning
B. If you have a have a well-written policy advising your
employees that you maintain the right to search the
lockers and desks at any time, the employees will not
have an expectation of privacy. Otherwise you will run
the risk of claims of invasion of privacy
C. Only after notifying her in advance that the search will
take place.
D. You may search her desk on a daily basis if you want to.
E. You may search only if you suspect a weapon.
A
- Answer: B
Source: Judith Homes, Sep 2005
286
Q
- A 38-year old white female who underwent multiple
lumbar surgeries with low back and lower extremity
pain underwent one-day adhesiolysis with CPT 62264.
She underwent adhesiolysis in the past with average
relief of 3 months on 3 occasions in the past. This has
improved her physical and functional status. Following
the last adhesiolysis, which was performed bilaterally,
however, the catheter was positioned at the end of the
procedure on the left side laterally and ventrally. The
medications included 5 mL of Xylocaine 2% preservative
free, 6 mL of 10% sodium chloride solution, and 6 mg of
non-particulate Celestone. She complained of signifi cant
pain with the last dose of hypertonic sodium chloride
injection in the recovery room on the right side. This
was managed by giving her 1 mL of Fentanyl and 30 mg
of Toradol. She presented 3 days after the injection with
severe intractable pain on the right side of the lower
extremity and low back with inability to move, however,
the examination showed only mild subject weakness
with no neurological defi cit. She was unable to tolerate
Neurontin. She received only 20% to 30% relief with
hydrocodone 4 times a day. A week after the procedure,
MRI showed no evidence of abscess, discitis, etc. since she
continued to be in pain, the physician performed a caudal
epidural steroid injection under fl uoroscopy in an ASC.
Choose the correct statement for coding this visit:
A. Code 62311 – epidural steroid injection and caudal or
lumbar epidural steroid injection and 99214 – established
outpatient visit due to a detailed history, detailed
examination and medical decision making of moderate
complexity
B. Code 62311 – caudal epidural steroid injection only
C. Code 99214-25 – offi ce visit only without a procedure
D. Neither Code 62311 nor an evaluation code 99214 or any
other code may be charged as the patient is in the 10-
day global period for the procedure
E. Code 62311-78 return to the operating room for a related
procedure in post-operative period and 99214-25
– may be charged
A
- Answer: D
Explanation:
CPT 62264 has a 10-day global period. Since the
procedure was performed within 10 days, basically the
statement in D is accurate. However, the procedure may be
charged with an attached note with modifi er -78 return to
the operating room for a related procedure during the
postoperative period. The visit may not be charged alone,
since this is in the 10-day global period.
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
287
Q
- A 58-year old white male underwent a trial subarachnoid infusion with morphine for neuropathic pain of lower
extremity. A day after the catheter was removed, the
patient complained of postural headache and was
diagnosed with postlumbar puncture headache. The
patient failed to respond to caffeine and bedrest , hence,
it was decided to proceed with an epidural blood patch.
Choose the correct statement with regards to coding of
this procedure.
A. CPT 62310 – caudal or lumbar epidural injection and
CPT 99213-25 – offi ce or other outpatient visit of low
complexity
B. CPT 62273- epidural blood patch
C. CPT 62273 – lumbar epidural blood patch, CPT 99213-
25 - offi ce or other outpatient visit with medical decision
making of low complexity
D. CPT 62311-78 – lumbar epidural injection, return to
the operating room for a related procedure during the
postoperative period
E. CPT 62311-79 – lumbar epidural, unrelated procedure
or service by the same physician during the postoperative
period
A
- Answer: B
Explanation:
The correct answer is 62273 – epidural blood patch. For
continuos intrathecal catheterization, the global period is
one day. Consequently, the global period rules do not
apply. Since the procedure is performed for the same
purpose as the patient complaints are, no evaluation
coding may be done in this scenario.
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
288
Q
- Which one of the following gifts is inappropriate?
A. A $5 gift certifi cate for lunch
B. $100 stethoscope
C. $200 pain management book
D. Information on continuing medical education
E. One month supply of cholesterol drug for personal use
A
- Answer: C
Source: Manchikanti L, Board Review 2005
289
Q
2209.If an implementation specifi cation in the HIPAA
security rule is labeled “addressable,” that means that
the specifi cation . . . ?Choose the word or phrase that best
completes the sentence.
A. Is required.
B. Is optional.
C. Does not need to be implemented now, but will need to
be implemented by April 20, 2010.
D. Is one whose appropriateness and reasonableness must
be assessed.
E. Does not need to be implemented now, but will need to
be implemented by April 20, 2006.
A
- Answer: D
Explanation:
A covered entity must assess whether an addressable
implementation specifi cation is appropriate and
reasonable for it in light of its security risks.
Source: 45 CFR 164.306.
Source: Erin Brisbay McMahon, JD, Sep 2005
290
Q
- Which one of the following procedures is the most
correct statement of the requirements of the HIPAA
privacy rule, assuming that the physician is a covered
entity under HIPAA?
A. The HIPAA privacy notice must be posted in a physician’s
offi ce and a copy need only be given to a patient
when s/he requests it.
B. A HIPAA privacy notice must be posted in a physician’s
offi ce and must be given to every patient on the date
s/he is fi rst rendered services.
C. A HIPAA privacy notice need not be posted in a physician’s
offi ce and a copy need only be given to a patient
when s/he requests it.
D. A HIPAA privacy notice need not be posted in a physician’s
offi ce, but must be given to every patient on the
date s/he is fi rst rendered services.
E. If the physician maintains a website, the patients may be
told to go to the website to obtain a copy of the privacy notce
A
- Answer: B
Explanation:
The HIPAA Privacy Rule requires a covered health care
provider with direct treatment relationships with
individuals to give the notice to every individual no later
than the date of fi rst service delivery to the individual and
to make a good faith effort to obtain the individual’s
written acknowledgment of receipt of the notice. If the
provider maintains an offi ce or other physical site where
she provides health care directly to individuals, the
provider must also post the notice in the facility in a clear
and prominent location where individuals are likely to see
it, as well as make the notice available to those who ask for
a copy.
Source: 45 CFR 164.520(c).
Source: Erin Brisbay McMahon, JD, Sep 2005
291
Q
- A new patient presenting to your clinic says he is
OxyContin 100 mg tid with Oxycodone 10 mg qid for
breakthrough pain. Records from old physician indicate
that he is worried about addiction. You also realize that
the physician has started reducing his dosage to 80 mg tid,
but the patient says he is running out of prescriptions.
Your diagnosis and options are as follows:
A. Diagnosis is drug abuse, refer to an addictionologist
B. Diagnosis is drug addiction, start rapid detoxifi cation
C. Diagnosis is pseudoaddiction, increase OxyContin and
oxycodone until he is pain free
D. Treatment is to change to methadone maintenance for
addiction
E. Diagnosis is typical pain behavior, continue narcotic
therapy
A
- Answer: A
Source: Manchikanti L, Board Review 2005
292
Q
- Your receptionist has fi led an EEOC Charge against
you and the clinic, claiming she has been the victim of
race discrimination and harassment in your offi ce. She
continues to work for you while this Charge is pending.
What should you do?
A. Immediately call a meeting with the rest of your staff,
tell them about the pending action and warn them not
to have any unnecessary conversations with the receptionist.
B. Transfer the receptionist to the fi le room and have her do
fi ling so that she won’t have contact with anyone she has
accused of discrimination.
C. You have the right to terminate her, because the tension
in the offi ce has cut down on productivity.
D. Don’t terminate her without fi rst gathering lots of documentation.
Start monitoring the receptionist’s attendance,
punctuality, and job performance more closely.
Document all policy violations, and when you have
enough ammunition against her, terminate h
E. Do none of the above as they are all examples of retaliation,
which is a violation of discrimination laws
A
- Answer: E
Source: Judith Homes, Sep 2005
293
Q
- A concert pianist and a vice president of a major
corporation have both suffered the loss of the second
fi nger of the dominant hand. Which of the following
statements is true regarding the condition of impairment
or disability due to the injury?
A. The concert pianist is more impaired than the vice
president.
B. The concert pianist and vice president are equally disabled.
C. The concert pianist and vice president are both handicapped.
D. The concert pianist is more disabled than the vice president.
E. The concert pianist is more handicapped than the vice
president
A
- Answer: D
Explanation:
Source: AMA Guides to the Evaluation of Permanent
Impairment, 2001.
Both the concert pianist and the company vice president
have an impairment due to the loss of their digit.
However, the concert pianist is signifi cantly more disabled
because the pianist will not be able to perform but the
vice president will still be able to do the job. They are not
signifi cantly handicapped because they can still perform
life’s activities without the use of assistive devices or
modifi cation of the environment.
Source: Manchikanti L, Board Review 2005
294
Q
- The HIPAA security rule applies to . . .? Choose the
answer that best completes the sentence.
A. Electronic protected health information only.
B. All forms of protected health information.
C. Protected health information transmitted electronically
or telephonically.
D. Oral protected health information.
E. Protected health information communicated orally or
telephonically.
A
- Answer: A
Explanation:
A covered entity must comply with the HIPAA Security
Rule with respect to electronic health information only.
Source: 64 CFR 164.302.
Source: Erin Brisbay McMahon, JD, Sep 2005
295
Q
- Which of the following statements is correct?
A. patient may request that a provider amend a diagnosis
that was submitted on a billing claim form.
B. A provider must act on a patient’s request for amendment
within 30 days, either deny or amend.
C. A provider does not agree with a patient’s request for an
amendment. The provider must make the amendment
but can note disagreement in the amendment and inform
the insurer.
D. Provider has to amend diagnosis in 30 days as provider
may not deny the patient requests.
E. Provider has no obligation even if the information on the
claim was inaccurate.
A
- Answer: A
Explanation:
Source: Manchikanti L, Principles of Documentation,
Billing, Coding & Practice Management 2004
The privacy rule allows patients to request amendments of
their records including amendments to billing records.
The provider is not obligated to make the amendment if
the provider believes that the original information (the
diagnosis in this scenario) was accurate as submitted.
In fact, from a billing compliance standpoint the
provider should not make the amendment if the original
information was accurate and complete.
A provider is given 60 days to act on amendment
requests and providers are always permitted to deny
amendment requests when the information is accurate
and complete when originally recorded.
Source: Manchikanti L, Board Review 2005
296
Q
- A physician bills bilateral facet joint injections at C4/5,
C5/6, and C6/7. What are the appropriate nerves to be
blocked to bill bilaterally C4/5, C5/6, and C6/7 joints?
A. Bilateral medial branch blocks of C2, C3, C4, and C5
nerves must be blocked
B. Bilateral medial branch blocks of C5, C6, and C7 nerves
must be blocked
C. Bilateral medial branches of C4, C5, C6, and C7 must
be blocked
D. Bilateral C3 through C8 medial branches must be
blocked
E. Bilateral 3 nerves (total) only must be blocked
A
- Answer: C
297
Q
- An interventional pain physician billed for blocking of
left T5/6 and T9/10 facet joints. What are the nerves to be
blocked for proper blockage of both joints?
A. T3 and T4 medial branches on the left side
B. T4 and T5 medial branches on the right side
C. T3, T4 and T6, T7 medial branches on the left side
D. T4, T5 and T7, T8 medial branches on the left side
E. T5, T6 and T8, T9 medial branches on the left side
A
- Answer: D
298
Q
- The intentions, motivations and moral affi rmations to
treat, heal and care as refl ecting the intellectual and moral
‘character’ traits of the physician support:
A. the use of the principlist approach to medical ethics
B. the benefi t of a casuistic approach to medical ethics
C. the importance of agent-based system of virtue ethics
D. a strongly utilitarian (ie.- ends justifying means) approach
to medical ethics
A
- Answer: C
Explanation:
Any encounter can be reduced to a circumstance, agents
involved, actions and consequences; thus the intentional,
motivational and ultimate acts arise from the agent(s). The
intentions and motivations, as refl ecting ingrained traits
of character, refl ect the virtue(s) of the agent involved.
These intentions, and motivations can empower better
intuition of the use of principles and the casuistic
approach in specifi c circumstances, and also ground the
agents’ actions to the defi ned ends of medicine, keeping
those acts consistent with the good of the practice.
(Giordano J. Moral agency in pain medicine:
Philosophy, practice and
virtue. Pain Physician 2006; 9: 41-46; Giordano J. Moral
virtue and the pain physician: Agency, intentions and
actions. Practical Pain Management 2006; 6(4): 76-80. See
also: Pellegrino ED. Professionalism, profession and the
virtues of the good physician. Mt Sinai J. Med. 2002; 69:
378-384)
Source: Giordano J, Board Review 2006
299
Q
- Which of the following statements about disulfi ram
treatmetn of chronic alcoholism are correct? - Indicated when the patient will not comply with other
treatments - Indicated in patients with Korsakoff syndrome
- Used when hepatic cirrhosis is present
- May be used in patients with antisocial personality
disorder
A
- Answer: D (4 Only)
Explanation:
Disulfi ram treatment is an important adjunct to the
rehabilitation program with the alcoholic. The patient
only has to make the decision about not drinking, and it
gives the individual time to think about the impulse to
drink. Therefore, the patient must be health (due to the
side effects with alcohol), highly motivated, and
cooperative.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
300
Q
- Select the statements that are true.
- A Pain Management Specialist, Specialty 72, may report
any code in the Osteopathic Manipulation Section of
the CPT Manual - A Pain Specialist, regardless of specialty designation,
may report any CPT code for which services h/she is
trained and licensed to perform - When a Pain Specialist reports a CPT code to a third
party payer, h/she represents that h/she is trained and
licensed to perform the service.The provider is legally
responsible from a patient care perspective and for
truthful billing of his/her services. - An Interventional Pain Specialist, Specialty 9 may not
report any of the CPT codes listed in the Chiropractic
Section of the CPT Manual
A
- Answer: A (1,2, & 3)
Explanation:
Page xiii of the CPT Manual affi rms that, “It is important
to recognize that the listing of a service or procedure and
its code number in a specifi c section of this book does not
restrict its use to a specifi c specialty group. Any procedure
or service in any section of this book may be used to
designate the services rendered by any qualifi ed physician
or other qualifi ed health care professional”.
Providers of medical service should consider the risk of
reporting services for which they are not fully trained and
licensed to perform. For example, when a Pain Specialist
advises a patient that a hip arthrogram is being performed
and charges the insurance carrier for a hip arthrogram, the
expectation is that a diagnostic radiological study has been
performed. The doctor would be expected to identify
whether or not there is any bone disease or arthritic
condition of the hip. If the doctor fails to identify a
condition that causes the patient future disability which
early treatment could have prevented, a malpractice suit
could result.
The “take home message” on Page xiii of the CPT Manual
is “…by any qualifi ed physician or other qualifi ed health
care professional.”
Source: CPT Coding Manual, Professional Version 2005
Source: Joanne Mehmert, CPC
301
Q
2221.Which of the following best describe approaches for
generating employee improvement that can be used as
part of the evaluation process?
1. Develop goals and objectives for employees whose performance
is satisfactory, and those whose performance
is inconsistent or marginal.
2. Develop a bar graph comparing productivity of all
employees in the department/division, and attach it to
each employee’s performance evaluation.
3. Develop performance requirements for employees
whose performance is unsatisfactory
4. Develop photos from the offi ce holiday party and
promise not to post at the front desk if performance
improves
A
- Answer: B (1 & 3)
Explanation:
Goals and objectives encourage improvement, while
performance requirements mandate that an unsatisfactory
employee improve or face the consequences. Both goals
and requirements are elements of an effective employee
evaluation
Source: Judith Holmes
302
Q
- Which of the following statements about Alcoholics
Anonymous are correct? - Closely integrated with mental health services in most
areas - Control is primarily through group support
- Goal is a socially acceptable level of alcohol intake
- Typical attendance is several times per week
A
- Answer: C (2 & 4)
Explanation:
Alcoholics Anonymous (AA) is a voluntary, supportive
fellowship, self-help group, and is worldwide. It was
founded in 1936 by Bill Wilson. Meetings provide
acceptance, understanding, forgiveness, confrontation, and
a means of positive identifi cation. Programs consist of 12
steps and the use of sponsors. AA is not tied to any
religion, but does allow for spiritual reevaluation.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
303
Q
- Abrupt drug withdrawal is likely to be life threatening in a patient addicted to:
- Cocaine
- Heroin
- Diazepam
- Meprobamate
A
- Answer: D (4 Only)
Explanation:
A physical withdrawal syndrome occurs when a drug has
become necessary to maintain homeostasis, usually after
months of use and doses above therapeutic level. Abrupt
stoppage of commonly used drugs such as narcotics,
benzodiazepines, barbiturates, and alcohol can result in
seizures, delirium, and cardiovascular collapse.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
304
Q
- Which of the following statements are correct in the
treatment of pregnant opioid addicts? - High-dose methadone maintenance leads to low-risk
neonatal withdrawal - Opioid withdrawal may lead to miscarriage or fetal
death - Women using opioids tend to have easy, uncomplicated
deliveries - Many opioid dependence women seek treatment when
they become pregnant
A
- Answer: C (2 & 4)
Explanation:
Opioid addicts who are pregnant present special risks as
high doses of narcotics (especially methadone) can lead to
fetal problems on withdrawal or during delivery.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
305
Q
- Which of the following statements about the treatment
of chronic alcoholism with disulfi ram are correct? - Alcohol dehydrogenase is inhibited
- Aldehyde accumulation causes vasodilation and hypotension
- Indicated in alcohol-induced dementia
- Treatment benefi t is not dose-related
A
- Answer: C (2 & 4)
Explanation:
Disulfi ram is taking in a 250-500 mg dose per day.
Higher doses can be toxic, resulting in psychosis, memory
impairment, and confusion without offering any better
control.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
306
Q
2226. Medical complications of chronic alcoholism include all of the following except: 1. Cardiomyopathy 2. Chronic pancreatitis 3. Fetal growth retardation 4. Hepatolenticular degeneration
A
- Answer: D (4 Only)
Explanation:
Medical complications of chronic alcoholism are gastric
bleeding, gastritis, achlorhydria, gastric ulcers, chronic
pancreatitis, fatty liver, hepatitis, cirrhosis,
cardiomyopathy, lowered immune response, hypoglycemia
(may result in sudden death), an inhibited vitamins and
amino acids absorption. In males, testicular atrophy,
feminine pubic hair pattern, breast enlargement, and
impotency may occur; female alcoholics may show
decreased menstruation and infertility. Fetal alcohol
syndrome (growth retardation before or after birth, small
head circumference, fl attening of facial features, CNS
problems) is likely to be present in infants of female
alcoholics.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
307
Q
2227. Which of the following statements about alcoholinduced blackouts are correct? 1. Remote memory defi cit 2. Immediate memory defi cit 3. Does not occur in non-alcoholics 4. Short-term memory defi cit
A
- Answer: D (4 Only)
Explanation:
During alcohol induced blackouts, an “amnestic disorder,”
there are periods of retrograde amnesia (short-term
memory defi cits), even though state of consciousness may
not appear to be abnormal.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
308
Q
- Which of the following statements are true?
- An employee must complain to the appropriate supervisor
in order to have claim of harassment - If most people laugh at your colorful language and jokes,
it’s not harassment. - Harassment doesn’t cover joking with people who are
my same sex or race. - Only the person who is targeted with offensive behavior
can complain.
A
- Answer: C (2 & 4)
Explanation:
An employee may have a claim of harassment even though
some people don’t fi nd the conduct or language offensive,
even if the comments were not directed to that employee,
and even if the harasser and victim are the same sex or
race.
Under certain circumstances, the employer will have a
defense to a harassment suit if the victim did notcomplain,
but the victim’s failure to complain will not insulate an
employer from an EEOC claim and subsequent costly
lawsuit
Source: Judith Holmes
309
Q
- True statements defi ning disability include the
following: - An alteration of an individual’s capacity to meet personal,
social, or occupational demands because of an
impairment. - Activity limitation or a diffi culty in the performance, accomplishment,
or completion of an activity at the level
of the person. - The inability to engage in any substantial, gainful activity
by reason of any medically determinable, physical, or
mental impairment(s). - Disability is a barrier to full functional activity that may be overcome by compensating in some way for the
causative impairment.
A
- Answer: A (1, 2, & 3)
Explanation: - An alteration of an individual’s capacity to meet
personal, social, or occupational demands because of an
impairment (AMA Guides to the Evaluation of Permanent
Impairment). - Activity limitation (formerly disability) is a diffi culty in
the performance, accomplishment, or completion of an
activity at the level of the person. Diffi culty encompasses
all of the ways in which the doing of the activity may be
affected (WHO). - The inability to engage in any substantial, gainful
activity by reason of any medically determinable physical
or mental impairment(s), which can be expected to last for
a continuous period of not less than 12 months (SSA). - “Temporary disability” means a decrease in wageearning
capacity due to injury or occupational disease
during a period of recovery. “Permanent disability”
results when the actual or presumed ability to engage in
gainful activity is reduced or absent because of permanent
impairment and no fundamental or marked change in the
future can be reasonably expected (Work Comp Law).
Source: AMA Guides to the evaluation of Permanent
Impairment, 2001.
310
Q
- Which of the following medications can be used
therapeutically in the rehabilitation of opioid dependent
patients? - Methadone
- Naltrexone
- Clonidine
- Levo-alpha-acetylmethadol
A
- Answer: E (All)
Explanation:
Medications used in the rehabilitation (maintenance) of
opioid-dependent patients are methadone (as a substitute
for opiates), a combination of naltraxone and clonidine
(long-acting antagonists) and L-alpha-acetylmethadol
(LAAM, an agonist similar to methadone but longer halflife).
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
311
Q
- The true statements with regards to Americans with
Disabilities Act include the following: - The Americans with Disabilities Act is a civil rights law
that was signed by President Bush in 1990. - ADA was intended to provide a clear and comprehensive
national mandate to end discrimination against
individuals with disabilities and bring those individuals
into economic and social mainstream of American life. - The ADA defi nes disability as a physical or mental impairment
that substantially limits one or more of the
major life activities of an individual. - A person needs to meet all the 3 criteria in the defi nition
to gain the ADA’s protection against discrimination.
A
- Answer: A (1, 2, & 3)
Explanation:
The ADA defi nes disability as a physical or mental
impairment that substantially limits one or more of the
major life activities of an individual; a record of
impairment, or being regarded as having an impairment.
A person needs to meet only 1 of the 3 criteria in the
defi nition to gain the ADA’s protection against
discrimination.
The physician’s input often is essential for determining the
fi rst 2 criteria and valuable for determining the third.
To be deemed disabled for purposes of ADA protection, an
individual generally must have a physical or mental
impairment that substantially limits one or more major
life activities. A physical or mental impairment could be
any mental, psychological, or physiological disorder or
condition, cosmetic disfi gurement, or anatomical laws that
affects one or more of the following body systems:
neurological, special sense organs, musculoskeletal,
respiratory, speech organs, reproductive, cardiovascular,
hematologic, lymphatic, digestive, genitourinary, skin, and
endocrine.
Conditions that are temporary are not considered to be
severe, such as normal pregnancy, are not considered
impairments under the ADA. Other non-impairments
include features and conditions such as hair or eye color,
left-handedness, old age, sexual orientation, exhibitionism,
pedophilia, voyeurism, sexual addiction, cleptomania,
pyromania, compulsive gambling, gender identity
disorders not resulting from physical impairment,
smoking, and current illegal drug use or resulting
psychoactive disorders.
312
Q
- Reduced effectiveness of cancer pain control with
intraspinal morphine infusions may be due to which of
the following: - Fibrosis
- Tolerance
- Disease progression
- Morphine metabolites
A
- Answer: A (1, 2, & 3)
Explanation:
Long-term loss of effi cacy is associated with technical
problems, disease progression and drug tolerance.
313
Q
- True statements about NMDA receptors are as follows:
- A number of heterogenous chemicals are antagonists of
the N-methyl-D-aspartate (NMDA) receptor subtype
of the major excitatory neurotransmitter, glutamic
acid, in the brain. - NMDA antagonists include phencyclidine, dizocilpine,
and nitrous oxide. - Most of the known NMDA antagonists are drugs of
abuse. - NMDA antagonists in low doses induce a psychotomimetic
state, which resembles schizophrenia.
A
- Answer: E (All)
Explanation: - A number of heterogenous chemicals are antagonists of
the N-methyl-D-aspartate (NMDA) receptor subtype of
the major excitatory neurotransmitter, glutamic acid, in
the brain. - NMDA antagonists include arylcyclohexylamines (of
which phencyclidine and ketamine are best known),
dizocilpine (MK-801), and nitrous oxide. - Most of the known NMDA antagonists are drugs of
abuse when used in sub-anesthetic doses/concentrations. - Sub-anesthetic doses of phencyclidine and ketamine
induces psychotomimetic state, which resembles many of
the signs and symptoms of schizophrenia.
Nitrous oxide or laughing gas has not yet been classifi ed
as psychotomimetic. However, its euphoric and dysphoric
properties have been known for more than 200 years but
have not been well studied by psychiatrists
314
Q
- In a malpractice action, the fi nal determination of
culpability and liability are determined by: - Deviation of the standards of practice
- Causation of incident
- Damage and suffering due to the incident
- History of previous lawsuits
A
- Answer: A (1, 2, & 3)
Explanation:
The fi nal determination of culpability or lack thereof is
contingent on determining whether the physician followed
standards of practice for his or her specialty.
Source: Hall and Chantigan.
315
Q
- Which of the following is a true statement with respect
to HIPAA Privacy Compliance? - Only practices with 10 or more employees need to comply
with the HIPAA Privacy Rule. - Disclosures for treatment, payment, and health care operations
must be tracked for accounting of disclosures
purposes - Even if it is discovered that an employee of the practice
violated the HIPAA Privacy Rule, no sanction need be imposed for a minor violation - The three major issues with respect to HIPAA privacy
compliance are (a) how to use and disclose protected
health information; (b) the patient’s rights under the
Privacy Rule; and (c) the provider’s legal obligations
under the Privacy Rule
A
- Answer: D (4 Only)
Explanation:
If a provider has less than ten full time employees, it can
continue submitting claims on paper. However, all
physician practices that conduct any of the electronic
transactions covered by HIPAA (including fi ling claims
electronically with a third-party payor) must comply with
HIPAA Privacy Rule.
2)Disclosures for treatment, payment, and health care
operations are not required to be tracked for accounting of
disclosures purposes. 45 CFR 164.528.
3)Sanctions have to be imposed under both the Privacy
and the Security Rules if an employee is found to have
violated either rule, no matter how small the violation
Source: Erin Brisbay McMahon, JD
316
Q
- Choose the answers that apply? Do non-Medicare payers
allow separate payment for supplies such as needles,
syringes and/or surgical trays used for nerve blocks and
injections when they are performed in the offi ce, POS 11? - No, private payers do not allow additional payment for
supplies - Payment for supplies used for nerve blocks and injections
is payer specifi c. There is no “every carrier”
policy. Payers that have a fee differential modeled after
Medicare’s higher “offi ce” rate are less likely to pay for
supplies - Yes, private payers will pay an additional fee for all supplies
used in the offi ce - Payment for supplies is an issue that should be addressed
in the fee schedule section of the contractual
agreement, especially when the carrier doesn’t have a
higher payment for services performed in an offi ce
A
- Answer: C (2 & 4)
Explanation:
Payer fee schedules seldom address the payment of
supplies nor are there any codes listed for surgical trays
and/or supplies. Unless the contractual agreement
specifi cally prohibits the physician from reporting
supplies, it is appropriate to bill separately for the
supplies. More expensive equipment and supplies should
be carved out to ensure adequate reimbursement.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC
317
Q
2237. In adults with no prior history of seizure disorder, seizures may be caused by: 1. Phencyclidine intoxication 2. Cocaine intoxication 3. Amphetamine intoxication 4. Meperidine intoxication
A
- Answer: E (All)
Explanation:
Drugs that can cause seizures are phencyclidine, cocaine,
alcohol, lithium, amphetamine, meperidine, and
benzodiazepines.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
318
Q
- Which of the following statements about psychedelic
drug use are corrects? - Tolerance quickly develops if used frequently
- Tolerance persists for extended period after drug use
stopped - No withdrawal phenomena when stopped after chronic
use - Cross-tolerance between LSD and amphetamines
A
- Answer: B (1 & 3)
Explanation:
Repeated psychedelic drug use over an extended period of
time can quickly result in tolerance. There is a crosstolerance
with LSD, mescaline, and psilocybin, but not
between LSD and emphetamines or delta9-THC. There is
no known withdrawal pattern.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
319
Q
- Level IA evidence for interventions to reduce blood
borne infections from central venous catheters include: - Maximal sterile barrier precautions
- Povidone-iodine ointment at exit site
- Chlorhexidine-based antiseptic is preferred
- Complete infusion of crystalloid fl uids within 4 hours
A
- Answer: A (1, 2, & 3)
Explanation:
No recommendations can be made regarding fl uid hang
time other than for lipids and blood. Povidone-iodine
ointment is Level II.
320
Q
- Payment for clinical services based on the Medicare
RBRVS includes all of the following components: - Physician work
- Malpractice
- Clinically-related practice expenses
- Physician availability for emergency care
A
- Answer: A (1,2, & 3)
Source: Manchikanti L, Board Review 2005
321
Q
- The term handicap
- Applies to a person who has impairment that substantially
limits life’s activities. - Is related to but different from the term impairment.
- Can be applied to an impaired person who requires the use of an assistive device to perform activities of daily
living. - Can be applied to a disabled person who requires
modifi cation of the environment to perform activities
of daily living.
A
- Answer: E (All)
Explanation:
All the statements listed apply to the term handicap as
defi ned in the AMA guidelines. It is the physician’s
responsibility to evaluate a patient’s health status and
determine the degree of impairment. If the physician also
has the ability to assess the patient’s activities and need for
assistive devices to perform those activities, an opinion
regarding the degree of disability or handicap may be
given as well.
Source: AMA Guides to the evaluation of Permanent
Impairment, 2001.
322
Q
- History of present illness includes multiple descriptors
showing the chronological description of development of
patient’s symptom(s). These include: - Location and quality
- Severity and duration
- Modifying factors
- Review of pertinent systems involved in the complaint
A
2242. Answer: A (1, 2, & 3 ) Explanation: Four components of history include: chief complaint (CC) history of present illness (HPI) past, family, social history (PFSH) review of systems (ROS) History of present illness includes: location quality severity duration timing context modifying factors associated signs and symptoms but not review of systems
323
Q
- The medical record includes each of the following:
- To be secure and uniquely identify the patient
- To be immediately available for patient and physicians
to review - Contain completed operative note within 24 hours of
the procedure - To explain rationale of procedure for CPT assessment
A
- Answer: B ( 1 & 3)
Explanation:
To comply with the recommended mandates in the
medical record, the record should be timely and legible,
secure, anduniquely identify the patient, confi dential,
contain a recent history and physical to be completed
within 24 hours of procedure, and contain preoperative,
intraoperative and postoperative nursing notes. At the
time the ASC experiences patient contact, medical decision
making is already completed for the procedure. The
ASC’s position is to assist in best documentation of the
procedure, and to assist the physician in supportive
documentation.
Source: Hans C. Hansen, MD
324
Q
2244. The following statements are true regarding Fentanyl as a good agent for transdermal use, 1. Low molecular weight 2. Adequate lipid solubility 3. High analgesic potency 4. Low abuse potential
A
- Answer: A (1, 2, & 3)
Explanation:
Fentanyl has a low molecular weight and high lipid
solubility; this allows it to be administered by the
transdermal route. It is interacts primarily with the ?-
receptors. It is about 80 times more potent than morphine.
The low abuse potential for fentanyl is a property of the
transdermal delivery system and not of the opioid itself.
Source: Chopra P, 2004
325
Q
- Which of the following statements about diazepamdependent
patients are correct? - Withdrawal symptoms become disabling within 24
hours of stopping - Low alcohol intake may precipitate overdose
- Most likely to be black male
- May show no disability until stopping diazepam use
A
- Answer: C (2 & 4)
Explanation:
Diazepam has a high potential for abuse and dependence,
which may develop over months (high doses) to years
(low doses). Alcohol, opiates, or cocaine intake may
precipitate overdose. The patient, if tolerant or dependent,
may show no disability until several days later after
stopping the use of diazepam when withdrawal symptoms
develop.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
326
Q
2246. The following are components of the RBRVS payment system: 1. Physician work component 2. Practice expense component 3. Professional liability component 4. Business risk component
A
- Answer: A (1, 2 & 3 )
Source: Marsha Thiel, RN, MA
327
Q
2247. In amphetamine delusional disorder, the patient is likely to show: 1. Paranoid delusions 2. Craving for food 3. Tactile hallucinations 4. Excessive REM sleep
A
- Answer: B (1 & 3)
Explanation:
Amphetamine and cocaine delusion disorders are very
similar and can resemble paranoid schizophrenia.
Common symptoms are paranoid delusions with
distortions of body image and misperception of face, a
predominance of visual and tactile hallucinations,
confusion, incoherence, hyperactivity and hypersexuality.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
328
Q
2248.The following components of physical therapy visit or
treatment cannot be carried out by a physical therapist
assistant:
1. Ultrasound and electrical stimulation treatment
2. Initial evaluation, examination, diagnosis
3. Daily assessment of patient’s progression toward goals
4. Discharge summary documentation
A
- Answer: C (2 & 4)
Explanation:
1)Modalities such as ultrasound and electrical stimulation
can be performed by a PTA when they are part of the
designated plan of treatment.
2)Initial evaluation, examination, and diagnosis require
the clinical decision making skills of a physical therapist
and therefore cannot be carried out by a PTA.
3)PTA’s are able to and should document a patient’s
progression at each visit.
4)Discharge documentation requires clinical decision
making and again, must be done by PT
Source: Guide to Physical Therapist Practice
Source: Marsha Thiel, RN, MA
329
Q
- Which of the following statements about L-alpha-acetyl methadol are correct?
- Similar in action to methadone
- Dispensed only three times a week
- May cause nervousness and stimulation
- Withdrawal syndrome much shorter than methadone
A
- Answer: A (1, 2, & 3)
Explanation:
Levo-alpha-acetylmethadol (LAAM) is an opioid agonist
similar to methadone in action but with a longer half-life.
Since it provides a longer time of suppression of
withdrawal for 72-96 hours, it can be dispensed (30-80
mg) only three times per week and has less abuse potential
due to its slow induction. LAAM may cause nervousness,
overstimulation, and mood side effects.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
330
Q
2250. Compared with fentanyl, characteristics of alfentanil include 1. Greater protein binding 2. More rapid clearance 3. Shorter elimination half-life 4. Greater volume of distribution
A
- Answer: A (1, 2, & 3)
331
Q
- Which of the following statements about LSD fl ashbacks
are correct? - Often triggered by marijuana use
- Usually cease within a few months of stopping hallucinogen
- Often pleasant to the hallucinogen user
- Subject may intentionally induce
A
- Answer: E (All)
Explanation:
LSD fl ashbacks are common, with 25% of users
experiencing an episode and with 5% there will be a severe reaction. Flashbacks usually cease in a few months after
stopping the drug use. The most common type of
fl ashbacks are hallucinations of formed objects (face,
geometric), sounds, voices, fl ashes of color, false
perceptions of movement, positive afterimages, and trails
of images from moving objects. Most of the fl ashback
symptoms are enjoyable. It is rare for the drug to produce
any lethal effects. Chromosomal damage from the use of
hallucinogens or from marijuana use is still questionable.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
332
Q
- Alcoholics using disulfi ram should avoid using?
- Aftershave
- Tricyclic antidepressants
- Cough syrup
- Pickled herring
A
- Answer: B (1 & 3)
Explanation:
Disulfi ram (Antabuse) results in a severe reaction if
alcohol is ingested; therefore, one must avoid using any
products containing alcohol such as aftershave lotions,
cough syrups, sauces, and vinegar. Disulfi ram completely
inhibits the enzyme aldehdye dehydrogenase, causing a
toxic reaction due to acetaldehyde accumulation in the
blood.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
333
Q
2253. Agents that produce an acute withdrawal response in patients addicted to heroine include 1. Pentazocine 2. Nalbuphine 3. Buprenorphine 4. Naloxone
A
- Answer: E (All)
334
Q
2254.The duration of severity of withdrawal symptoms in
sedative-anxiolytic abusers depend on:
1. Duration of drug use
2. Amount of drug used
3. Rate of elimination of drug and metabolites
4. Method of drug administration
A
- Answer: A (1, 2, & 3)
Explanation:
Sedative,hypnotic, or anxiolytic drugs have a high index or
therapeutic safety but can be abused, especially in
combination with other substances such as alcohol.
Duration of drug use (use is usually for short-term
adjustments), the amount of drug use, and the role of
elimination of drug and metabolites, all are factors in
producing tolerance of dependency.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
335
Q
2255.Clinically signifi cant Cytochrome P450 related
interactions include which of the following?
1. Tricyclics and tetracyclic agents, dopamine receptor antagonists
and type 1C antiarrhythmic drugs are safe to
use with concomitant use of SSRIs
2. Fluvoxamine and fl uoxetine should be used in combination
with alprazolam, or carbamazepine to negate their
activating side effects
3. Induction of CYP enzymes is of no clinical importance
relative to the problems caused by inhibition of these
enzymes
4. Codeine and hydrocodone may not be effective when
given in combination with fl uoxetine and paroxetine
A
- Answer: D (4 Only)
Source: Cole EB, Board Review 2003
336
Q
- When children of alcoholics are compared with controls
in adopt-out studies, which of the following statements
are correct? - Six times higher incidence of psychopathology in children
of alcoholics - Three times risk of psychopathology in daughters of
alcoholics - Ten times higher risk of alcoholism in sons of alcoholics
- Four times rate of alcoholism in sons of alcoholics
A
- Answer: D (4 Only)
Explanation:
There is a strong genetic factor seen in alcoholics and their
families. Sons of male alcoholics are more vulnerable than
daughters and become alcoholic four times more often
than children of nonalcoholics, even when they are not
raised by their biological parents. Monozygotic twins have
twice the concordance rate for alcoholism as compared
with dizygotic twins of the same sex. Further, family
alcoholism results in earlier onset, mor antisocial features,
worse medical problems, and a poorer prognosis.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
337
Q
2257.CPT provides Level I modifi ers to explain all of the
following situations:
1. When face-to-face services provided by a provider are
greater than usually required for the highest level of
E&M service for a given category
2. When one surgeon provides only postoperative services
3. When the same laboratory test is repeated multiple
times on the same day
4. When a patient sees a surgeon for follow-up care after
surgery
A
- Answer: A (1,2, & 3)
338
Q
2258. True statements regarding drug therapy in terminal pain syndromes include: 1. Anxiolytics are useful 2. Anti-infl ammatory agents are useful 3. Narcotics are useful 4. Neural blockade is useful
A
- Answer: E (All)
Explanation:
Useful therapeutic modalities in the treatment of pain fromterminal disease include anti-infl ammatory agents,
narcotics, anxiolytics, antidepressants, and neural
blockade. Also essential to treating terminal pain are
psychological support, family support, and a
multidisciplinary approach to managing this complex
problem.
339
Q
2259.The true statements describing tolerance include the
following:
1. Tolerance is defi ned as requiring more drug to produce
the same effect.
2. Tolerance can occur with or without physical dependence.
3. Tolerance is generally a characteristic feature of opioids.
4. Tolerance is synonymous with abuse and addiction
A
- Answer: A (1, 2, & 3)
340
Q
- Which of the following are likely to be shown by patients
with alcoholic hallucinosis? - Hallucinatory voices commenting unfavorably
- Underlying schizophrenic illness
- Consciousness not impaired
- No evidence of delusional thinking
A
- Answer: B (1 & 3)
Explanation:
Alcohol hallucinosis is a rare withdrawal symptom in
which the patient experiences vivid visual or auditory
voices commenting unfavorably. It usually last 48 hours,
but may go on for one week or more. The symptoms occur
shortly after cessation (within a day or two) or after the
reduction of heavy ingestion of alcohol. Patients are likely
to show fear, anxiety, and agitation. The hallucinations are
not part of the alcohol withdrawal delirium, and the
sensorium is clear.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
341
Q
2261. Requirements for informed consent include statements of: 1. Material risks 2. Expected outcome 3. Alternative treatments 4. Effects of no treatment
A
- Answer: E (All)
Explanation:
Fifth not included in the question is - Statement of the material risks.
2.Statement of the expected outcome and the likelihood of
success. - Statement of alternative procedures or
treatments and supporting information regarding those
alternatives. - Statement of the effect of no treatment, the effect on
the prognosis, and material risks associated with no
treatment.
Other: Statement of the nature and purpose of
the proposed treatment.
342
Q
- Choose the accurate statement(s) below:
- To provide equal access to all patients, a hospital with
high occupancy rate offers a small bonus to doctors for
each patient they discharge in less than 10 days. - Hospitals may bill Medicare or Medicaid for experimental
drugs used in clinical trials. - Hospitals may recruit physicians by offering them productivity
bonuses if it requires them not to apply for
privileges at any other hospital. - Falsifying trial results is considered fraud, while paying
for doctors enrolling patients in bona fi de clinical trials,
if properly disclosed, is not fraud.
A
- Answer: D (4 Only)
Explanation: - It is illegal for a hospital to knowingly make payments
directly or indirectly to a physician as an inducement to
reduce or limit services provided to Medicare or Medicaid
benefi ciaries who are under the physician’s direct care.
Hospitals that make (and physicians who receive) such
payments are liable for CMPs of up to $2,000 per patient
covered by the payments. - Some clinical-trial risk areas to avoid are as follows:
Institutions billing Medicare for services that are already
paid by the sponsor of a clinical trial are committing fraud
by double billing.
Trial patients should be separated from the regular patient
mix.
Medicare does not pay for most procedures using
experimental drugs or devices.
The physicians who run these studies or principal
investigator must supervise the work being done.
Falsifying results has clear quality-of-care implications for
patients.
Prosecutors also might argue that providers
must return payments for procedures performed using
devices that were approved due to falsifi ed trial results. - Both the Stark and anti-kickback laws sometimes allow
hospitals in health care professional shortage areas to,
under certain circumstances, persuade doctors to their
service areas by offering inducements that might normally
be viewed as illegal.
Under Stark, hospitals may persuade a physician to move
to the hospital’s area if certain specifi c conditions are met.
The Anti-Kickback Statute also has a corresponding
physician recruitment exception with many detailed
requirements that must be satisfi ed. - Patient enrollment fees: These might be paid to doctors
for enrolling patients in bona fi de clinical trials. If such
fees are not fully disclosed, they could be prosecuted as
fraud.
343
Q
- Multiple types of documentation are as follows:
- Procedural documentation
- Discharge
- Billing and coding
- Patient payment sources
A
- Answer: A (1,2, & 3)
Source: Manchikanti L, Board Review 2005
344
Q
2264. Which of the following symptoms are characteristic of phencyclidine intoxication? 1. Elevated blood pressure 2. Pinpoint pupils 3. Vertical nystagmus 4. Hematuria
A
- Answer: B (1 & 3)
Explanation:
Phencyclidine (PCP, “angel dust,” developed in the 1950s
for veterinary use) and related arycyclohexylamines have
CNS stimulation, CNS depressnat, hallucinogenic and
analgesic actions. Structurally related compounds are
dexoxadrol, ketamine (Ketalar), and N-(1-[z-thienyl]
cyclohexyl)-piperidine (TCP). PCP can be detected in the
urine for several days after use. Prominent features of
PCP use are increased blood pressure, heart rate, and
vertical or horizontal nystagmus. There is decreased
response to pain, ataxia, dysarthria, muscle rigidity,
seizures, and hyperacusis. Individual can have a serious
catatonic syndrome, toxic psychosis, acute mental
syndrome, or come. Suicide is a risk.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
345
Q
- The physician may however refuse to see a patient who
is: - Non-compliant
- A non-payer of services
- Potential threat to the offi ce personnel
- Diffi cult to accommodate due to specifi c disease type
such as HIV
A
- Answer: A (1, 2 & 3)
Source: Hans C. Hansen, MD
346
Q
- The function of vocational rehabilitation
- Use physical therapy and occupational therapy to improve
work skills. - Vocational rehabilitation includes an interdisciplinary
approach. - Vocational counselor works as a case coordinator and
mediator between employer and patient. - Vocational specialist identifi es patient’s vocational interest,
transferrable skills,and identifi es the job market
availability for positions within patient’s transferrable
skills.
A
- Answer: E (All)
347
Q
- True statements regarding suicide are:
- Less than 10% of patients who commit suicide have seen
their physicians in the last 3 months. - Women between the ages of 40 and 50 have the highest
suicide rate. - Five percent of suicide victims use medications prescribed
by their physicians to commit suicide. - Depressed chronic pain patients should routinely be
asked about suicidal ideation.
A
- Answer: D (4 Only)
Explanation: - Eighty percent of patients who commit suicide have
seen their physician in the last 3
months - Elderly males with a chronic illness have the highest
risk of suicide. - 50% of the patients commit suicide with medications
prescribed by a physician. - All depressed patients should be routinely asked about
suicidal thoughts.
348
Q
- A 27-year-old nurse who works for you has come in
contact with blood from a spill. The patient is unknown,
as is the HIV and HBV status. The owner/physician
should perform the following: - Document routes of exposure
- Identify if a vector source is known, and identify.
- Provide the employee the opportunity for serological
testing - Avoid repeat exposure by allowing the employee to convalesce
for one month.
A
- Answer: A (1, 2 & 3)
Explanation:
If an exposure incident occurs, the employer’s
responsibility is to document the routes of exposure and
how the exposure occurred, placed in an appropriate
documentation manual. If an injury occurs, an OSHA 300
form must also be displayed, prominently in a place of
commonality, such as a lunchroom. Furthermore, the
employer must attempt to identify the vector source,obtain
consent and test the individual serology, and provide the
employee needed information about test results. If the
employee does not want testing, 90 days may be offered for
retesting
Source: Hans C. Hansen, MD
349
Q
2269. Which of the following agents is associated with withdrawal anxiety 1. Opioids 2. Lorazepam 3. Dexamethasone 4. Haloperidol
A
- Answer: A (1, 2, & 3)
Source: Jackson KC. Board Review 2003
350
Q
- An upset patient presenting with depression, anxiety, and
possible substance abuse has been labeled by Workman’s
Comp as a “malinger”. The differential diagnosis should
include: - Somatoform disorder
- Undiagnosed or untreated psychopathology such as
bi-polar disease. - Untreated depression
- Early signs of suicidal ideation
A
- Answer: A (1, 2 & 3)
Explanation:
Undiagnosed psychopathology in the pain management
population is a signifi cant concern. A patient health
questionnaire is sometimes useful, including simple
questions as to lifestyle, interactions with individuals, and
directed questions to diagnose depression and anxiety.
Questions should determine complaints of altered sleep,
which shouldn’t be confused with depression and mood
alterations such as dysphoria, anxiety, and potential for
substance abuse. Patients with undiagnosed psychiatric
illnesses have increased incidences of drug abuse,
diversion and misuse, as well an increased risk
management concern for the pain management physician
Source: Hans C. Hansen, MD
351
Q
- The following may be considered reasons for alterations
and stress in the patient-physician relationship: - Managed care constraints.
- Physician time of encounter less than 5 minutes.
- Poor response to patient concerns and follow-up.
- Magnifi cation of the disease.
A
- Answer: A (1, 2 & 3)
Explanation:
In our healthcare system, “the patient-physician
relationship has resulted in many stressors over the past
number of years, particularly the managed care system has
increased patient mistrust” Theodosakis, J. et al. Don’t Let
Your HMO Kill You: How to Wake Up Your Doctor, Take
Control of Your Health, and Make Managed Care Work
for You. New York: Routledge 2000. Patients are
dissatisfi ed with their visits when they don’t feel nursing
staff has time, physician has time, and that they are not
being heard. A correlation to mistrust, and lack of patient satisfaction is related to time of encounter, and ability of
the patient to contact the staff either during business
hours or on-call, after hours.Patients have high levels of
expectations, and when these expectations are unmet,
patients become more demanding and they feel the
physician is less responsive their needs. This may result in
alteration of patient-physician relationship, at the least, or
increased malpractice risk and unnecessary accusations of
poor care.
Source: Hans C. Hansen, MD
352
Q
- Patients who are non-compliant, may be manifesting:
- Unrecognized psychiatric disease
- Malingering, or factitious disease
- Secondary gain
- Operant conditioning
A
- Answer: A (1, 2 & 3)
Explanation:
A considerable number of patients fall into the category, of
a variant of personality disorder. According to the Journal
American Family Physician, Leonard J. Haas, PhD et al.
volume 72 number 10, sub-clinical personality disorders
interfere with the patient-physician relationship. These
patients may become dependant, demanding and selfdestructive.
This is a common patient we see in the Pain
Management setting. Operant conditioning is irrelevant.
Source: Hans C. Hansen, MD
353
Q
- The Balance Sheet is a fi nancial statement that includes:
- Assets
- Liabilities
- Owners Equity
- Expenses
A
- Answer: A (1,2, & 3)
Explanation:
The Balance Sheet is a fi nancial picture of all the assets
owned, the money owed and the owners value in the
company. This statement is updated monthly, but refl ects
the ongoing fi nancial position of the company since it
started.
Source: Trent Roark,MBA
354
Q
2274.A physician may choose to exclude a patient from the
practice, but must be very careful when a protected status
of patient may emerge. In the case of HIV, discrimination
may be alleged unless the physician has made it clear
that there is no discrimination of care, particularly to
a protected status, where the practice chooses not to
treat the individual based solely on preference and not
by discrimination. This may be diffi cult to prove, and
the costly legal pathways to defense are borne on the
physician should even an allegation be made. It may be
seen that the patient is actually represented at no cost, on
the basis of discrimination. The physician pays his/her
own defense. Discrimination laws tend to vary state to
state. The Americans Disability Act (ADA) is broad in its
scope and favors the patient.When confronting a patient
for non-payment of bill, you may consider discharging
the patient if:
1. A formal process in writing warns the patient of discharge
2. The patient has not made an effort to pay
3. The patient is not protected from fi nancial crisis such
as bankruptcy
4. The patient has refused all attempts to pay
A
- Answer: A (1, 2 & 3)
Explanation:
To avoid allegations of abandonment the patient, the
practice must have no barriers to communication with the
physician, understanding that the offi ce will accommodate,
and be responsive to a patient’s fi nancial distress, but open
communication is necessary. If a patient is unable to pay,
and the process was formally, in writing, elaborated with
the patient, it is felt that the patient has received suffi cient
notice to withdraw care. 30-days notice usually applies,
but for risk management purposes, particularly as
individual states vary, a policy should be developed with
practice council to discharge patients for non-payment to
avoid allegations on discrimination or abandonment.
Source: Hans C. Hansen, MD
355
Q
2275.Types of methods to measure patient satisfaction include: 1. Mystery Shopper 2. Survey 3. Testimonials 4. Physician’s”feeling”
A
- Answer: A (1, 2 & 3 )
Explanation:
Mystery Shopper will evaluate the practice from the
patient’s point of view. Surveys can be useful if designed
correctly, but can’t be overused. It is important with
surveys that you get a large return of surveys on your
sample size. Testimonials are important because a patient
willing to speak on behalf of their experience is the
strongest source of referral.
Source: Trent Roark,MBA
356
Q
2276.Physicians may be accused of the following when improperly discharging a patient: 1. Abandonment 2. Discrimination 3. Wrongful Termination 4. Unethical accommodation
A
2276. Answer: A (1, 2 & 3) Explanation: If a physician chooses not to treat a patient, he/she may do so by statutes of involuntary servitude. Source: Hans C. Hansen, MD
357
Q
2277.Choose the accurate statement(s) about physical
examination of a patient with low back and lower
extremity pain of 6 months duration.
1. Physical examination may be conducted either by
choosing general multi-system examination or a single
system examination.
2. A single system examination utilizing psychiatric, respiratory,
or skin is suffi cient.
3. To cover appropriate physical examination in the above
patient, the examination should consist of a general
multi-system examination or a single system examination
encompassing musculoskeletal or neurological
systems.
4. Single system examination of musculoskeletal system
involves examination of all components in musculoskeletal
system and no other examination is required.
A
- Answer: B (1 & 3)
358
Q
2278.True statements associated with abuse of opioid
analegesics are:
1. No cross-tolerance develops among opiod analgesics
2. Tolerance develops equally to all effects of opioids
3. Opioids reduce pain, aggression, and sexual drives
4. The symptoms of acute methadone withdrawal are
qualitatively different from those of acute heroin withdrawal
A
- Answer: D (4 Only)
Explanation:
Reference: Hardman, pp 556-559.
1.In opioid abuse, there is always a high degree of crosstolerance
to other drugs with a similar pharmacologic
action even if the chemical composition of the opioids is
totally different.
2.Tolerance develops at different rates to different effects
of opioids. Signifi cant tolerance develops to most of the
effects of narcotics, except for constipation and pinpoint
pupils, to which there is minimal tolerance.
3.Opioids reduce pain, aggression, and sexual drive.
4.With methadone, abrupt withdrawal causes a syndrome
that is qualitatively similar to that of morphine but is
longer and less intense, thus following the general rule that
a drug with a shorter duration of action produces a
shorter, more intense withdrawal syndrome.
5.The crimes associated with narcotic abuse are considered
to be motivated by the need to acquire the drug and not
from the effects of the drug per se.
Source: Stern - 2004
359
Q
- In evaluation of a work injury patient, the following
statements are accurate: - Maximum medical improvement is defi ned as a state
when the patient has been optimally treated, medically
and surgically, so that no further improvement is expected
in the condition or the patient’s function. - Permanent impairment is provided within 1 year after
the injury with or without maximum medical improvement. - Temporary impairment is not expected to last indefi -
nitely and there is no assignment of the rating for temporary
impairment. - Partial impairment implies that the entire body is impaired,
but rating is provided to only a portion of the
body.
A
- Answer: B (1 & 3)
Source: AMA Guides to the evaluation of Permanent
Impairment, 2001.
360
Q
- Engineering controls in Universal/Standard Precautions
in exposure prevention requires that: - Staff consultants engineer recommended protocols for
waste disposal - Develop mechanical biosafety protocols
- Develop and build a waste station
- Assist in device management such as disposable needle
precaution systems, and waste containment devices
A
- Answer: C (2 & 4)
Source: Hans C. Hansen, MD
361
Q
2281.True statements concerning carbon monoxide (CO)
poisoning include
1. blood gases show normal PaCO2 and PaO2 , metabolic
acidosis, and low oxygen saturations of hemoglobin
2. hypoxia is caused by the strong affi nity of CO for hemoglobin
3. tissue hypoxia is caused by a shift to the left of the oxygen
dissociation curve by carboxyhemoglobin
4. there is a direct toxic effect on aerobic metabolic pathways
A
- Answer: E (All)
Explanation:
(Miller, 4/e, pp 2431-2432.)
Carbon monoxide poisoning is the most common cause
death in people involved in fi res. One must have a high
index of suspicion for CO poisoning. Treatment is with
100% oxygen or hyperbaric oxygen if available. An arterial
blood gas will also give a carboxyhemoglobin level that
will be helpful with the diagnosis. Patients with severe CO
poisoning do not hypervnetilate in response to metabolic
acidosis. CO diffuses into cells, binding to myoglobin and
cytochromes. This may be why measured levels of COHb
do not always correlate with the severity of the clinical
presentation.
Source: Curry S
362
Q
2282.True statements with regards to perioperative pain
management in opioid-tolerant patients including the
following:
1. During the intraoperative phase, maintain baseline
opioids
2. Increase intraoperative and postoperative opioid dose to
compensate for tolerance
3. In the postoperative period, use patient-controlled
analgesia
4. In the postoperative period, you should not provide any
opioids other than baseline opioids
A
- Answer: A (1, 2, & 3)
363
Q
- When terminating a patient it is suggested that:
- The physician confronts the patient regarding non-compliance,
and document in the chart. - In cases of non-payment, it should be elaborated to the
patient that services rendered require service payment. - Recommended that the patient not be provoked, withholding
specifi cs, that might lead to misunderstanding,
and discharge from the practice. - Defi ne in patient friendly terminology of policies and
procedures to avoid patient confusion when confronted.
A
- Answer: C (2 & 4)
Explanation:
Experts and risk managers have some disagreement about
this point, but agree that non-compliance should be
documented in the chart. Putting too many specifi cs into
the discharge letter might allow for a patient to formulate
a
debate, or allege inappropriate discharge. Better put, “the
patient-physician relationship based on trust and
compliance has eroded, and therefore I must withdraw as
your physician”. The exact reason for discharge may
ultimately avoid confusion, but the termination letter
should not be written to evoke anger.
Source: Hans C. Hansen, MD
364
Q
2284.Identify the true statements in reference to work
hardening programs.
1. Work hardening is a highly structured, goal oriented, individualized
treatment program designed to maximize
ability to return to work.
2. Work hardening provides a transition between acute
care and return to work and addresses the issues of
productivity, physical tolerance, etc.
3. Indications for work hardening program include signifi -
cant impairment that prohibits a safe return to work.
4. Major psychological or behavioral dysfunction is an
indication for work hardening.
A
- Answer: A (1, 2, & 3)
Explanation:
Explanation: - Work hardening is a highly structured, goal oriented,
individualized treatment program designed to maximize
ability to return to work.
Work hardening programs are interdisciplinary and use
conditioning tasks that are graded for progressive
improvement of the injured worker’s biomechanical,
neuromuscular, cardiovascular, metabolic, and
psychological function by using a series of real or
simulated work activities. - Work hardening provides a transition between acute
care and return-to-work and addresses the issues of
productivity, safety, physical tolerance, and behavior.
·Emphasis is placed is placed on job-specifi c simulation
activities with the goal of returning an injured worker to
the workplace. - Indications include:
Signifi cant impairment that prohibits a safe return to
work
To return safely to regular or modifi ed duty
Contraindications include:
Major psychological or behavior dysfunction
Incomplete medical work up or treatment
Serious health risks that may outweigh benefi t of the
program
365
Q
- Identify accurate statements describing the difference
between fraud and abuse? - Fraud involves deliberate deception used to get money
from Medicare that a provider is not owed. - There is no difference between fraud and abuse.
- Abuse involves errors caused by mistakes or aggressive
billing or coding inconsistent with accepted practices
that result in a loss of Medicare funds. - Fraud results in overpayments to a provider $100,000
or more, in contrast to abuse which results in overpayments of $10 to $99,999.
A
- Answer: B (1 & 3)
Source: Laxmaiah Manchikanti, MD
366
Q
- Which of the following can result in the imposition of
civil money penalties? - Upcoding.
- Billing a service as “incident to” a physician’s service if
the physician falsely represented to the patient that he/
she was certifi ed by a medical specialty board. - Routinely waiving co-payments for Medicare recipients.
- Being convicted of a misdemeanor relating to the prescription
of controlled substances.
A
- Answer: A (1, 2 & 3 )
Explanation:
1)Civil money penalties may be imposed for knowingly
fi ling claims for services that were not provided as
claimed. See 42 U.S.C. § 1328a-7a(a)(1).
2) Billing a service as “incident to”a physician’s service if
the physician falsely represented to the patient that he/she
was certifi ed by a medical specialty board may result in the
imposition of civil money penalties. See 42 U.S.C. §
1328a-7a(a)(1).
3)Routinely waiving co-payments for Medicare recipients
may result in a civil money penalty under 42 U.S.C. §
1320a-7a(i)(6)(A).
4)Being convicted of a misdemeanor relating to the
prescription of controlled substances can lead to exclusion
from federal health care programs, but is not a basis for
imposing a civil money penalty.
Source: Health Care Fraud and Abuse: Practical
Perspectives, Linda A. Baumann ed. (American Bar
Association 2002).
Source: Erin Brisbay McMahon, JD
367
Q
- Why does the Federal Anti-Kickback Law prohibit
referrals for remuneration? - It can distort medical decision making.
- It can cause a reutilization of services or supplies.
- It can increase costs to federal healthcare programs.
- It can result in unfair competition by shutting out competitors
who are unwilling to pay for referrals.
A
- Answer: E (All)
Explanation:
The federal government lists all of the above as problems
that can result from referrals for remuneration.
Source:65 Fed. Reg. at 59940.
Source: Erin Brisbay McMahon, JD
368
Q
2288.This question contains four suggested responses of
which one or more is correct.
1. If a group practice recruits a physician with an income
guarantee from a hospital, a written agreement signed
by the hospital, the group practice, and the physician is
required to meet a Stark law exception
2. If a group practice recruits a physician with an income
guarantee from a hospital, the income guarantee cannot
be conditioned on the recruit making referrals to
the hospital
3. If a group practice recruits a physician with an income
guarantee from a hospital, the income guarantee must
be for the purpose of inducing the physician to relocate.
4. A group practice that recruits a physician with an income
guarantee from a hospital can require the physician
to sign a covenant not to compete.
A
- Answer: A (1, 2 & 3)
Explanation:
A group practice that recruits a physician with an income
guarantee from a hospital cannot require the physician to
sign a covenant not to compete.
Source: 42 USC §1395nn(e)
Source: Erin Brisbay McMahon, JD
369
Q
- Choose correct statements in reference to exclusion:
- A health care provider may knowingly employ an excluded
person when the excluded person’s job does not
involve providing or billing for services reimbursed by a
federal health care program - A provider with a felony conviction relating to a controlled
substance is subject to mandatory exclusion - The minimum length of time for mandatory exclusion
is 10-15 years - The Balance Budget Act enacted a three strikes – you are
out provision
A
- Answer: C (2 & 4)
Explanation: - If a provider employs, contracts or enters into an
arrangement with an individual or company that the
provider “knows or should know” is excluded from
Medicare or Medicaid, the provider is liable for a civil
money penalty of up to $10,000. - Individual or companies must be excluded under the
following circumstances.
¨A criminal offense conviction related to items or services
covered by Medicare or Medicaid.
¨A criminal offense conviction relating to patient abuse or
neglect (the patient doesn’t have to be a Medicare or
Medicaid benefi ciary).
¨A felony conviction related to health care fraud or “anyact
of omission” under Medicare, Medicaid, or other health
care program fi nanced in whole or in part by federal, state
or local governments. The felonies include fraud, theft,
embezzlement and breach of fi duciary responsibility.
¨A felony conviction relating to controlled substances,
including unlawful manufacture, distribution, prescription
or dispensing of a controlled substance.
A person or company is considered to be convicted when
any of the following has happened.
¨A conviction has been entered against an individual or
company by a federal, state or local court, regardless of
whether there’s a post-trial motion or appeal pending, or
whether conviction or other record of the criminal
conduct has been expunged or removed.
¨A federal, state or local court has made a fi nding of guilt
against an individual or company.
¨A federal, state or local court has accepted a guilty please
or a plea of nolo contendere by an individual or company.
¨An individual or company has entered into participation
in a fi rst offender, deferred adjudication or other program
or arrangement where the conviction has been withheld. - For offenses requiring mandatory exclusion, the
minimum period is fi ve years, with one exception: In the
case of providers convicted of program-related crimes,
HHS can waive the exclusion of a company or individual
that is either a sole community physician or the sole source
of essential specialized services in a community. - The Balanced Budget Act of 1997 included a threestrikes-
and-you’re-out provision, under which an
individual convicted on one previous occasion of one or
more exclusion offenses will be excluded from Medicare
or Medicaid for at least 10 years, and a person convicted
ontwo or more previous occasions of one or more
exclusion offenses will be permanently excluded.
370
Q
- Which of the following is a requirement for the rental of
space or equipment exception under the Stark law? - The rental must be documented by a signed written
agreement - The rental must have a term of at least one year
- The rent is for fair market value.
- The rent does not vary with the volume or value of
referrals
A
- Answer: E (All)
Explanation:
All four of the above are requirements for the rental of
space or equipment exception under the Stark law.
Source: 42 USC §1395nn(e)
Source: Erin Brisbay McMahon, JD
371
Q
- The following statement or statements accurately refl ect
duties and actions of carriers and fi scal intermediaries. - When they suspect fraud that involves sensitive issues or
that may get widespread publicity they alert the Department
of Justice - A carrier or fi scal intermediary have to notify a provider
if it’s going to suspend payments to the provider; except
when they fi nd reliable evidence of fraud or willful misrepresentation - A carrier or fi scal intermediary may exclude a provider
from participation in Medicare, Medicare, or other federally
funded health care program - When the HHS Offi ce of Inspector General (OIG) receives
a recommendation for a sanction from a carrier
or fi scal intermediary; OIG develops a proposal and
sends it to the affected provider(s)
A
- Answer: C (2 & 4)
372
Q
- The income statement is done monthly and captures:
- Revenue
- Expenses
- Net Income
- Assets
A
- Answer: A (1,2, & 3)
Explanation:
Income Statement includes the Revenue less the Expenses
which leaves the Net Income. The income statement is a
snap shot taken at a moment in time – usually monthly.
Source: Trent Roark,MBA
373
Q
2293. True statements regarding employee indemnity benefi ts in compensation system include: 1. Wage continuance benefi ts 2. Termination of temporary benefi ts 3. Permanency awards 4. Death benefi ts
A
- Answer: E (All)
374
Q
- True statements based on the Controlled Substances Act
and State Board of Medical Licensure: - A physician may prescribe all scheduled drugs to family
members. - A physician cannot prescribe Schedule II or III for family
members. - A physician may provide samples and prescriptions of
any drugs to a person in a sexual relationship. - A physician cannot provide controlled substances to
anyone, including friends, if documentation of H & P
and current medical condition is not available.
A
- Answer: C (2 & 4)
Explanation:
The following rules must be followed in prescribing
controlled substances based on State Board of Licensure
Rules and Regulations.
(1)A physician may not prescribe any scheduled drugs to
family members.
(2)A physician cannot prescribe Schedule II or III for
family members.
(3)A physician may not provide samples and prescriptions
of any drugs to a person in a sexual relationship.
(4)A physician cannot provide controlled substances to
anyone, including friends, if documentation of H & P and
current medical condition is not available.
State Board Rules:Cannot Rx Schedule II or III for family
members
Can provide samples of unscheduled drugs for family,
but MUST document in a medical record
Cannot Rx for anyone in sexual relationship, EVER.
Cannot Rx for yourself, EVER.
Cannot Rx to anyone (including friends) if you have not
documented their H&P and have a current chart on fi le.
375
Q
- When considering an electronic medical record in an
Ambulatory Surgery Center, the risk-reward benefi t
favors an electronic environment. An electronic medical
record would be expected to: - Increase quality and productivity
- Enhance compliance
- Improve physician compliance and decrease variability
in documentation - Improve reimbursement
A
- Answer: A (1,2, & 3)
Explanation:
Reimbursement at the ASC is set by CPT guidelines, and
should not necessarily be affected by the EMR. EMR in the
offi ce setting improves documentation for specifi c
evaluation and management codes, and improves
diagnostic considerations. The Ambulatory Surgery
Center will best utilize an EMR to improve
communication, and to enhance inter-physician
communication. The EMR should also help the
Ambulatory Surgery Center document procedures, and
improve the medico-legal risk of documentation deletions
or errors.
Source: Hans C. Hansen, MD
376
Q
- Accurate statements describing interventional procedure
documentation are: - Procedural documentation in an offi ce includes only the
procedure and discharge - Procedural documentation in an offi ce includes medical
necessity and procedure. - Documentation for an offi ce procedure requires H & P,
medical necessity and procedure. - Documentation of a procedure in a facility requires H &
P, medical necessity and procedure.
A
2296. Answer: C (2 & 4) Explanation: INTERVENTIONAL PROCEDURE DOCUMENTATION 1. History & Physical 2. Medical necessity 3. Procedure FACILITY Requires 3 of 3 OFFICE Requires 2 of 3
377
Q
- Components of documentation of a procedure include:
- Preoperative: informed consent, discussion and plan,
preparation - Intraoperative: monitoring, preparation, description
- Postoperative: monitoring, complications
- Discharge/Disposition: Status, instructions, return appointment
A
- Answer: E (All)
Explanation:
DOCUMENTATION OF PROCEDURE
PREOPERATIVE: Informed consent, discussion and plan,
preparation
INTRAOPERATIVE: Monitoring, preparation, sedation,
position, description
POSTOPERATIVE: Monitoring, complications
DISCHARGE/DISPOSITION: Status, instructions, return
appointment
378
Q
- Principles of development quality clinical policies
include the following: - Evidence-based approach
- Standardized criteria for assessing literature
- Defi ned process for development
- Levels of strength of recommendations
A
- Answer: E (All)
Explanation:
Principles of Quality Clinical Policies include the
following:
Evidence-based approach
Consensus with disclosure
Defi ned process for development
Standardized criteria for assessing literature
Levels of strength of recommendations
Identify participants
Incorporation societal/ethcial/cost issues
379
Q
- What are the documentation guidelines for physical
examination? - Level 1 - Problem Focused visit requires a limited exam
of affected body area with documentation of 1-5 elements
in one or more area(s)/systems(s) - Level 2 - Expanded Problem Focused - Limited visit
requirements include exam of affected body area and
other symptomatic or related organ systems with
documentation of 6 elements in one or more area(s)/
systems. - Level 3 - Detailed Extended - Detailed visit requirements
include exam of affected body area and other symptomatic
or related organ systems with documentation
of at least 2 elements from each of 6 area(s)/system(s)
or at least 12 elements in 2 or more are - Level 4 & 5 - Comprehensive visit requirements encompass
documentation of at least 18 elements from at least
9 area(s)/system(s).
A
- Answer: E (All)
Explanation:
LEVEL 1 - PROBLEM FOCUSED
Limited Exam of Affected Body Area.
1-5 Elements in one or more area(s)/systems(s)
LEVEL 2 -EXPANDED PROBLEM FOCUSED -LIMITED
Exam of affected body area and other symptomatic or
related organ systems.
6 Elements in one or more area(s)/systems.
LEVEL 3- DETAILED EXTENDED - DETAILED
Exam of Affected Body Area and other symptomatic or
related organ systems.
At least 2 elements from each of 6 area(s)/system(s)
OR
At least 12 elements in 2 or more area(s)/system(s)
LEVEL 4 & 5 - COMPREHENSIVE
At least 18 Elements from at least 9 area(s)/system(s).
380
Q
- Which of the following statements about alcohol
metabolism are correct? - In the liver, alcohol is metabolized to acetic acid
- When exposed to air, alcohol is broken down to acetic
acid - Disulfi ram blocks the enzymatic breakdown to acetic
acid - A large proportion of alcohol ingested is expered in the
breath
A
- Answer: A (1, 2, & 3)
Explanation:
Alchol metabolism and excretion begin immediately after
absorption. Kidneys and lungs excrete about one-tenth of
the alcohol ingested unchanged, whereas the rest
undergoes a fairly constant rate of oxidation. The liver is
the main site for alcohol catabolism. Disulfi ram inhibits
the enzyme aldehyde dehydrogenase and alcohol ingestion
causes a toxic reaction due to the acetaldehyde
accumulation in the blood. Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
381
Q
- True statements about fraud and abuse include the
following: - Fraud is an intentional deception or misrepresentation
that the individual knows to be false. - Abuse is when physician does not believe to be true,
and physician makes knowing that the deception could
result in some unauthorized benefi t to himself/herself
or some other person. - Abuse is billing Medicare for services that are not covered.
- Fraud is coding incorrectly.
A
- Answer: B (1 & 3)
Explanation:
Fraud
- Intentional deception or misrepresentation that the
individual knows to be false or
- Does not believe to be true, and the individual makes
knowing that the deception
could result in some unauthorized benefi t to
himself/herself or some other person.
Abuse
- Billing Medicare for services that are not covered or
- Coding incorrectly.
Fraud = Felony
- Knowingly, willfully, and intentionally
- Deliberate miscoding
- False documentation
- Billing for services
- not provided
Abuse
- Unknowing and unintentional
Fraud as per HIPAA
. . . the term should know means that a person . .
(A)acts in deliberate ignorance of the truth or falsity of the
information;
or
(B) acts in reckless disregard of the truth or falsity of the
information, and no proof of specifi c intent to defraud is
required.
Abuse
- Most errors do not represent fraud
- Most errors are not knowing, willful, and intentional.
Fraud
- High error rate
- Repeated submission of claims with errors
- Failure to follow plan of correction
382
Q
- This question contains four suggested responses of
which one or more is correct. Select: - Developing a mechanism for responding to and correcting
identifi ed problems is important in developing
a corrective action plan - Developing warning indicators is important in developing
a corrective action plan - Open door policies are important in implementing a
compliance plan - Sanction policies are not required for an effective compliance
plan
A
2302. Answer: A (1, 2 & 3) Explanation: A sanction policy is necessary in order for employees to take the compliance plan seriously. Source: 65 Fed. Reg. at 59,444 Source: Erin Brisbay McMahon, JD
383
Q
- Medical decision making involves multiple components.
The following are involved in medical decision making. - Risk of signifi cant complications, morbidity, mortality
- Risks associated with presenting problems, diagnostic
procedures, management options - Review of records and investigations
- Comprehensive physical examination
A
- Answer: A (1, 2, & 3)
384
Q
- A 26-year old male hurt his back while lifting a large,
heavy box. He described the pain as being in the
lumbosacral region. Examination shortly after the injury
was normal, except for a slight decrease in lumbar motion
due to pain, and mild paravertebral tenderness. He was
off work for 3 days and then returned and continued to
work. However, he continued to have occasional soreness
in the low back with heavy lifting. He denied any leg
pain or numbness. Physical examination continued to
be normal. Identify the accurate statements with his
impairment rating. - The diagnosis is lumbar strain
- The diagnosis is lumbar disc herniation
- Impairment rating is 0% impairment of the whole
person - 10% impairment of the whole person
A
- Answer: B (1 & 3)
385
Q
- The following statements regarding partial agonists are
true - the slope of the dose-response curve is less steep than
that of a full agonist - the dose-response curve has no limit
- concomitant administration of a partial and a full agonist
can antagonize the effect of the full agonist - the agent can act as an agonist at one receptor and an
antagonist at another simultaneously
A
- Answer: D (4 Only)
Explanation:
Partial agonists exhibit certain characteristic
pharmacologic properties:
(1) the slope of the dose-response curve is less steep than
that of a full agonist;
(2) the dose response curve exhibits a ceiling effect (i.e., a
submaximal response as compared with that of a full
agonist); and
(3) concomitant administration of a partial and a full
agonist can reduce (antagonize) the effect of the full
agonist.
(4) Mixed agonist-antagonists act simultaneously as an
agonist at one receptor and an antagonist at another.
386
Q
- Which of the following statements about daily, heavy
marijuana users are correct? - Decrease in tachycardia caused by marijuana
- Detectable in urine 2-3 weeks after stopping
- Reduced mood elevation effect
- Reduced need to continue marijuana use
A
- Answer: A (1, 2, & 3)
Explanation:
Heavy marijuana users have an “amotivational syndrome,”
characterized by passivity, decreased drive, diminished
goal-directed activity, decreased memory, fatigue, apathy,
and poor problem solving. Physiological changes consist
of an increased heart rate, blood pressure (therefore
problems with those who have cardiovascular diseases),
and chronic obstructive lung disorders. Cannabinoids can
be detected in urine up to 21 days after stopping in chronic
users, due to redistribution in fat, but are usually detected
from one to fi ve days in occasional users.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
387
Q
- The Sharps Injury Log is established to record
subcutaneous injuries from contaminated objects or
from contaminated items. The log will contain: - Type and brand of inflicting item
- A complete explanation of incident
- The exposure incident location
- Then length and gauge
A
- Answer: A (1, 2 & 3 )
Source: Hans C. Hansen, MD
388
Q
- When an employee is involved in a minor contact with
blood or body fl uids the employee may: - Administer their own fi rst aid
- Dispose of the material in a plastic lined container or
toilet - Allowed cleansing and covering of the injury
- Required to seek immediate medical care.
A
- Answer: A (1, 2 & 3 )
Source: Hans C. Hansen, MD
389
Q
- The Hepatitis B vaccination (HBV) is:
- Offered to all employees
- Non required for employees with no positive serology
- Refused by an employee, if the employee desire.
- Required only in employees that are in immediate contact
with patients
A
- Answer: A (1, 2 & 3 )
Source: Hans C. Hansen, MD
390
Q
2310.Which of the following statements are applicable to
alcohol idiosyncratic intoxication?
1. Amnesia for time of intoxication
2. Behavioral changes usually last several days
3. Occurs within minutes of drinking
4. Hallucatinations occur in stat of clear consciousness
A
- Answer: B (1 & 3)
Explanation:
Alcohol idiosyncratic intoxication, also known as
“pathological intoxication,” is manifested by the sudden
onset of marked behavior changes after consumption of a
small amount of alcohol: these symptoms usually last for
a few hours, terminate in prolonged sleep, and the
individual is able to recall the episode. There can be blind,
unfocused, assaultive behavior, as well as suicidal ideation
and attempts.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
391
Q
- OSHA training is considered:
- Voluntary
- Mandatory for full-time employees only
- Congruent to the individual practice
- Necessary employment requirement for full time and
part time employees
A
- Answer: D (4 only)
Explanation:
OSHA training is considered mandatory and the employer
can be fi ned if adherence is not followed. Refresher
courses are suggested annually, or when a serious violation
occurs, or when a major change in OSHA statutes is
placed.
OSHA training, and familiarity with Blood Borne
pathogens in particular, is important to the pain management practitioner. Failure to follow this directive
may lead to expensive and cumbersome fi nes and
sanctions. OSHA training is included for all members of
the practice, or those that might be in contact with a risk
environment. This includes independent contractors, and
full-time, part-time or leased employees.
Source: Hans C. Hansen, MD
392
Q
- The following statements are true with relation to routine
drug screens and their detectability. The following drugs
may not be detected in routine urine drug screens: - Methadone
- Fentanyl
- Oxycodone
- Morphine
A
- Answer: A (1, 2, & 3)
393
Q
- Intervals for OSHA training are required at:
- Hiring
- With changes in regulatory statutes
- Annual thereafter
- When a violation occurs
A
- Answer: A (1, 2 & 3 )
Explanation:
OSHA training is required at hiring, and suggested
annually thereafter, and is a part of an active compliance
environment. A major event does not necessarily refl ect
poor training,but should reveal an appropriate response in
policies and procedures within the practice. Incidents will
occur, and the employee/owner is ready.
Source: Hans C. Hansen, MD
394
Q
- Appropriate therapy for alcohol withdrawal includes the
administration of the following medications: - Diazepam
- Clonidine
- Lorazepam
- Buprenorphine
A
- Answer: B (1 & 3)
Explanation:
1 & 3. Diazepam and Lorazepam are long-acting
benzodiazepines are the most commonly administered
medications to prevent the onset of potentially lethal
delirium tremens during abstinence from alcohol.
Dosages should be high enough to prevent symptoms of
delirium tremens and should be tapered slowly as the
patient undergoes detoxifi cation in a setting that provides
psychological and social support to the recovering
alcoholic. Lorazepam and diazepam are long-acting
benzodiazepines.
2 & 4. Clonidine and buprenorphine have been used in
opioid detoxifi cation programs.
(Savage, J Pain Symptom Management 1993; 8:265-278)
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
395
Q
- HHS Offi ce of Inspector General (OIG) may exclude
individuals or companies from participation in federal
health care program: - If convicted of certain misdemeanors
- Convicted of any misdemeanor offense related to controlled
substances - If they refuse to permit examination or duplication of records that OIG states are needed to determine if reimbursement
was due - If whistleblower suits are brought by employees, former
employees, or anyone
A
- Answer: A (1, 2, & 3)
Explanation: - OIG can exclude individuals or companies if they have
been convicted of the following violations:
A misdemeanor for fraud, theft embezzlement, breach of
fi duciary responsibility or other fi nancial misconduct
related to either:
Health care items or services
Act or omissions under any health care program fi nanced
by federal, state or local governments other than Medicare
or Medicaid (which are covered under mandatory
exclusions).
A criminal offense for fraud, theft,embezzlement,breach of
fi duciary responsibility or other fi nancial misconduct
related to an act or omission in any non-health care
program fi nanced by federal, state or local governments.
Length of exclusion: Three years, unless there are
aggravating or mitigating factors, in which case the
exclusion period may be increased or decreased.
Aggravating Factors:
The acts caused a loss of $1,500 or more to thegovernment
or other entities, or had a “signifi cant fi nancial impact” to
patients or others.
The acts were committed over a period of one year or
more.
The acts had a signifi cant adverse physical or mental
impact on patients or others.
The court sentence included prison time.
The convicted individual had a prior record of criminal,
civil or administrative actions.
Mitigating Factors:
The individual or company was convicted of three or fewer
misdemeanors, and the loss to Medicare or Medicaid was
less than $1,500.
The court found that the individual had a mental, physical
or emotional condition that reduced his or her culpability.
Cooperation by the individual or company with federal or
state offi cials resulted in others being convicted or
excluded from Medicare, Medicaid or any other federal
health care program or the imposition of a civil money
penalty or assessment against anyone.
Alternative sources of the type of health care items or
services provided by the individual or company aren’t
available. - OIG can exclude individuals or companies if they are
convicted of a criminal offense related to the unlawful
manufacture, distribution, prescription or dispensing of a
controlled substance.
Length of exclusion: Three years, unless there are
aggravating or mitigating factors, in which case the
exclusion period may be increased or decreased.
Aggravating factors:
The acts were committed over a period of one year or
more.
The acts had a signifi cant adverse physical or mental
impact on patients or others.
The court sentence included prison time.
The convicted individual had a prior record of criminal,
civil or administrative actions.
Mitigating factors:
Cooperation by the individual or company with federal or
state offi cials resulted in others being convicted or excluded from Medicare, Medicaid or any other federal
health care program or the imposition of a civil money
penalty or assessment against anyone.
Alternative sources of the type of health care items or
services provided by the individual or company aren’t
available. - OIG can exclude any individual or company that fails to
supply Medicare or Medicaid with payment information
necessary to determine whether the payments were due, or
that refuses to permit examination or duplication or
records needed to verify payments.
Length of exclusion: OIG must consider the following
factors in determining the exclusion period:
Number of times information was provided
Circumstances under which the information was provided
Amount of payment at issue
Individual or company’s prior record of criminal, civil or
administrative sanction (the lack of a record is considered
neutral).
Availability of alternative sources of the type of health care
items or services provided by the individual or company. - Civil actions for false claims or whistleblower lawsuits
– private citizens fi ling lawsuits on behalf of the
government and receiving a portion of any money
collected are authorized by the False Claims Act.
Whistleblower lawsuits are more formally known as qui
tam suits, the Latin name derived from an expression
meaning “who as well for the king as for himself sues in
this matters.
Whistleblower suits can be fi led by virtually anyone. The
whistleblower doesn’t even have to be an employee, but
could literally be “the guy on the street. While
whistleblowers can fi le suits by themselves, most go
through attorneys, given the various forms and procedures
that must be followed. The suits are fi led with the U.S.
District Court in whatever region they are located.
Whistleblower suits in themselves are not a cause for
exclusion.
396
Q
- Which of the following statements regarding Hepatitis
B vaccinations is true? - All employees with occupational exposure must receive
the hepatitis B vaccine and vaccination series. - The hepatitis B vaccine and vaccination series should be
provided at no cost to employees. - The hepatitis B vaccine must be provided within 10
calendar days of an employee’s initial assignment to a
position with occupational exposure. - The hepatitis B vaccine must be provided within 10
working days of an employee’s initial assignment to a
position with occupational exposure.
A
- Answer: C (2 & 4)
Explanation:
1) The regulations specifi cally provide that the hepatitis B
vaccine must be offered to all employees with occupational
exposures, but that the employee can decline to receive the
vaccine. In such an instance, the employee must sign a
Vaccine Declination form.
2) The vaccine, vaccine series and post-exposure followup
are to be made available to the employee at no cost.
3) The vaccine must be made available within 10 working
days of initial assignment to all employees who have
occupational exposure unless the employee has previously
received the complete hepatitis B vaccination series,
antibody testing has revealed that the employee is
immune, or the vaccine is contraindicated for medical
reasons.
4) See number 3) above.
Source: 29 CFR 1910.1030(f).
Source: Erin Brisbay McMahon, JD, Sep 2005
397
Q
- Which of the following statements about opioid
potencies are true? - The potency of hydromorphone to morphine is 5:1.
- The potency of morphine to hydrocodone is 10:1.
- The potency of levorphanol to morphine is 5:1.
- The potency of morphine to codeine is 10:1.
A
- Answer: B (1 & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
398
Q
- Which of the following practices can lead to problems
for physician groups? - A group practice bills for services performed by Dr.
Brown, who has not been issued a Medicare provider
number, using Dr. Adams’ Medicare provider number - Dressings and instruments were included in a fee for
a minor procedure, but the dressings were also billed
separately - A group practice has no system in place to screen for
National Correct Coding Initiative restrictions, coding
patterns, and groupings - A group practice relies on a bookkeeper with no training
in coding and billing to submit claims to Medicare.
They have provided the bookkeeper with a sheet of
commonly used codes with which to bill
A
- Answer: E (All)
Explanation:
All four of these practices can lead to false claims act
liability.
Source: 65 Fed. Reg. at 59439; CMS Manual System, Pub
100-04 Medicare Claims, Transmittal 563 at p. 2 (May 20,
2005).
Source: Erin Brisbay McMahon, JD
399
Q
- Which of these drugs are the most hydrophilic
- fentanyl
- morphine
- hydromorphone
- sufentanil
A
- Answer: D (4 Only)
Source: Lou Etal. Pain Practice: march 2001
400
Q
- This question contains four suggested responses of
which one or more is correct. Select: - Workstation use is an addressable physical safeguard
under the HIPAA Security Rule - Contingency operations is an addressable physical safeguard
under the HIPAA Security Rule - Audit controls are an addressable technical safeguard
under the HIPAA Security Rule - Automatic logoff is an addressable technical safeguard
under the HIPAA Security Rule
A
- Answer: C (2 & 4)
Explanation:
1)Workstation use is a required physical safeguard under
45 CFR 164.310.
2)This is a true statement. See 45 CFR 164.310.
3)Audit controls are required technically safeguard under
the HIPAA Security Rule. See 45 CFR 164.312.
4)This is a true statement under 45 CFR 164.312.
Source: 45 CFR 164.310-.312
Source: Erin Brisbay McMahon, JD
401
Q
- Which of the following statements about the treatment
of chronic alcoholics are correct? - It is essential to face them with the physical consequences
of their drinking during the fi rst interview - It is necessary to discuss frankly the patient’s drinking
patterns when initially interviewed - Family history of alcoholism is irrelevant in the individual
treatment prognosis - The alcoholic’s denial often makes the patient unavailable
for treatment
A
- Answer: C (2 & 4)
Explanation:
Treatment of chronic alcoholics is the treatment of a
chronic relapsing illness. A nonjudgmental approach
needs to be used towards slips, drinking patterns, and the
patient’s denial. Education and treatment of the family are
essential. Emphasis on support groups, self-help aspects
of treatment, especially AA’s 12-step program, aids
resocialization and acceptance of an identity as a
recovering person.
Treatment of underlying psychiatric disorders is
important. About two-thirds of chronic alcoholics have
additional psychiatric problems such as depression,
anxiety disorder, and attention defi cit. Those alcoholic
patients with a primary or secondary psychiatric illness
have an increased suicide rate compared with those who
do not hae any additional psychiatric diagnosis.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
402
Q
- Select the accurate statements?
- A local nursing home, hires a consulting fi rm to put
together a defense in an elder abuse case. An attorney
engaged for this purpose would be considered a business
associate and an agreement is required. - Ambulatory Surgery Centers, Inc. discloses PHI to a
health plan for payment purposes. A business associate
agreement is not required. - A medical malpractice insurer is given PHI by an insured
to provide a malpractice risk assessment of a case. An
attorney engaged for this purpose would be considered
a business associate and an agreement is required. - None of these entities are considered business associates.
A
- Answer: A (1,2, & 3)
Explanation: - A local nursing home, hires a consulting fi rm to put
together a defense in an elder abuse case. Yes, an attorney
engaged for this purpose would be considered a business associate and an agreement is required. - Ambulatory Surgery Centers, Inc. discloses PHI to a
health plan for payment purposes. No, this disclosure is
for the benefi t of the health plan, not the covered entity,
and therefore a business associate agreement is not
required. - A medical malpractice insurer is given PHI by an
insured to provide a malpractice risk assessment of a case.
Yes, an attorney engaged for this purpose would be
considered a business associate and an agreement is
required. - Entities described in 1 & 3 are considered business
associates.
Source: Laxmaiah Manchikanti, MD
403
Q
- The following statements are true with regards to
physical dependence. - It is interchangeable with DSM-IV defi nitions of substance
abuse and dependence. - The defi nition meets the criteria for addiction defi nition
by the Controlled Substances Act. - It encompasses loss of control, craving, compulsive use,
and continued use despite consequences. - It is a state of adaptation manifested by a withdrawal
syndrome produced by abrupt cessation or rapid dose
reduction.
A
- Answer: D (4 Only)
Explanation:
Physical Dependence:A state of adaptation manifested by a
withdrawal syndrome produced by abrupt cessation, rapid
dose reduction, decreasing blood levels of a drug or
administration of an antagonist
DSM-IV defi nition for substance dependence is as follows:
¨Tolerance
¨Withdrawal
¨Larger Amounts/Longer periods
¨Efforts or desire to cut down
¨Large Amount of time using/obtaining/recovering
¨Activities given up: social/work/recreation
¨Continued use despite problems
¨Need 3 of above in 12 months
An alternate defi nition from the American Society of
Addiction Medicine for addiction is as follows:
¨Addiction
A primary, chronic neurobiologic disease with genetic,
psychosocial and environmental factors effecting its course
and presentation
Characterized by one or more of the following
·Impaired control of drug use
·Compulsive use
·Craving
·Continued use despite harm
The 4 Cs of addiction are as follows:
¨Loss of Control
¨Craving
¨Compulsive Use
¨Continued use despite consequences
404
Q
2324.True statements regarding worker’s compensation
include:
1. Medical expenses are paid.
2. There is monetary compensation for pain and suffering.
3. There is compensation for lost wages.
4. Fault or negligence of the employer must be established.
A
- Answer: B (1 & 3)
Explanation: - Worker’s compensation provides injured workers with
funds to cover medical expenses and lost wages.
It does not, however, totally replace lost income.
A totally disabled worker will receive approximately
two-thirds of his average weekly wage. - There is no compensation for pain and suffering.
- There is compensation for lost wages.
- There is not any determination of fault or negligence
on the part of the employer or the worker.
Source: AMA Guides to the evaluation of Permanent
Impairment, 2001.
405
Q
- A 34-year old male was evaluated for back and lower
extremity pain which started following a twisting injury
in a fl exed position during lifting. He had a positive
straight leg raising test, Achilles tendon refl ex separation,
and sensory defi cit. Treatment with physical therapy
and transforaminal epidural steroid injection failed to
provide any signifi cant improvement. He underwent
surgical discectomy. He improved and returned to work
without restrictions after rehabilitation after 6 months of
injury. He has no pain at rest or numbness in the lower
extremities. He was able to do almost all activities of daily
living but complained of back pain with heavy lifting.
The following are true statements. - His diagnosis is herniated disc with radiculopathy, resolved
after discectomy. - Due to discectomy, his impairment is greater than without
discectomy. - He is entitled to 10% impairment of the whole person.
- He is entitled to 20% impairment of the whole person.
A
- Answer: A (1, 2, & 3)
406
Q
2326. The medications which could be used as treatment for opioid withdrawal include the following: 1. Clonidine 2. Diphenylhydantoin 3. Buprenorphine 4. Phenobarbital
A
- Answer: B (1 & 3)
Explanation: - Clonidine, an alpha-adrenergic agonist, and
buprenorphine, a mixed agonist-antagonist opioid, have
been used to successfully treat the symptoms of opioid
withdrawal.
Clonidine should be administered around the clock in a
tapered protocol over the fi rst 7 days of withdrawal.
Hydroxyzine, dicyclomine, and triazolam may be helpful
as well. - Diphenylhydantoin and phenobarbital are not generally
used in opioid withdrawal. - Buprenorphine is given in a tapered regimen, every 4 h
over the fi rst 6 days of withdrawal. However, a physician
will need a separate approval from the DEA to do this. - Diphenylhydantoin and phenobarbital are not generally
used in opioid withdrawal.
407
Q
- Which of the following include the seven common
elements that the HHS Offi ce of Inspector General (OIG)
strongly encourages providers to have in a comprehensive
compliance program? - Written standards of conduct
- Hotline for complaints
- Disciplinary procedures
- Procedures to prevent qui tam law suits
A
- Answer: A (1, 2, & 3)
Explanation:
At a minimum, comprehensive compliance programs
should include the following seven elements:
¨Written standards of conduct, policies and procedures
that promote the company’s commitment to compliance
(for example, by including adherence to the compliance
program as an element in evaluating managers and
employees) and that address such specifi c areas ofpotential
fraud as the claims submission process, code gaming and
fi nancial relationships with providers.
¨Designating a compliance offi cer and other appropriate
high-level corporate structures (for example, a corporate
compliance committee that operates and monitors the
compliance program and reports directly to the CEO and
the governing body. (Important: Structure the compliance
program so it accomplishes the key functions of a
corporate compliance offi cer and a corporate compliance
committee).
¨Compliance training and education program for all
affected employees. They should be detailed and
comprehensive, covering specifi c procedures, as well as
the general areas of compliance.
¨Communication. Maintaining a hotline to receive
complaints and the adoption of procedures to protect the
anonymity of complainants and protect callers from
retaliation.
¨Auditing and monitoring or other risk-evaluation
techniques to monitor compliance and assist in the
reduction of identifi ed problem areas.
¨Disciplinary procedures and development of policies
addressing the non-employment of sanctioned
individuals.
¨Corrective actions to enforce appropriate disciplinary
action against employees who violate laws, regulations,
guidelines or company policies.
The elements are a guide that can be tailored to fi t the
needs and fi nancial realities of a particular billing
company, large or small, regardless of the type of services
offered.
408
Q
2328. What are the consequences of a violation of the Stark Law?: 1. Civil monetary penalties 2. Repayment of all affected claims 3. Exclusion from Medicare 4. Assessed up to 3 times of the money
A
- Answer: E (All)
Explanation: - Civil monetary, assessed and exclusion.
- Refunds. If a provider collects on a bill for a service that
was in violation of Stark, the provider must refund the
money within 60 days. - The physician may be excluded from the Medicare and
Medicaid programs. - Any provider presenting a claim or bill for a service that
the provider knows or should know is a violation or for
which a refund has not been made can be hit with a civil
monetary penalty of up to $15,000 for each service
claimed.
In addition, an assessment of up to three times the amount
of money may be required.
Other:
Violators of the Stark Law are subject to one or more of
the following sanctions:
Denial of payment. Medicare will deny payment for
services rendered in violation of Stark.
Civil monetary penalty and exclusion for circumvention
schemes.
This provision is intended to crack down on physicians
who enter into arrangements or schemes (such as crossreferral
arrangements) that they know or should know are
designed to get around the Stark prohibition.
Civil monetary penalty for failure to report information.
Any provider who fails to report required information to
Medicare or Medicaid is liable under the Stark law for
civil monetary penalty of up to $10,000 for each day the
information goes unreported.
409
Q
2329.Drs. Abbott and Costello are in a group practice and
they employ a nurse practitioner. Dr. Abbott implanted
a permanent tunneled catheter (90 day global) and a
programmable pump (90 day global) to control the pain
condition of a Medicare benefi ciary on March 17. On
March 30, when the patient returned for a post operative
check up, Dr. Abbott was on vacation and Dr. Costello did
the post operative check up and sent an encounter form
to billing to record the post-op visit. A new person in
the billing department reported Dr. Costello’s visit using
code 99213 and a diagnosis code of 722.83, which was the
condition reported for the March 17, surgery. Medicare
allowed $59.13 for Dr. Costello’s visit. The offi ce manager
should instruct the physicians and billing staff:
1. The group can increase its revenue if a different physician
or the nurse practitioner does the post-operative
follow-up visits within the global period since Medicare
allows payment when a different provider bills the
visit;
2. Instruct the providers that to prevent an overpayment
of this type, the person that sees a patient during a post
operative global period, should indicate on the encounter
form that there is no charge and that the encounter
should be recorded for records
3. The practice can keep the money since Medicare made
a mistake in paying the group for an E&M service for
same condition for which the procedure with a 90-day
global was performed.It isn’t groups fault that Medicare
doesn’t process its claim correctly
4. Provide in-service education to the billing/collection
staff relative to global days and refund Medicare because
the group is not entitled to payment;
A
- Answer: C (2 & 4)
Explanation:
Medicare’s payment rules relative to payment for group
practices are available on the CMS web site and providers
are expected know the payment rules. When in a group
practice, all physicians, in the same specialty, that reassign
payment to the group, are paid as a single physician. It
would be a deliberate intent to be paid for services that the
group is not entitled to be paid for if a different provider
performed post op care because the Medicare carrier did
not have its claim edits in place. When a provider knows
or should have known that money has been paid in error,
regardless of payer error, the provider is required to
return the money.
Sources: Source: Medicare Claims Processing Manual,
100-04 Chapter 12 Physicians/Nonphysician Practitioners
and OIG Compliance Program Guidance for individual
and Small Group Physician Practices (65 FR59434;
October 5, 2000)
Source: Joanne Mehmert, CPC
410
Q
- You are asked to consult on a patient who has end-stage
liver disease. The cirrhotic patient has severe pancreatitis,
and legitimate need of medication is met. The primary
care physician asks you to choose a medication for pain
control that will effectively treat pain, and have minimal
risk of toxicity to the patient. Furthermore, the patient
will be in a long-term care facility where the medications
are controlled by others. Choices for consideration
include: - Sustained release Morphine Sulfate, with immediate
release Morphine for breakthrough. - Timed release Oxycodone with immediate release Oxycodone
for breakthrough. - Hydromorphone prn.
- Hydrocodone
A
- Answer: A (1, 2 & 3 )
Explanation:
Hydrocodone requires liver participation in breakdown, and is believed that some of the bio-activity and pain relief
characteristics of hydrocodone are derived from
hydrocodone breakdown components, one being
hydromorphone. Oxycodone and Morphine have been
used in end-stage liver disease effectively, with the
understanding that there is no ideal drug. In Morphine’s
case, breakdown products, particularly glucuronides, may
accumulate, particularly if there is renal excretion issues.
These glucuronides may result in dysphoria. Oxycodone
has breakdown components as well, but is very well
tolerated, particularly in the elderly. Hydromorphone
again, has a long-standing safety profi le, and is tolerated
well by patients with liver disease, and is excreted
predictably. Each drug should be scrutinized by the
concept of elimination. The liver and kidneys are the two
principal organs of elimination, where the kidney is
responsible for the excretion of chemically unaltered drug.
The liver is the primary path of metabolism, but other
organs may also contribute after metabolism, therefore
explaining the effective elimination of a number of drugs
when liver function is poor.
Source: Hans C. Hansen, MD - Answer: B (1 & 3)
Explanation:
Impairment is a medical condition specifi cally related to a
disease process. It is expressed as a percentage of the body
as a whole and may be defi ned as the derangement or loss
of use of any body part, system, or function. Disability
relates to employment or activities of daily living and is
characterized as temporary, permanent, partial, or total
411
Q
- Impairment may be defi ned as:
- Derangement or loss of use of any body part, system,
or function. - The limiting, loss, or absence of the capacity of a person
to meet personal, social, or occupational demands. - A condition that relates to a disease process.
- A condition that relates to function relative to work or
other obligations
A
- Answer: B (1 & 3)
Explanation:
Impairment is a medical condition specifi cally related to a
disease process. It is expressed as a percentage of the body
as a whole and may be defi ned as the derangement or loss
of use of any body part, system, or function. Disability
relates to employment or activities of daily living and is
characterized as temporary, permanent, partial, or total
412
Q
- True statements regarding tolerance include
- it is characteristic of opioids as a class of drugs
- it cannot occur without physical dependence
- it is defi ned as requiring more drugs to produce the
same effect - it is synonymous with addiction
A
- Answer: B (1 & 3)
Source: Kahn and Desio
413
Q
2333.True statements about suggested guidelines for
administration of methadone are as follows:
1. Recovering opioid dependent patients enrolled in
maintenance programs should receive methadone daily
doses at the same time as usual.
2. The relationship between oral and parenteral methadone
is 2 is to 1.
3. Opioid dependent patients not enrolled in maintenance
programs should receive methadone 20 to 40 mg orally
every 24 hours or 1.25 to 2.5 mg intravenously every 5
to 10 minutes.
4. Recovering opioid dependent patients enrolled in maintenance
programs should receive double the dose of
methadone at the same time as usual.
A
- Answer: A (1, 2, & 3)
414
Q
- Which of the following statements are accurate?
- Voluntary Disclosure Program offers immunity to providers
who come forward within 30 days of discovering
an offence. - Providers must always repay all Medicare overpayments
within 30 days. - Health care providers in Medically Underserved Areas
(MUAs) may automatically waive coinsurance and deductible
payments. - Before the HHS Offi ce of Inspector General (OIG) may
issue a demand letter in a civil money penalty case, the
government must have legally suffi cient evidence for 8 elements of civil monetary penalties offense.
A
- Answer: D (4 only)
Explanation:
1.The Voluntary Disclosure Program is designed to allow
providers and others to come forward and admit health
care fraud in exchange for the possibility of lenient
treatment from the federal government. Providers already
under investigation for fraud can also come forward to
volunteer information. Making full disclosure to the
investigative agency at an early stage generally benefi ts the
individual or company, but there is no limit as to 30 days.
2.Normally, Medicare expects overpayments to be paid
back in 30 days after the fi rst demand letter. But if a lump
sum refund would cause severe fi nancial hardship, a
provider can apply for an extended repayment plan (either
through direct payments or deductions from theprovider’s
future payments). For Part B providers, here are the
deadlines a provider may face for making payments(MCM
7160) (MIM 2224):
$5,000 or less within 2 months
$5,001-$25,000 within 3 months
$25,001-$100,000 within 4 months
$100,001 and above within 6 months
3.Regardless of their location, doctors, durable medical
equipment (DME) suppliers and other Part B billers must
make a good faith effort to collect the deductible and
coinsurance payments owed by their Medicare patients
– or face reimbursement cuts from CMS and possible
Medicare suspension or exclusion. OIG sent out a Fraud
Alert in 1990 targeting physicians and other suppliers who
inappropriately waive co-payments or deductibles.
The government also could hold a provider liable under
the Anti-Kickback Statute because routinely forgiving copayments
or deductibles may be considered an improper
inducement for patients to buy Medicare items or services.
Government penalties for illegal waivers can include
imprisonment, criminal fi nes, civil damages and
forfeitures, fi nes and exclusion from Medicare and
Medicaid.
Typically, if providers make a reasonable collection effort
for coinsurance or deductibles, failure to collect payment
isn’t considered a reason for the carrier to reduce the
charge or refer the provider to OIG or the Justice
Department. A “reasonable collection effort” is one that is
consistent with the effort a doctor’s offi ce typically makes
to collect co-payments and deductibles. It must involve
billing the patient and may include subsequent billings,
collection letters, telephone calls or personal contacts,
depending on the provider’s usual practice. These efforts
must be genuine, not token, collection efforts. A provider
should check to see whether its local carrier or
intermediary has defi ned a Fair Effort to Collect, for
instance, three bills in 120 days.
4.The HHS Offi ce of Inspector General (OIG) has
identifi ed eight elements of a civil money penalties offense:
Any person
Presents or causes to be presented
To the United States or an agent of the United States
A Claim
For an item or Service
Not provided as claimed
Which the person knows or has reason to know was not
provided as claimed
Materiality
Source: Manchikanti L, Board Review 2005
415
Q
2335.The 28-year-old male is sent to your offi ce for
evaluation and management of pain. The MRI reveals
modest facet disease in the cervical spine, and the
exam is unremarkable. His complaints are intractable
paracervical and suprascapular pain interfering with his
ability to work. He requests narcotics, Percocet® by name,
and when this is refused he states that he will report
you to the Medical Board because he will “go through
withdrawal” if not given his medication.Your correct
response is:
1. Discharge the patient and document aggressive behavior.
2. To prescribe Percocet® as legitimate medical need may
be argued
3. Develop a multimodality treatment course emphasizing
function and progressive analgesic, initiating with the
milder schedule for drug, such as CIV Darvocet®.
4. Treat the patient as any other with similar presenting
symptoms emphasizing function,and defi ning clear
legitimate medical need for controlled substances, irrespective
of a patient’s demands.
A
- Answer: D (4 Only)
Explanation:
It is recommended that patients who are focused on
controlled substances, particularly those that ask for
medications by name, be addressed from a risk
management perspective. Patients do not necessarily need
a controlled substance simply because the statement of
“pain” is made. Assessment of function and quality of life
indices is refl ected in the medical record. If controlled
substances are recommended, the schedule of the drug does not refl ect potency. The schedule suggests abuse
potential,and therefore, Darvocet® has the same
habituation potential as oxycodone, and is not necessarily
“milder”.
Source: Hans C. Hansen, MD
416
Q
- Hazardous chemicals require:
- Container labels
- Training as to appropriate response to spill and storage
- Material Safety Data Sheets, MSDS, referencing these
chemicals - Reinforced glass container
A
- Answer: A (1, 2 & 3 )
Explanation:
Hazardous chemicals require each of the above and an
antidote if available. These important safety items are
defi ned by OSHA. MSDS fi les should be kept in view, or
easily retrieved. Glass is an option for containment, but
not required.
Source: Hans C. Hansen, MD
417
Q
- You are maintaining a patient with carcinoma on 300
mg of morphine, by mouth, once daily. In the process of
a trial for and intrathecal infusion system, she was given
1 mg of intrathecal morphine and the oral morphine
was discontinued. Approximately 36 hours later, she
complains of diaphoresis and tachycardia. The most
likely diagnosis is: - cocaine use
- methamphetamine use
- accidental injection of naloxone instead of morphine
- morphine withdrawal
A
- Answer: D (4 Only)
Explanation:
This dose of intrathecal morphine, although appropriate
for pain control, will not prevent opioid withdrawal.
418
Q
- The OSHA hazard violation most commonly cited is:
- Blood Borne Pathogen
- Chemical
- Fire
- Communication
A
- Answer: D (4 Only)
Explanation:
Communication standard. Lack of training and posting.
Source: Hans C. Hansen, MD
419
Q
- OSHA training includes familiarity with procedures
to handle on Blood Borne pathogens, a citation will be
issued if: - The employer fails to keep the workplace free of hazard
- Hazard was recognized and not responded to in an appropriate
or timely manner - Hazard, was, or could cause harm, and no corrective
response was made by the employer - Antiseptics and spill kits weren’t at the site of exposure
A
- Answer: A (1, 2 & 3 )
Explanation:
Citations and enforcement policy are a necessary part of
OSHA. Fines can be imposed fi nancially, or far more
punitive in nature (prison) depending on the infraction.
Willful risk of an employee from an employer might result
in civil and criminal prosecution, with generally an
expensive outcome. Spill kits and personal protective gear
must be readily available, not necessarily at the site of a
spill.
Source: Hans C. Hansen, MD
420
Q
- Characteristics that describe methadone for cancer pain include:
- High potency
- Long half-life
- Low cost
- Low lipid solubility
A
- Answer: A (1, 2, & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
421
Q
2341.Identify true statements to assist in your practice
by specialty designation of interventional pain
management:
1. Physician profi ling or comparative utilization assessment
2. 500% increase of practice expense calculation immediately
3. Carrrier Advisory Committee (CAC) membership
4. 100% increase in physician reimbursement
A
2341. Answer: B (1 & 3) Explanation: Interventional Pain Management -09 designation Profi ling Practice Expense CAC Membership Source: Laxmaiah Manchikanti, MD
422
Q
- What are some of the true statements describing
bundling and unbundling? - Bundling is combining multiple codes or charges into
one comprehensive charge, when separate codes or
charges are justifi able - Unbundling is charging multiple CPT codes when one
code generally describes the service - Unbundling is charging multiple procedures with the
primary service that are generally included in primary
service - Bundling and unbundling are essential elements of
proper coding and accurate reimbursement
A
- Answer: A (1,2, & 3)
Explanation:
Bundling Or Disbundling
Combining multiple codes or charges into one
comprehensive charge, when separate codes or charges are
justifi able.
Vs
Unbundling
Charging multiple CPT codes when one code generally
describes the service.
Charging multiple procedures with the primary service
that are generally included in primary service.
Source: Laxmaiah Manchikanti, MD
423
Q
- Correct coding essentially means:
- Unbundling codes to achieve maximum reimbursement.
- Using whichever code is most convenient for the physician
performing a procedure. - Using multiple codes to ensure that at least one code will
be reimbursed. - Reporting a group of procedures with appropriate comprehensive
code.
A
- Answer: D (4 Only)
Explanation:
CMS has developed general policies that defi ne the coding
principles and edits that apply to procedure and service
codes. Item #4 best describes the essential idea of these
policies. The remaining items represent coding practices
that should be avoided.
Source: James A. Mirazita, MD, Sep 2005
424
Q
- The Health Insurance Portability and Accountability Act
(HIPAA): - Is also referred to as the Kennedy-Kassebaum Health
Reform Bill of 1996. - Provides the offi ce of Inspector General and the Federal
Bureau of Investigations (FBI) with broad powers to
identify and prosecute health care fraud and abuse. - Makes correct medical coding mandatory.
- Includes patient privacy provisions.
A
- Answer: E (All)
Source: James A. Mirazita, MD, Sep 2005
425
Q
- What are different places of service?
- POS 11 = Offi ce
- POS 21 = Inpatient hospital
- POS 22 = Outpatient hospital
- POS 24 = ASC
A
- Answer: E (All)
Explanation:
Place of Service
* POS 11 = Offi ce = Higher reimbursement
“Where you routinely provide health examinations,
diagnosis, & treatment”
* POS 21 = Inpatient hospital
* POS 22 = Outpatient hospital
* POS 24 = ASC
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
426
Q
- How do Program Safeguard Contractors work?
- They show up unannounced
- You have to talk
- They generally want to talk to MD
- Call attorney only after you talk
A
2346. Answer: B ( 1 & 3) Explanation: Program Safeguard Contractors * Show up unannounced * Want to talk to MD * Don’t have to talk * Call attorney immediately * Example Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
427
Q
2347.What are components of bullet methodology in
Evaluation and Management(E/M) services?
1. History - 8 possible factors
2. ROS - 14 possible factors
3. Exam includes single organ system or multi-system
4. Medical decision making
A
2347. Answer: E (All) Explanation: Bullet Methodology * History - History - 8 possible factors - ROS - 14 possible systems - PFSH - 3 possible histories * Exam - Single organ system - Multi-system * Medical Decision Making Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
428
Q
- What are Safe Harbor requirements common to all types
of ASC? - No loans from ASC or other investors
- Returns directly proportional to capital invested
- Non-discriminatory treatment
- “One-third income” test - at least one-third of each
physician’s practice income from ASC procedures
A
- Answer: E (All)
Explanation:
Safe Harbor Requirements - Common to all types of ASCs
Terms not related to previous or expected volume or value
of referrals
“One-third income” test
At least one-third of each physician’s practice income
from ASC procedures
No loans from ASC or other investors
Returns directly proportional to capital invested
No separately billable ancillaries
Non-discriminatory treatment
Disclosure
Source: Ron Wiser, JD
429
Q
- What are the rules of “incident to” services?
- For initial visit, the MD must do the entire visit/consult
- Incident to in the hospital even if MD has no face to face
documentation - MD must be in the offi ce
- Regulations are applied uniformly across the US
A
2349. Answer: A (1,2, & 3) Explanation: Incident to: * For initial visit, the MD must do the entire visit/consult * TN/NY Medicare: 2005 - Not just the assessment/plan - The HPI, exam, and MDM * MD must be in the offi ce * No incident to in the hospital - Unless MD rounds & notes face to face Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
430
Q
- Due to the Needlestick Safety and Prevention Act,
employers of an ASC should understand the following
items to be true: - The new regulation has language that requires an employer
to evaluate innovations in technology development
that reduce sharps exposure. - Employers need to seek input regarding sharps safety
devices from non managerial employees who are responsible
for direct patient care and may be exposed to
injuries themselves. - Requires employers to maintain a “sharps incident”
tracking log - Requires exposure control plans be reviewed and updated
at least annually to refl ect changes in sharps safety
technology.
A
- Answer: E (All)
Explanation:
The provisions of the Needlestick Safety and Prevention
Act did not include penalties for increased injuries of
employers who fail to comply with the provisions of the
Needlestick Safety and Prevision Act.
American Society of Interventional Pain Physicians page
235,236,237
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tml _ for some reason you can not click on this web site
from here you need to copy this email address then paste it
to your internet and select go.
http://www.osha.gov/pls/oshaweb/owadisp.show_docume
nt?p_table=NEWS_RELEASES&p_id=36
1910.1030(c)(1)(iv) The Exposure Control Plan shall be
reviewed and updated at least annually and whenever
necessary to refl ect new or modifi ed tasks and procedures
which affect occupational exposure and to refl ect new or
revised employee positions with occupational exposure.
The review and update of such plans shall also:
1910.1030(c)(1)(iv)(A) Refl ect changes in technology that
eliminate or reduce exposure to bloodborne pathogens;
and
1910.1030(c)(1)(iv)(B) Document annually consideration
and implementation of appropriate commercially
available and effective safer medical devices designed to
eliminate or minimize occupational exposure.
1910.1030(c)(1)(v) An employer, who is required to
establish an Exposure Control Plan shall solicit input
from non-managerial employees responsible for direct
patient care who are potentially exposed to injuries from
contaminated sharps in the identifi cation, evaluation, and
selection of effective engineering and work practice
controls and shall document the solicitation in the
Exposure Control Plan
Source: Marsha Thiel, RN, MA, Sep 2005
431
Q
2351.What are the correct statements about lysis of
adhesions?
1. 62264: 1 day
2. 62263: 2 or more days
3. Bundled services include epidural, fl uoro/epidurography,
and transforaminal epidural
4. 62264 must be used to report spinal endoscopy
A
2351. Answer: A (1,2, & 3) Explanation: Lysis of Adhesions * 62263: 2 or more days * 62264: 1 day * Services which are bundled: - Contrast injection (62311/19) - Fluoro/epidurography (76005/03/72275) - Transforaminal epidural (64483) - Peripheral nerve blocks (64450) Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
432
Q
- What are add-on codes?
- Primary procedure has a code
- Add-on codes are modifi er 51 exempt
- Second level has a separate code
- Multiple interlaminar epidural codes may be used as
add-on codes
A
2352. Answer: A (1,2, & 3) Explanation: Add-on Codes * Primary code has a code * Second level has a separate code * Examples: - Facets, therapeutic and RF - Transforaminal epidurals - Vertebroplasty * Do not use a 51 modifi er; pays differently * Add-on codes are modifi er 51 exempt Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
433
Q
2353.What are the some of coding methodologies for injections affecting multiple levels? 1. Add-on code methodology 2. 51 Modifi er methodology 3. Mutually exclusive code methodology 4. Single code methodology
A
2353. Answer: E (All) Explanation: 4 Coding Methodologies for Injections Affecting Multiple Levels * Add-on code methodology * 51 Modifi er methodology * Mutually exclusive code methodology * Single code methodology Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
434
Q
- Areas of development of the EMR include:
- Data input and development of outcome management
- Document transfer to federal health programs
- Information management of medication interactions,
dosing areas, and document management - Portable tools to eliminate redundant systems such as:
pagers, cell phones, and telephone systems
A
- Answer: B ( 1 & 3)
Explanation:
The role of the EMR is not to eliminate access tools; it is
for data management, and data assessment. It is also a risk
reduction tool. The EMR’s role fi rst and foremost is to
safely retrieve information, in a secure environment.
There is no one single tool that allows the EMR to
eliminate pagers, telephones, etc. Expecting an EMR to be
a multitasking tool diminishes the effectiveness of the
primary purpose of the EMR; that being electronic
paperless storage of the medical record and patient data
management.
Source: Hans C. Hansen, MD
435
Q
- An EMR performs the following roles:
- Enhances quality of care
- Decreases cost of care
- Improves quality of life for providers
- Increases potential risk of record breach to the practice
A
- Answer: A (1,2, & 3)
Explanation:
The electronic medical record performs each of the rolesof
enhancing quality of care, decreasing cost, and improving
quality of life of the providers, if implementation of the
proper tools, hardware, and training is afforded the
practice. The EMR should be considered a risk reduction
tool, and not an item where further contamination or loss
of data could be incurred. The purpose of the EMR is
convenience, safety, and improved productivity.
Source: Hans C. Hansen, MD
436
Q
- Doctoral level clinical psychologists are licensed to
practice independently within a scope of practice that
includes: - The assessment, diagnosis, and treatment of mental
health disorders - Billing for services when working within the hospital
setting - Assessment and treatment, but not diagnosis, of physical
health disorders - Conducting research in the university hospital setting
A
- Answer: E (All)
Explanation:
Doctoral level clinical psychologists are licensed to
practice independently within a scope of practice that
includes the assessment, diagnosis, and treatment of
mental health disorders; assessment and treatment,but not
diagnosis, of physical health disorders; hospital
privileges, in many states; as well as consultation;
supervision; research; teaching.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
437
Q
2357. What are the components of OIG Work Plan for 2005 for coding issues? 1. E & M Coding 2. 25 Modifi er 3. 59 Modifi er 4. ASC billing
A
2357. Answer: E (All) Explanation: OIG Work Plan for 2005 Coding Issues * E&M Coding - $29 Billion - Correct level * 25 Modifi er - $1.7 Billion - Procedure and visit on same day * 59 Modifi er - Bypass CCI edits Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual Meeting
438
Q
- A physical therapy visit is 37 minutes in length. During
that 37 minutes, ultrasound (CPT code 97035) is
performed for 4 minutes; exercise instruction (CPT code
97110) is performed for 25 minutes; and neuromuscular
re-education (CPT code 97112) is performed for 8
minutes.This visit would be billed as: - 97035 x 1 unit, 97110 x 2 units, 97112 x 1 unit
- 97110 X 1 unit, 97035 X 1 unit
- 97035x 1 unit, 97110 x 1 units, 97112 x 1 unit
- 97110 x 1 unit, 97112 x 1 unit
A
- Answer: D (4 Only)
Explanation:
The total treatment time was 37 minutes which supports
only two units to be billed with the “8 Minute Rule”. The 8
minute rule applies to all timed PT CPT codes that
require direct, one to one contact by the PT provider. It
states that for any single, timed CPT code, providers bill a
single 15’ unit for treatment greater than or equal to eight
minutes and less than 23 minutes. Two units would be
billed for treatment 23 minutes to less than 38 minutes. If
more than one CPT code is billed during a calendar day,
then the total number of units that can be billed is
constrained by the total treatment time. Ultrasound was
performed for only four (4) minutes and therefore should
not be billed.
Source: WPS Comminque May 2005, PHYSMED-009
Source: Marsha Thiel, RN, MA, Sep 2005
439
Q
- In order to properly bill for behavioral health services,
- The clinical psychologist should follow all appropriate
state and federal guidelines. - The clinical psychologist should bill incident to the interventional
pain physician. - The clinical psychologist should bill under his or her
own provider number. - The clinical psychologist should bill incident to the certifi
ed nurse practitioner who did the original medical
evaluation
A
- Answer: B (1 & 3)
Explanation:
A Clinical Psychologist should follow all appropriate state
and federal guidelines). The CP is eligible to obtain a
Medicare provider number and should bill under this
number. Clinical Psychologists are licensed to practice
independently in all 50 states and are generally not billed
incident to interventional pain physicians because in most
cases interventional pain physicians would not have the
requisite training and skill set to appropriately supervise
the work of a pain psychologist.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
440
Q
- A physical therapist is employed by a physician group
practice. The therapist does not have an individual
provider number with the designation of physical
therapist in private practice but instead bills for physical
therapy services incident to the physician present in the
offi ce, which is the case today. A Medicare patient arrives
at the clinic with an order for physical therapy. The order
was written by a physician who is not a member of the
group practice that employs the physical therapist. Which
statements are true about this situation? - The patient cannot be seen by the PT because the service
cannot be billed incident to a physician who has
not participated in the patient’s care. - The patient can be seen by the PT but would fi rst need to
be seen by one of the physician members of the group
practice that employs the physical therapist, to allow
billing incident to. - The physical therapist can bill under her own Medicare
provider number with payment reassigned to the group
practice, in order to receive referrals for physical therapy
from physicians outside of the group practice. - The patient can be seen with the visit billed incident to
the physician because the physician is present in the offi
ce suite at the time of the visit.
A
- Answer: B ( 1 & 3)
Explanation:
Physical therapy services cannot be billed incident to a
physician who is not involved in the patient’s care,
regardless of whether or not physician supervision of
ancillary personnel is met. Physical therapists can accept
referrals for physical therapy from providers outside of a
group practice they are employees of if they have their
own
Medicare provider numbers to bill under Source: WPS- PHYSMED-004, WPS National Coverage
Provision, Incident To Billing
Source: Marsha Thiel, RN, MA, Sep 2005
441
Q
- A physical therapist assistant(PTA) is working within a
medical clinic as an employee of the group practice. She
is approached by the physician who has just evaluated
a patient and would like the patient to begin physical
therapy immediately to assist with pain management.
The PTA points out that she cannot see the patient. What
is the reason that the patient cannot be seen? - The patient has not exhausted all medical options for
pain management fi rst - The patient has not been an active patient of the medical
clinic for at least 30 days - The patient cannot receive physical therapy on the same
day they see the physician if both are employed by the
same group practice. - The patient has not been evaluated by a physical therapist
A
- Answer: D (4 only)
Explanation:
Physical therapy is provided upon evaluation and
examination of a patient in accordance with the plan of
care, treatment frequency and duration, and functional
goals that were established by a physical therapist. Physical
therapy services cannot be initiated by physical therapist
assistants.
Source: Medicare Benefi t Policy Chapter 15, 230.1,
Practice of Physical Therapist
Source: Marsha Thiel, RN, MA, Sep 2005
442
Q
- A physical therapist assistant performs treatment with a
Medicare benefi ciary. The physical therapist assistant is
an employee of the physician group practice which also
employees a physical therapist. The physical therapist
has gone home for the day at the time of the Medicare
benefi ciary’s visit with the PTA. The physician is still
present in the clinic. How would the PTA bill for physical
therapy services for this patient? - The charges would be billed incident to the physician.
- The charges would be billed under the physical therapists
Medicare provider number. - The charges would be billed under the physical therapist
assistant’s Medicare provider number. - The visit would not be billable.
A
- Answer: D (4 Only)
Explanation:
Physical therapist assistants do not have provider
numbers. Services provided by a physical therapist
assistant may be billed by the supervising physical
therapist if the physical therapist is in the clinic. The visit
cannot be billed by the supervising PT if the PT is not
present in the clinic. Medicare does not allow PTA’s to bill
work that they do incident to a physician who may be
present. In this case therefore, there are no options for
billing for the visit and it would be a no charge visit.
Source: Medlearn Matters #SE0533
Source: Marsha Thiel, RN, MA, Sep 2005
443
Q
- A Medicare benefi ciary is seen by his physician on March
1 and physical therapy is ordered at that time. The patient
begins physical therapy on March 3 and on May 2, at the
patient’s tenth visit, the decision is made by the PT that
three additional PT visits will be needed. The patient has
not seen his physician since March 1 however the original
PT plan of care included a treatment frequency and duration of 1 x per week for 12 weeks and the physician
has recertifi ed the therapy plan of care twice. What would
prevent this patient from continuing physical therapy? - He would need a new signed order from his physician
before returning to PT because the original order was
more that 60 days old. - Medicare limits the number of physical therapy visits to
10 per episode of care. - The maximum duration for physical therapy services
is 60 days. - He has not seen his physician in the last 60 days.
A
- Answer: D (4 Only)
Explanation:
Medicare requires benefi ciaries receiving physical therapy
services to see their ordering physician or a member of the
physician’s group practice within 60 days of starting PT if
PT care is to continue beyond 60 days. The benefi ciary is
then required to see the physician every 30 days thereafter
if therapy is ongoing.
Source: www.cms.hhs.gov/manuals/pm_trans/R5BP.pdf,
CMS Manual, Pub 100-02, Medicare Benefi t Policy,
Transmittal 5, January 9, 2004
Source: Marsha Thiel, RN, MA, Sep 2005
444
Q
- Certifi cation documentation completed by the physical
therapist for Medicare benefi ciaries receiving Physical
Therapy services must contain the following elements: - Certifi cation period dates which encompass a thirty
day period - A treatment duration that does not exceed 30 days
- Functional and measurable treatment goals
- Records of previous physical therapy episodes of care
A
- Answer: B ( 1 & 3)
Explanation:
Certifi cation documentation requires a stated treatment
frequency and duration, an identifi ed certifi cation period
that is thirty days from the time of the physical therapy
evaluation, and a treatment plan to address functional and
measurable goals. Mention of previous PT is not
necessary but may be helpful in establishing the chronicity
of a condition. The treatment duration is required to be a
stated and defi ned period, but does not need to be thirty
days.
Source: CMS Manual, Pub 100-02, Medicare Benefi t
Policy, Transmittal 34, Chapter 15, Sections 220 and 230
Source: Marsha Thiel, RN, MA, Sep 2005
445
Q
- True statements regarding coding in interventional pain
procedures include: - Coding in 2000, 2001, and 2002 Current Procedural Terminology
(CPT) procedure manuals is identical. - No understanding of procedure codes is required by the
physician; rather only billing personnel must understand
procedure codes. - Current Procedural Terminology (CPT) procedure
manuals, whether older or newer, are interchangeable. - The interventional pain physician should thoroughly
understand each procedure code used in describing interventional
pain procedures to avoid misunderstanding,
incorrect coding, or unbundling.
A
- Answer: D (4 Only)
Source: James A. Mirazita, MD, Sep 2005
446
Q
- Four patients are seen for physical therapy for one hour,
simultaneously, as part of a back stabilization group class.
The four patients are performing similar exercises, under
the instruction and direction of one physical therapist.
How would you most appropriately bill for this? - Each patient would be billed for four units of therapeutic
exercise, CPT code 97150. - Each patient would be billed for one unit of therapeutic
exercise, CPT code 97110 and a group therapy code,
CPT code 97150. - Each patient would be billed for four units of therapeutic
exercise and one group therapy code. - Each patient would be billed for one group therapy
code, CPT 97150.
A
- Answer: D (4 Only)
Explanation:
If a provider is overseeing the therapy of more than one
patient during a period of time, he or she must bill 97150
since he or she is not furnishing constant attendance to a
single patient. The therapist is required to be in constant
attendance but one on one patient contact is not required
This is an un-timed code and can only be charged one
time per patient per visit.The therapeutic exercise code
identifi es one on one instruction and is a timed code. A
physical therapist can provide direct one to one patient
contact with only one patient at a time.
Source: Federal Register November 22, 1996, page 59542;
Transmittal #1753, May 17, 2002.
Source: Marsha Thiel, RN, MA, Sep 2005
447
Q
- What are the true statements about federal regulations
impacting ambulatory surgery centers? - Immunity from anti-kickback prosecution
- Ownership of ASCs includes - Physician Ownership,
Single Specialty, Multi-Specialty and Hospital/
Physician owned - Protection limited to physician investors who either use
facility on regular basis, or practice in same specialty - Non-compliance with safe harbors means illegal leading
to hefty criminal and civil penalties
A
2367. Answer: A (1,2, & 3) Explanation: ASC Safe Harbors Immunity from anti-kickback prosecution 4 Categories: Surgeon-Owned, Single Specialty, Multi- Specialty and Hospital/Physician Protection limited to physician investors who either – Use facility on regular basis, or Practice in same specialty (so cross referrals less likely) Must meet all requirements to qualify Voluntary Non-compliance does not mean illegal Source: Ron Wisor, JD
448
Q
- A physical therapist is providing physical therapy
treatment to Patient A in a closed treatment room. A
physical therapist assistant is providing treatment to
Patient B in a different room, within the same clinical
space. There is a physician (who is also the employer
of the PT and the PTA) is also working on site. The
physical therapist is employed by the medical clinic but
has an individual Medicare provider number, making it
a physical therapy private practice setting. The physical
therapist assistant services are billed by the supervising
PT. The level of PTA supervision by the physical therapist
required for this setting is: - General supervision
- Direct supervision by the physician only
- Direct personal supervision
- Direct supervision
A
- Answer: D (4 Only)
Explanation:
Direct supervision requires the PT to be present and
immediately available for direction and supervision; it is
the supervision level required in a physical therapy private
practice setting, unless state practice requirements are
more stringent, in which case those requirements must be
followed. Although the PT and PTA are working within a
medical clinic, because PTA services are billed by the
supervising PT, they are considered to be a part of a
physical therapy private practice.
Source: APTA website, H.O.D. 06-00-15-26
Source: Marsha Thiel, RN, MA, Sep 2005
449
Q
- True statements about postoperative pain management
in patients receiving methadone maintenance treatment
are as follows: - Continue maintenance treatment without interruption.
- Immediately stop maintenance treatment.
- Provide adequate individualized doses of opioid agonists,
which must be titrated to the desired analgesic
effect. - If opioids are administered in methadone maintenance
patients, doses should be given less frequently and on
a prn basis.
A
- Answer: B (1 & 3)
Explanation: - Continue maintenance treatment without
interruption. - Maintenance treatment must be continued.
- Provide adequate individualized doses of opioid
agonists, which must be titrated to the desired analgesic
effect. - Doses should be given more frequently and on a fi xed
schedule rather than prn basis.
450
Q
- A patient called to schedule an appointment at
your clinic. He told you that he has Federal Workers’
Compensation coverage for his area of pain. As a medical
provider, you will have to be aware of the following: - You can know what the accepted conditions are for
a claim by asking the injured worker. If the worker
does not know, he can contact the Employing Agency
directly. - With Federal Workers’ Compensation all services need
to be prior authorized - You need to be enrolled as a provider to treat an injured
federal employee. - Authorization may be obtained by any one of the following
means: online, by phone, or by fax.
A
- Answer: B ( 1 & 3)
Explanation:
Explanations under www.dol.gov/esa—-Information for
Medical Providers
“Ask the injured Worker for her/his accepted conditions.
If s/he doesn’t know these, s/he can contact her Employing
Agency or OWCP district offi ce for this information, or
you can contact the Employing Agency directly. The
Privacy Act prohibits OWCP and ASC from disclosing
this information to anyone other than the Injured Worker.”
“To be paid for treating federal employees covered by the
FECA, you must enroll. As of March 31. 2004, all bills
submitted by non-enrolled Providers will be returned
along with instructions on how to enroll. Enrollment is
free and is simply a registration process to ensure proper
payments. It is not a PPO enrollment.”
“Level 1 procedures (for example, Offi ce Visits, MRI’s,
Routine Diagnostic Tests) do not require authorization.
Level 2, 3 and 4 procedures require authorization”
“An authorization is not required when an Injured Worker
is referred by her/his treating physician to a specialist for a
consultation. However, you must be enrolled as a
Provider to be paid for the consultation visit.”
“You may request authorization online at
http://owcp.dol.acs-inc.com. Or you may fax the
appropriate Medical Authorization form and supporting
documentation to 800-215-4901. The Medical
Authorization forms are available online at
http//owcp.dol.acs-inc.com.” You may not call for
authorization.
Source: Marsha Thiel, RN, MA, Sep 2005
451
Q
- As you are walking by an exam room, you hear your
nurse practitioners making fun of the new physician (a
Muslim) you have hired. Although the physician was not
in the room, you heard the nurses mock his accent and
call him “towel head.” What should you do? - Deal with the situation immediately. Explain to the
nurses that they are violating the clinic’s policy against
harassment, and warn them that any future inappropriate
conduct will result in discipline, up to and including
termination. Then note the warning - Ignore it – the physician didn’t hear it and you simply
overheard the remarks. Injecting yourself into the situation
will simply cause morale problems. - Run to the personnel manual and make sure you have an
anti-harassment policy. - Have a private conversation with the new Muslim doctor.
Explain that his accent and his turban is causing
distractions to the offi ce staff. Ask him to dress like
other doctors in the offi ce, and to work on speaking
without an accent.
A
- Answer: B (1 & 3)
Explanation:
Explanation:This is not as outlandish as it sounds.
Harassment and discrimination against employees of
mideastern origin are on the rise since 9/11. It is critical to
adopt a zero tolerance policy. Inappropriate racial or
ethnic jokes and mocking an employee’s accent are not
acceptable merely because the “target” did not hear the
remarks or because you only “overheard.” If you know
about the conduct and do nothing,you and the clinic are at
risk.
Source: Judith Homes, Sep 2005
452
Q
- What is sequential coding?
- Line 1, surgery with greatest relative value – 100%
- Line 1, describes the procedure you had complications
with - Lines 2-5, surgery with 50% reduction
- Lines 2-5, describe easiest procedures
A
2372. Answer: B (1 & 3) Explanation: Sequential Coding: * Line 1 Surgery with greatest relative value – 100% * Lines 2-5 - 50% Source: Laxmaiah Manchikanti, MD
453
Q
- Which of the following is true about the cash accounting
method? - Must use this method if business carries inventory to
sell to public - Revenue is recorded when earned
- Evens out revenue and expenses over time
- Expenses are recorded when a check is written
A
- Answer: D (4 Only)
Explanation: - A business that stocks inventory for sale to the public
must use the accrual method of accounting - Revenue is recorded when earned under the accrual
method of accounting - Accrual accounting will even out the revenue and
expenses over time - Under the cash method of accounting, expenses are
recorded when cash is paid out
Source: Marsha Thiel, RN, MA, Sep 2005
454
Q
- Your offi ce manager fi led an EEOC charge against your
clinic, claiming he was terminated because of his age. He
has evidence that he was called “senile,” an “old fart,” and
was accused of having “Old-Timer’s Disease.” Which of
the following are potential defenses to his Charge? - He is under the age of 40
- You have several good examples of his poor work product
and you have documented the warnings he received
before his termination. - He was hired 6 months ago by the same person that
terminated him. - He has always been a “whiner” and you can present evidence
that he complains about everything.
A
- Answer: A (1,2, & 3)
Explanation:
Explanation: Age discrimination complaint may be made
by those who are 40 years or older. The issue of age
discrimination is a growing concern as the “baby
boomers” continue to age and demand their rights. It is
important to keep ageist comments out of the workplace
and to make certain that those individuals responsible for
employment decisions, such as hiring and fi ring, do not
engage in discriminatory conduct. You have a better
chance of prevailing on a discrimination claim if you have
good documentation to show a legitimate reason for the
termination, such as poor work quality.
Source: Judith Homes, Sep 2005
455
Q
- The following statements about the eight minute rule
are true: - The number of units billed cannot exceed the total time
spent with the patient. - One unit of a timed code refl ects treatment that encompasses
at least 8 minutes and up to 22 minutes. - Interventions that require less than 8 minutes of work
should not be billed. - Total treatment time can include the time spent to set up
equipment for the visit
A
- Answer: A (1,2, & 3)
Explanation:
The eight minute rule applies to all timed PT CPT codes
that require direct, one to one contact by the PT provider.
It states that for any single, timed CPT code, providers bill
a single 15’unit for treatment greater than or equal to eight
minutes and less than 23 minutes. Two units would be
billed for treatment 23 minutes to less than 38 minutes. If
more than one CPT code is billed during a calendar day,
then the total number of units that can be billed is
constrained by the total treatment time. Time is defi ned as
actual treatment time.
Source- WPS Communique May 2005, PHYSMED-009
Source: Marsha Thiel, RN, MA, Sep 2005
456
Q
- Which of the following is a true statement with respect
to an Exposure Control Plan? - An Exposure Control Plan must include an exposure
determination, procedures for evaluating the circumstances
surrounding an exposure incident, and a schedule
and method for implementing the provisions of the
regulations. - An Exposure Control Plan must be in writing.
- The input of non-managerial employees who are responsible
for direct patient care and are potentially
exposed to injuries from contaminated sharps must be
solicited in the identifi cation, evaluation and selection of effective engineering and work practice - An Exposure Control Plan must include the telephone
number and address of OSHA’s closest regional offi ce.
A
- Answer: A (1,2, & 3)
Explanation:
An Exposure Control Plan must be in writing and contain at least the following elements: (1) an exposure
determination, (2) the procedures for evaluating the
circumstances surrounding an exposure incident and (3) a
schedule of how and when other provisions of the
regulations will be implemented, including methods of
compliance, hepatitis B vaccination and post-exposure
follow-up, communication of hazards to employees, and
recordkeeping. The standard also requires employers to
solicit and document in the Exposure Control Plan input
of non-managerial employees who are responsible for
direct patient care and are potentially exposed to injuries
from contaminated sharps with regard to the
identifi cation, evaluation and selection of effective
engineering and work practice controls. The telephone
number and address of OSHA’s offi ce is not a required
element of the Exposure Control Plan,although it could be
included and may be required to be posted elsewhere
in theworkplace.The Exposure Control Shall must be
reviewed and updated annually and whenever necessary to
refl ect new or modifi ed tasks and procedures which affect
occupational exposure and to refl ect new or revised
employee positions with occupational exposure.
Source: 29 CFR 1910.1030(c).
Source: Erin Brisbay McMahon, JD, Sep 2005
457
Q
- Which of the following statements apply to an Advanced
Benefi ciary Notice (ABN)? - A physician may use an ABN when a benefi ciary is
under great duress and requires a non-covered treatment.
Great duress is when the benefi ciary’s condition
requires urgent and/or emergency care. - An ABN is a written notice a physician gives to a Medicare
benefi ciary before providing a specifi c item or
service that the physician believes Medicare probably or
certainly will not pay for. - A physician can have a Medicare Benefi ciary sign an
ABN on his/her fi rst visit and it will cover any future
item or service that Medicare denies as non- covered. - Medicare charge limits do not apply to either assigned or
unassigned claims when collection from the benefi ciary
is permitted on the basis of an ABN.
A
- Answer: C (2 & 4)
Explanation:
The purpose of an ABN is to inform a Medicare
benefi ciary before h/she receives specifi ed items or services
that otherwise might be paid for, that Medicare probably
will not pay for them on that particular occasion.The ABN
allows the benefi ciary to make an informed decision
whether nor not to receive the items or services since h/she
may have to pay out of pocket or, if available, through
other insurance.
Medicare does not limit the amount which the physician
or supplier, participating or nonparticipating, may collect
from the benefi ciary in such a situation. Medicare charge
limits do not apply to either assigned or unassigned claims
when collection from the benefi ciary is permitted on the
basis of an ABN.
Source: Program Memorandum Intermediaries/Carriers,
Transmittal AB-02-114, July 31, 2002, ABN’s and
DMEPOS Refund Requirements – Implementation of
Form CMS-R-131 Advanced Benefi ciary Notice (ABN),
and of Limits of Benefi ciary Liability or Medical
Equipment and Supplies.
Source: Joanne Mehmert, CPC, Sep 2005
458
Q
- You suspect your employees are spending unauthorized
time on your computer system sending jokes to each
other, playing games, and visiting porn sites. What can
you do to get the situation under control? - Give your employees a warning that unauthorized use of
your offi ce equipment will not be tolerated. - Install software on the computers to identify employees
engaging in unauthorized computer use. Continue to
monitor employees on a regular basis - Discipline employees who violate the computer use
policy. - None of the above. It is an invasion of the employees’
right of privacy to monitor computer use, or to attempt
to restrict their computer use. They have a right to unrestricted
use of the computer at lunch and on breaks.
A
- Answer: A (1,2, & 3)
Source: Judith Homes, Sep 2005
459
Q
- Select all statements that are correct.
- Medicare does not require an NDC number be included
on the claim for drugs; however some non-Medicare
payers do require this number - Compounded drugs are drugs mixed to meet a specifi c
prescription order that is not sold by a manufacturer in
the strength or mixture that the patient requires - The “J” codes that are listed in the HCPCS manual do
not describe the compounded medications since they
are “mixed to order” by a compounding pharmacist. - Claims to all payers must include the NDC number and
the “J “code from the Healthcare Common Procedure
Coding System (HCPCS) book
A
- Answer: A (1,2, & 3)
Explanation:
Currently Medicare does not require an NDC number; the
“J” code is all that is required. There are some non-
Medicare carriers that do require the NDC number. The
billing staff should watch the EOB’s carefully to be sure
that the drugs are paid appropriately.
There is much confusion in the industry relative to the
appropriate method to bill for compounded medications.
The basic coding principle that applies to procedures and
other services pertains to coding for compounded drugs.
When the code doesn’t describe the item or service, use an
unlisted code and tell the insurer what it is. The “J” codes
do not represent compounded, specially mixed, drugs.
Source: Correct Coding Conventions; various Medicare
Carrier Policies
Source: Correct Coding Conventions; various Medicare
Carrier Policies
460
Q
- What method does CMS use to pay for drugs?
- Every Medicare Carrier prices drugs based on the cost in
its geographic region - Medicare pays the Average Wholesale Price for drugs
- Payment for drugs is published in the Medicare Physician’s
Fee Schedule (MPFS) in November of each year - Medicare pays on the basis of Average Sales Price
(ASP).
A
- Answer: D (4 Only)
Explanation:
Drug manufacturers are required to submit their average
sales price to CMS every quarter. The data will include
almost all Medicare Part B drugs not paid on a cost or
prospective payment basis. Medicare’s payment to the
provider is equal to the lesser of 106 percent of the average
sales price or 106 percent of the wholesale acquisition cost
of the Health Care Common Procedure Coding System
(“HCPCS”) drug. Physicians can download a complete
list of the drugs and the payment for each every quarter.
Source: CMS web site www.cms.gov. Medicare Program;
Revisions to Payment Policies Under the Physician Fee
Schedule for Calendar Year 2005 – CMS-1429-FC, on
display at the Offi ce of the Federal Register November 2,
2004.
Source: Joanne Mehmert, CPC, Sep 2005
461
Q
- Do non-Medicare payers allow separate payment for
supplies such as needles, syringes and/or surgical trays
used for nerve blocks and injections when they are
performed in the offi ce, place of service (POS) 11? - Private payers do not allow additional payment for
supplies - Payment for supplies used for nerve blocks and injections
is payer specifi c. - Private payers will pay an additional fee for all supplies
used in the offi ce - Payment for supplies is an issue that should be addressed
in the fee schedule section of the contractual
agreement.
A
- Answer: C (2 & 4)
Explanation:
Payer fee schedules seldom address the payment of
supplies nor are there any codes listed for surgical trays
and/or supplies. Unless the contractual agreement
specifi cally prohibits the physician from reporting
supplies, it is appropriate to bill separately for the
supplies. More expensive equipment and supplies should
be carved out to ensure adequate reimbursement.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
462
Q
- What expenses listed below does a physician practice
have to incur to report Place of Service 11, (POS 11)? - All fi xed expenses such as rent and utilities
- Administrative, billing, nursing and technical staff costs
- Supplies and equipment
- Laboratory Expenses
A
- Answer: A (1,2, & 3)
Explanation:
Medicare and an increasing number of non-Medicare
payers allow a higher payment for procedures and services
performed in POS 11. Medicare calculates the higher
payment based on a component called “practice expense”.
A physician must incur the entire expense of the practice
to justifi ably report POS 11 as the site of service.
Source: Source: Manchikanti L, Principles and Practice of Documentation, Billing, Coding, and Practice
Management 2005; Medicare Physician’s Fee Schedule
(MPFS)
Source: Joanne Mehmert, CPC, Sep 2005
463
Q
- What are the true statements in selection of eligible
investors in ASCs: - Physicians in position to use facility
- Employed by the facility or any investor
- Group practices composed exclusively of physicians to
use facility - In position to make or infl uence referrals
A
- Answer: B ( 1 & 3)
Explanation:
Eligible Investors
Physicians in position to use facility
Group practices composed exclusively of such physicians
Others who are not –
Employed by the facility or any investor
In position to provide services to facility
In position to make or infl uence referrals
Source: Ron Wiser, JD
464
Q
- In an offi ce setting; place of service (POS) 11: Dr.
Ken is across the street (available by telephone) at the
ambulatory surgical center and a Medicare benefi ciary
arrives an hour early for his pump refi ll. The offi ce nurse,
an R.N., who usually refi lls the pumps when the doctor is
in the offi ce, refi lls the pump. How is this service reported
to Medicare? - Report code 95990, Refi lling & maintenance of implantable
pump or reservoir for drug delivery; spinal
(intrathecal, epidural or brain), when performed by
the nurse under Dr. Ken’s name and Medicare provider
identifi cation number (PIN); - Report code 95990, under Dr. Ken’s PIN and the nurse’s
name on the claim in the “signature” space - Report code 96530, refi lling and maintenance of implantable
pump or reservoir for drug delivery, systemic
(eg, intravenous, intra-arterial) under Dr. Ken’s name
and PIN - Medicare may not be billed for this service
A
- Answer: D (4 Only)
Explanation:
The service may not be reported as an “incident to” service
since the physician is not in the offi ce. When the doctor’s
PIN is on a claim sent to Medicare, it represents that the
service was provided by the physician or incident to a
physician service, the nurse’s name on the form will not
mitigate having the doctor’s PIN listed. Code 96530 has
not been used for morphine pump refi lls for pain control
since 2003, when code 95990 was added to CPT.
No charge may be reported to Medicare for the nurse’s
service in this circumstance.
Source: Centers for Medicare and Medicaid,
www.cms.gov, Incident to reporting guidelines.
Source: Joanne Mehmert, CPC, Sep 2005
465
Q
- Select the reason(s) that it is important for a practice
to report services within the context of CPT coding
instructions, guidelines and conventions, even if the
medical provider disagrees with the AMA instructions? - Deliberately reporting codes that are contrary to CPT
coding instructions may be considered by CMS and/or
third party payers as knowingly submitting a false claim
to obtain payment for a service that was not provided
- a criminal offense - The most important step toward solving the problem of
health insurer’s use of “black box edits” and downcoding
claims is to gain the confidence of the insurer(s) by
submitting claims that follow CPT instructions - When the government brings a criminal indictment for
submission of false claims against a provider, the provider
may be sentenced to prison - Loss of payer confi dence in the physician community.
A
- Answer: E (All)
Source: www.cms.gov. ; Manchikanti L, Principles and
Practice of Documentation, Billing, Coding, and Practice
Management 2005
466
Q
- When the practice is making a decision whether to bill
a drug and/or how to bill for the drug, it should consider
which of the following? - Is the drug an expense to the practice?
- Does the “J” code descriptor accurately describe the
drug administered? - What is the specifi c dosage described by the drug and
how much was given? - Does the local Medicare carrier have an LCD regarding
coding/billing requirements for this particular drug (or
compound)?
A
- Answer: E (All)
Explanation:
The drug must be an expense to the practice; a physician
practice may not bill a drug for which it did not pay.When
the patient “brown bags” the drug, it is not billable. Brown
bagging is when a patient brings the drug that h/she paid
for, or the pharmacy billed to the insurer. Drugs furnished
by a manufacturer to be used for clinical trials or drug
samples are other examples of non-billable drugs.
When the “J” code does not accurately describe the drug
administered, an unlisted code should be reported such as
for a compounded drug. The practice should also be
familiar with its local Medicare Carrier coverage
decisions relative the conditions for which drugs are
covered. Some Medicare carriers do not cover Botulinum
toxin (Bo-Tox) injections that are administered for
headache pain. In this circumstance, neither the drug nor
the injection will be covered.
Several of the Medicare carriers also have policies where
they require the practice to report an unlisted drug when a
compound medication is used for a pump refi ll. Close
attention should be given to all aspects of billing for drugs.
Source: Medicare Contractors Manual, 100-04, Chapter
14; Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
467
Q
- A physician performed stellate ganglion block under
fl uoroscopy – What is the correct coding? - CPT 64510 - cervical sympathetic block
- CPT 64505 – sphenopalatine ganglion block
- CPT 76003 – fl uoroscopic guidance
- CPT 76005 - fl uoroscopic guidance
A
- Answer: B ( 1 & 3)
Explanation:
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
468
Q
- Choose accurate statement(s) of fair market value under
the Stark regulations on a physician referral: - Fair market value is tied into a number of defi nitions
and exceptions under Stark Law - Fair market value means the price that willing buyer
gives to a willing seller - For rentals and leases, fair market value is the value of
rental property for general commercial purposes without
taking into account the property’s intended use - Under Stark Law, there are no fair market value exceptions
A
- Answer: B (1 & 3)
469
Q
- Designated Health Services providers that furnish 20
or more Part A and Part B services during the year must
maintain certain information in the form, manner and
at the times that the Centers for Medicare and Medicaid
Services or the Offi ce of Inspector General specifi es. The
information required to be kept does NOT include the
following: - The name and unique identifi cation number (“UPIN”)
of each physician who has a reportable fi nancial relationship
with the entity. - The name and unique identifi cation number of each
physician who has a family member who has a reportable
fi nancial relationship with the entity. - The covered services furnished by the entity.
- The name and social security number of each physician’s
immediate family members.
A
- Answer: D (4 Only)
Explanation:
Answer (4) is wrong; it is not a required reporting
element.
Source: 42 CFR 411.361.
Source: Erin Brisbay McMahon, JD, Sep 2005
470
Q
- What are the examples of “unbundling?”
- Fragmenting one service into component parts and
coding each component part as if it were a separate
service. - Reporting separate codes for related services when one
comprehensive code includes all relates services. - Breaking out bilateral procedures when one code is appropriate.
- Downcoding a service in order to use an additional
code when one high-level, more comprehensive code
is appropriate.
A
- Answer: E (All)
Explanation:
Unbundling is when a provider bills separately for items,
services or procedures that should be billed together under
one code. This practice also sometimes is called
fragmenting or exploding. - Separate procedures: If provided as a more
comprehensive procedure, “separate procedure” codes
should be submitted with their related and more
comprehensive codes. - Most extensive procedures: When CPT descriptors
designate several procedures of increasing complexity,
only the code describing the most extensive procedure
actually performed should be submitted. - With/without services: Certain code designate several
procedures performed with or without other services.
Submit only the code for the service actually performed. - Sex designation: When code descriptors identify
procedures requiring a designation for male or female,
submit only the appropriate code. - Standards of medical practice: For Medicare, all services necessary to perform a given procedure are
considered included in that procedure. Even if
independent CPT codes exist for these ancillary services,
Medicare considers billing for these independent CPT
codes “unbundling,” so don’t do it. - Laboratory panels: When a codes exists for a grouping
or panel of lab tests, bill it – don’t submit codes for
individual lab tests. - Sequential procedures: If a doctor fi nds it necessary to
attempt several procedures in direct succession to
accomplish the same end in a patient encounter, bill for
only the procedure that was successfully accomplished.
(This applies mainly to limited procedures that are
unsuccessful, showing the need for more comprehensive
procedure.) However, procedures performed at the same
session that are diagnostic in nature and establish the
decision to perform the more comprehensive service may
be separately billed. - Modifi er -59: This modifi er is used to indicate a
distinct procedural service done on the same day as other
services. However, it does not replace modifi ers -25, -51,
-76 or -79. The -59 modifi er is used only after the other
modifi ers are analyzed and no other modifi er fi ts the
service. - Anesthesia performed during medical/surgical
procedures: Medicare prohibits payment of a separate fee
for anesthesia when the same doctor provides anesthesia
and performs the medical/surgical procedure. So don’t
submit codes describing anesthesia services necessary to
provide anesthesia with primary procedure/service codes.
Source: Laxmaiah Manchikanti, MD
471
Q
2392.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, place of service (POS) 11?
1. Needles and syringes used to perform an injection/nerve
block
2. Lidocaine that is used to anesthetize the area
3. Pulse oximetry
4. A substance such as Depo Medrol that is injected when a
lumbar epidural steroid injection is performed
A
- Answer: D (4 Only)
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, Sep 2005
472
Q
- The following statements are true with reference to types
of muscular contractions and strength. - Isometric muscular contractions involve no motion
despite muscular activity. - Concentric muscular contractions include increased
muscular length during a contraction. - Isokinetic muscular contraction involves muscular contraction
at a constant velocity, with very little proven
relevance to real conditions. - Isometric contraction is useful during motions that do
not require stabilization.
A
- Answer: B (1 & 3)
Source: Manchikanti L, Board Review 2005
473
Q
- What are the principles of reimbursement governing the
Medicare fee schedule? - Controlled by Congress and Centers for Medicare &
Medicaid Services (CMS) - Based on sustainable growth rate formula
- May be based on performance
- Becoming basis for payment by private payors
A
- Answer: E (All)
Source: Laxmaiah Manchikanti, MD
474
Q
- What are the true statements about Correct Coding
Policies? - A new patient is the one who has not received any professional
services from the physician or another physician
of the same specialty who belongs to the same
group practice, within the past 3 years. - If a patient received anesthesia 3 months prior by the
same group, the patient becomes an established patient. - An established patient is the one who has received professional
services from the physician or another physician
of the same specialty who belongs to the same
group practice, within the past 3 years. - If a patient develops a different problem, the patient
automatically becomes a new patient.
A
- Answer: B (1 & 3)
Source: Laxmaiah Manchikanti, MD
475
Q
- A consultation consists of some of the following
elements: - An opinion is requested
- Request for opinion is received
- The service/opinion is rendered and reported back
- Patient is referred
A
2396. Answer: A (1,2, & 3) Explanation: Consultation An opinion is requested Patient is not referred 3 R’s Request for opinion is received Render the service/opinion Report back Source: Laxmaiah Manchikanti, MD
476
Q
- Identify true statements differentiating consultation and
referral visit: - Written request for opinion or advice received from
attending physician, including the specifi c reason the
consultation is requested. - Patient appointment made for the purpose of providing
treatment or management or other diagnostic or
therapeutic services. - Only opinion or advice is sought. Subsequent to the
opinion, treatment may be initiated in the same encounter
if criteria are fulfi lled. - Transfer of total patient care for management of the
specifi ed condition.
A
- Answer: B (1 & 3)
Explanation:
Consultation vs. Referral Visit - Problem
Consultation
Suspected
Referral visit
Known - Request language
Consultation
“Please examine patient and provide me with your
opinion and recommendation on his/her
condition.”
Referral visit
“Patient is referred for treatment or management of
his/her condition.” - Request
Consultation
Written request for opinion or advice received from
attending physician, including the specifi c reason the
consultation is requested.
Referral visit
Patient appointment made for the purpose of providing
treatment or management or other diagnostic or
therapeutic services. - Report language
Consultation
“I was asked to see Mr. Jones in consultation by Dr.
Johnson.”
Referral visit
“Mr. Jones was seen following a referral from Dr.
Johnson.” - Patient care
Consultation
Only opinion or advice sought. Subsequent to the
opinion, treatment may be initiated in the same encounter
Referral visit
Transfer of total patient care for management of the specifi ed condition. - Treatment
Consultation
Undetermined course
Referral visit
Prescribed and known course - Correspondence
Consultation
Written opinion returned to attending physician.
Referral visit
No further communication (or limited contact) with
referring physician is required. - Diagnosis
Consultation
Final diagnosis is probably unknown.
Referral visit
Final diagnosis is typically known at the time of referral. - Follow-up
Consultation
Patient advised to follow up with attending physician.
Referral visit
Patient advised to return for additional discussion, testing,
treatment, or continuation of treatment and management. - Further follow-up
Consultation
Confi rmatory or follow-up consultation or established
patient based on specifi c situation.
Referral visit
Always established patient for three years.
Source: Laxmaiah Manchikanti, MD
477
Q
- Local Medical Review Policy (LMRP) or Local Coverage
Determination (LCD) are utilized in all states. What are
true statements? - LMRP or LCD is developed to assure benefi ciary access
to care - Frequent denials indicate a need for development of
LMRP or LCD - A need for development of LMRP or LCD includes a
validated widespread problem - LMRPs or LCDs are those policies used to make coverage
and coding decisions in the absence of: Specifi c statute,
Regulations, National coverage policy, National coding
policy or as an adjunct to a national coverage policy.
A
- Answer: E (All)
Explanation:
Local Medical Review Policy or Local Coverage
Determination
LMRPs or LCDs are those policies used to make coverage
and coding decisions in the absence of:
Specifi c statute
Regulations
National coverage policy
National coding policy
As an adjunct to a national coverage policy.
Development of LMRP - Identifi cation of Need
* A validated widespread problem
Identifi ed or potentially high dollar and/or high volume
services
* To assure benefi ciary access to care
* LMRP development across its multiple jurisdictions by a
single carrier
* Frequent denials are issued or anticipated
LMRP’s reduce utilization and Save money
Source: Laxmaiah Manchikanti, MD
478
Q
- Your administrative assistant has threatened to fi le an
EEOC Charge against you and the clinic for allowing
a hostile work environment because she overheard a
sexually explicit joke being told by a coworker to another
coworker. When you talk to the coworkers, they insist
your assistant has repeatedly told them very sexually
explicit jokes and that she always laughs more than
anyone else. Are you in big trouble? - No. One joke is not “severe” or “pervasive” conduct and
does not alone create a “hostile work environment.” - No. The conduct must be considered harassing to a
reasonable person AND to the complaining employee.
If she has a history of telling raunchy jokes, it will be
diffi cult to prove she was personally offended. - Either way, you need to get control of your employees
and insist they stop telling inappropriate jokes - Yes. An employer is strictly liable to his or her employees
for sexually explicit jokes at the office.
A
- Answer: A (1,2, & 3)
Explanation:
Explanation: One of the elements of a sexual harassment
claim is that the alleged victim is personally offended.
That is not enough – the conduct or incidents must also be
offensive to a “reasonable person.” The lesson from this
situation is that the physician is getting a wake up call and
must rid the offi ce of inappropriate conduct through
adopting appropriate policies, training and disciplinary
procedures.
Source: Judith Homes, Sep 2005
479
Q
- There are some items and services for which Medicare
will not pay because they are not Medicare benefi ts and
for which a provider will furnish a form known as a
Notice of Excluded Medicare Benefi ts, (NEMB) instead of
an ABN. Which one of the following services, although
never covered, requires an ABN? - Vaccinations
- Routine eye care, eyeglasses and examinations
- Services under a physician’s private contract
- Acupuncture
A
- Answer: D (4 Only)
Explanation:
CMS denies acupuncture as not reasonable and necessary
under §1862(a)(1) of the Social Security Act (SSA). This
service has commonly been thought to be “non covered”
and many providers did not have an ABN signed for
acupuncture services provided to a Medicare Benefi ciary.
At present all acupuncture services are denied as not
reasonable and necessary and require an ABN.
Source: Joanne Mehmert, CPC, Sep 2005
480
Q
2401.What are some of the true statements about bilateral
codes?
1. Bilateral codes include transforaminal, facet joint interventions,
and SI joint injections
2. Facet joint neurolysis codes may not be billed as bilateral,
and require modifi ers 59 and 51
3. Unlisted codes may not be used as bilateral codes
4. Bilateral codes include intercostal nerve blocks, sympathetic
blocks, and occipital nerve blocks
A
2401. Answer: B (1 & 3) Explanation: Bilateral Codes Transforaminal Facet Joint Blocks Facet Neurolysis SI Joint Injection Not Bilateral: Intercostal Nerve Blocks Sympathetic Blocks Occipital Nerve Blocks, etc Source: Laxmaiah Manchikanti, MD
481
Q
2402.Under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) which third party
payers are required to use the National Correct Coding
Initiative (NCCI) bundling edits to determine claim
payment?
1. All of the private payers that have insured lives in all
regions of the United States such as United Health Care,
(UHC), Cigna, Aetna and Blue Cross Blue Shield.
2. All State Worker’s Compensation payers.
3. All Federal and third party payers regardless of size of
plan or location of insured lives
4. Medicare Part B Contractors are the only payers that are
mandated by CMS
A
- Answer: D (4 Only)
Explanation:
Although a number of private payers use the NCCI to edit
claims, it is not a mandatory requirement. HIPAA does not
regulate private payer policy benefi ts and claims payment.
Source: CMS website www.cms.gov. Manchikanti L,
Principles and Practice of Documentation, Billing,
Coding, and Practice Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
482
Q
2403.The following are the true statements explaining the
mechanisms of increased opioid requirements.
1. Tolerance
2. Tachyphylaxis
3. Physical dependence
4. Psychological dependence
A
- Answer: E (All)
483
Q
- What constitutes an electronic “clean claim”?
- A claim that doesn’t have any modifi ers appended to the
procedure codes - A claim that has includes the physician’s telephone
number - A claim that links only one diagnosis per procedure
line item - A Claim that is compliant with the HIPAA Transactions
and Code Sets Rule and has accurate information about
the patient and insured party
A
- Answer: D (4 only)
Explanation:
In addition to compliance with the Transaction and Code Sets Rule, a clean claim should have the CPT and/or
HCPCS code(s) that accurately represents the service the
provider rendered, it should not have unbundled codes
following CPT coding conventions, and it should have the
ICD-9 code that correctly identifi es the condition for
which the service was rendered.
Source: L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
484
Q
2405.When a physician practice receives an adverse
determination for all or part of a claim for services
from a payer with whom h/she is contracted, it should
immediately
1. Write to the State Insurance Commission to complain
and ask for intervention
2. Call the payer provider information line to ask why the
claim was not paid
3. Resubmit the claim with a different CPT procedure code
and/or a different ICD-9 diagnosis code
4. Review the reason for denial, documentation, payers
Medicare policy, and any pre authorization.
A
- Answer: D (4 Only)
Explanation:
The fi rst step when a claim denial is received is to review
the EOB and the denial reason. When the claim denial is
“medical necessity” or “bundled services”, CPT coding
conventions, instructions in the CPT Manual, articles
published in the CPT Assistant, NCCI and the payer’s
medical policy, (if available), should be reviewed to ensure
that an accurate claim was submitted. When claim
accuracy is confi rmed, proceed with an appeal following
the payer’s procedure.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. AMA Model Contract
Source: Joanne Mehmert, CPC, Sep 2005
485
Q
- Medicare benefi ciaries now have Medicare HMO options
known as Medicare+Choice (M+C). With regard to a
provider and/or benefi ciary’s appeal rights, choose all
that apply. - The right to request an expedited reconsideration of a
denied service - The right to request and receive appeal data from M+C
organizations - The right to receive notice when an appeal is forwarded
to an Independent Review Entity (IRE) - The right to request Administrative Law Judge (ALJ)
hearing if the IRE entity upholds the original adverse
determination and the remaining amount in controversy
is $100 or more.
A
- Answer: E (All)
Explanation:
Medicare +Choice organizations must have a process that
is very similar to the appeal process that applies to
Medicare Part B carriers. Complete information may be
found on the CMS web site.
Source: www.cms.hhs.gov/healthplans/appeals
Source: Joanne Mehmert, CPC, Sep 2005
486
Q
- Some of the true statements include:
- Global period for major procedures is 90 days
- Procedures with a 10-day global period include adhesiolysis
and facet joint neurolysis - Global period for minor procedures is day of the procedure
or 10 days - Implantables and disc decompression procedures fall
into category of 10-day global period
A
2407. Answer: A (1,2, & 3) Explanation: Global Period Major day prior, day of, and 90 days after Minor day of or day of and ten days after Major Procedures DISC Decompression Nucleoplasty® DekompressorTM IDET® Spinal endoscopy ?? Implantables Minor Procedures One-day global period Spinal puncture Epidurals Facet blocks Intercostal blocks Discography Sympathetic blocks Ten-day global period Lysis of adhesions Facet radiofrequency Neurolytic blocks Source: Laxmaiah Manchikanti, MD
487
Q
- Select the most import item(s), (in the following
list), that a practice specializing in the treatment of
interventional pain management needs to know before it
signs a managed care contract - How important this contract is to its practice
- Whether or not all of the pain management specialists in
the city or region are members of the plan - What the reimbursement is for the services the practice
currently provide or anticipate adding to its practice in
the future, by CPT procedure code - How much the insurer pays for the list of CPT codes that
it provides as an Exhibit or an Attachment
A
- Answer: B ( 1 & 3)
Explanation:
The practice should have a general idea of the cost to
provide its specifi c services and whether or not the insurer
will compensate it beyond the practice expense. When an
insurer attaches a list of codes it will often include many
codes that an interventional pain specialist seldom or
never performs. It is not unusual for a practice to lose
money when it signs a “blank contract”.
A physician practice can and should say “no” when a
contractual agreement does not pay enough to addrevenue
to the practice. The practice should carefully review its
patient demographics and understand the economic
impact of every contract before signing.
Source: AMA Model contract, Fourth Edition 2005; 15
Questions to ask before signing a managed care contract.
Source: Joanne Mehmert, CPC, Sep 2005
488
Q
- Incorrect coding may be defi ned as:
- Intentional billing of multiple procedure codes for a
group of procedures that are covered by a single, comprehensive
code. - Utilizing a comprehensive code for a group of procedures.
- Unintentional billing of multiple procedure codes for a
group of procedures that are covered by a single, comprehensive
code. - Complying with CMS guidelines.
A
- Answer: B ( 1 & 3)
Explanation:
The defi nition of incorrect coding encompasses items #1
and #3. Items #2 and #4 refl ect correct coding principles.
Source: James A. Mirazita, MD, Sep 2005
489
Q
- What are some of the true statements about modifi ers?
- A modifi er indicates that an encounter or procedure
has been altered by some specifi c circumstance, but not
changed in its basic defi nition or code - A modifi er indicates that an encounter or procedure has
been altered in its basic defi nition and code. - Common modifi ers for interventionalist include modifi
er -50 bilateral procedure, and -51 multiple procedures - Common modifi ers for interventionalist include -52
-reduced procedure, -59 - distinct procedure, and -25
- separate E & M service on the same day of procedure
A
2410. Answer: B ( 1 & 3) Explanation: Modifi ers Means to indicate that an encounter or procedure has been altered by some specifi c circumstance, but not changed in its basic defi nition or code. Common Modifi ers -21 prolonged E & M services -22 unusual procedure services -24 unrelated E & M by same physician in post-op period -25 separate E & M on same day of procedure -50 bilateral procedure -51 multiple procedure -52 reduced services -53 discontinued procedure -59 distinct procedural service -76 repeat procedure by same physician Source: Laxmaiah Manchikanti, MD
490
Q
2411.Choose the accurate statement(s) of fair market value
under the Stark regulations on a physician referral:
1. Fair market value is tied into a number of prohibitions
and exceptions under stark law
2. Fair market value means the price that willing buyer gives to a willing seller
3. For rental and leases, fair market value is the value of
rental property without taking into account the property’s
intended use
4. Under Stark Law, there are no fair market value exceptions
A
- Answer: B (1 & 3)
491
Q
- What are some of the important aspects of
documentation of medical necessity? - Medicare will reimburse. Irrespective of the procedure,
furnished, not for improvement function, but 20% pain
relief. - The physician practice should be able to provide
documentation such as a patient’s medical records and
physician’s orders, to support the appropriateness of a
service that the physician has provided. - Medicare concurs with physician opinion and patient
request with respect to duration, frequency, and setting
a procedure performed. - The physician practice should only bill those services
that meet the Medicare standard of being reasonable
and necessary for the diagnosis and treatment of a
patient
A
- Answer: C (2 & 4)
Explanation:
Reasonable and Necessary
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.
Documenting Medical Necessity
The physician practice should be able to provide
documentation such as a patient’s medical
records and physician’s orders, to support the
appropriateness of a service that the physician has
provided
Only bill those services that meet the Medicare standard
of being reasonable and necessary for
the diagnosis and treatment of a patient
Source: Laxmaiah Manchikanti, MD
492
Q
- A clinical psychologist saw Mrs. Smith today. The
Clinical Psychologist (CP) did a health assessment which
took 45 minutes, called the patient’s psychiatrist to discuss
Mrs. Smith’s current status (15 minutes), interpreted the
MMPI report (20 minutes) and spent 45 minutes writing
the report of the MMPI fi ndings. The CP can be expected
to get reimbursed when billing for: - Provision of direct services to patients.
- The length of time it takes to coordinate care with other
healthcare providers. - The time it takes to interpret the MMPI
- The time it takes to complete the writing of a report
when psychometric testing is performed.
A
- Answer: A (1,2, & 3)
Explanation:
Clinical Psychologists will be reimbursed for providing
direct services to patients, interpreting psychometric
testing and time it takes to write the report. CP generally
do not bill for coordination of care or other types of case
management services, and would not generally be
expecting to get reimbursed for these services if they did
bill for them.
CPT 2005 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
493
Q
- It is recommended that a physician practice identify
a compliance offi cer, a compliance committee or key
compliance contacts within the practice. The duties of
such an offi cer, committee or contact might entail . . . - Answering billing questions.
- Participation in the development of Practice Standards.
- Developing a process to communicate with and disseminate
information to individuals within the practice. - Conducting a baseline audit of the practice’s operations.
A
- Answer: E (All)
Explanation:
Explanation: Compliance personnel should participate in
developing the Practice Standards, developing a process to
communicate with and disseminate information to the
individuals in the practice, answering billing questions,
and conducting a baseline audit.
Reference: 65 Fed. Reg. at 59442.
Source: Erin Brisbay McMahon, JD, Sep 2005
494
Q
2415.Components of Physical Examination if the planned
anesthesia includes intravenous sedation, regional or
general anesthesia should include the following:
1. An assessment of the patient’s mental status
2. An examination specifi c to the proposed procedure
3. Documentation of the results of an auscultatory examination
of the heart and lungs
4. An assessment and written statement about the patient’s
general health
A
- Answer: E (All)
Explanation:
Physical Examination - II
If the planned anesthesia includes intravenous sedation,
regional or general anesthesia, there should be:
* An assessment of the patient’s mental status
* An examination specifi c to the proposed procedure
* An examination specifi c to any co-morbid conditions
* Documentation of the results of an auscultatory
examination of the heart and lungs, and
* An assessment and written statement about the patient’s
general health.
495
Q
- What are the components of Medical Decision Making?
- Review of records/investigations
- Chronological description of development of patient’s
symptoms - Risk of signifi cant complications, morbidity, mortality
- Insurance coverage
A
2416. Answer: B (1 & 3) Explanation: MEDICAL DECISION MAKING - THREE COMPONENTS * Review of Records/Investigations Requested , Obtained, Reviewed, Analyzed * Diagnoses/Mgmt Options Minimal, Limited, Multiple, Extensive * Risk of signifi cant complications, morbidity, mortality Associated with presenting problems, diagnostic procedures, management options
496
Q
- The purpose of documentation is:
- To record information
- To communicate information
- To obtain proper reimbursement
- To document level of service
A
- Answer: E (All)
497
Q
- Identify accurate statements about clinical policies
- They are expensive and labor intensive to develop and
maintain - The actual impact on the quality of care is nearly impossible
to determine - There are probable multiple indirect positive benefi ts
of this effort with improved patient care and decreased
practice variation - They provide an inordinate amount of restrictions
A
- Answer: A (1,2, & 3)
Explanation:
Conclusions: Clinical Policies
Expensive and labor intensive to develop and maintain
Actual impact on the quality of care is nearly impossible
to determine
Probable indirect positive benefi ts of this effort
Increased acceptance of concept of “standards”
Increased attention to our individual practices of
medicine, especially over time
Decreased practive variation
Pay for performance
Source: Laxmaiah Manchikanti, MD
498
Q
- What are the principles and objectives of pay for
performance for physicians? - Encourage coordination of Part A and Part B services
- Discourage effi ciency through investment in administrative
structure and process - Reward physicians for improving health outcomes
- Encourage upcoding
A
- Answer: B (1 & 3)
Explanation:
Objectives of Physician Program Encourage coordination of Part A and Part B Services
Promote effi ciency through investment in
administrative structure and process
Reward physicians for improving health outcomes
499
Q
- Landmarks in regulations in healthcare in the United
States include: - 1965 - Health Care Law
- 1992 - Addition of Medicaid
- 1993 - Health Security Act of Clinton
- 1976 - Health Insurance Portability and Accountability
Act
A
2420. Answer: B (1 & 3) Explanation: 1965 - Health Care Law Called for by Theodore Roosevelt in 1912 Signed by Lyndon Johnson in 1965 1972 - Addition of Medicaid 1983 - PPS, DRG’s 1993 - Health Security Act of Clinton - Failed because it was ‘not credible’ 1992 - RBRVS 2000 - HOPD – PPS 1995 - Balanced Budget Act 1996 - Health Insurance Portability and Accountability Act 2003 - Medicare prescription drug, improvement and modernization act of 2003
500
Q
- Identify all Accurate Statements
- The Emergency Medical Treatment and Active Labor
Act (EMTALA) only applied to patients who are physically
in a hospital’s Emergency Department. - Physicians in a group practice may receive productivity
bonuses without violating the Stark Self-referral rules if
the bonuses are based on a physician’s total number of
patient encounters or Relative Value Units (RVUs). - You purchase a medical practice that is currently subject
to a corporate integrity agreement (CIA), and the transfer
of ownership will void the CIA - According to the HHS Offi ce of Inspector General, having
a compliance program without appropriate, ongoing
monitoring is worse than not having a compliance
program
A
- Answer: C (2 & 4)
Explanation: - EMTALA, also known as the patient anti-dumping law
applies to an individual who requests examination or
treatment and who is on hospital property (including offcampus
clinics and hospital-owned ambulances that are
not on hospital grounds). An individual in a non-hospitalowned
ambulance on hospital property is also considered
to have come to the hospital’s emergency department. - Profi t shares and productivity bonuses are permitted if
they meet certain conditions. Physicians in a group
practice, including independent contractors,may get shares
of “overall profi ts” of the group or receive bonuses for
services they personally perform – including incident-toservices
– if such rewards are not based on referrals for any
of the designated health services.
Regardless of which type of reward is given,
documentation that verifi es how much was given and on
what basis must be made available to investigators if
requested.
Overall profi ts are the profi ts from designated health
services for the entire group or any part of the group that
has at least fi ve physicians. The profi ts are not based on
referrals if only one of the following conditions is met:
The profi ts are divided per capita (per member or per
physician, for example).
Designated health services revenue is distributed based on
the way non-designated health services revenue is
distributed.
Designated health service revenue is both less than 5% of
the group’s of the group’s total income and is less than 5%
of any physician’s total compensation from the group.
Overall profi ts are distributed in a reasonable and
verifi able way that is unrelated to designated health service
referrals.
Productivity bonuses are not based on referrals if:
It is based on a physician’s total number of patient
encounters or Relative Value Units (RVUs).
It is not based in any way on designated health services.
Designated health service revenue is both less than 5% of
the group’s total income and is less than 5% of any
physician’s total compensation from the group.
It is distributed in a reasonable and verifi able way
unrelated to designated health services DHS referrals. - Corporate integrity agreements (CIAs) are typically
large, detailed and restrictive compliance plans that
companies enter into as part of a deal with theDepartment
of Health and Human Services Offi ce of Inspector General
(OIG). CIAs are intended to make sure that a company
never again commits the kind of offenses against the
Medicare program that landed it in trouble in the fi rst
place. There are strict reporting requirements and other
rules a company must live up to once it agrees on a plan
with OIG, but on the plus side, OIG allows the company to
continue to do business with Medicare.
CIAs typically contain provisions requiring any third
parties that acquire covered entities to adhere to the
guidelines outlined in the CIA. These clauses transfer any
obligations for independent review, continued compliance
program administration and exclusion from the original
owners to the new owners. - Implementation of an effective compliance program
requires a substantial commitment of time, energy and
resources by senior management and a health care
provider’s governing body. Superfi cial programs that
simply purport to comply with the elements described in
this guidance or programs that are hastily constructed and
implemented without appropriate ongoing monitoring
will likely be ineffective and could expose the organization
to greater liability than no program at all.
Nothing is worse than adopting a compliance plan and,
then, failing to implement it properly. That would be the
equivalent of telling regulators that, yes, you knew what to
do, but you chose not to do it. In such cases, a compliance
plan would be seen to have been designed to cover up
problems the organization had no intention of correcting.
Source: Manchikanti L, Board Review 2005
501
Q
- Identify the true statements describing functional
restoration - Functional restoration is a monotherapy intended to
return patients to work. - Functional restoration includes an interdisciplinary approach with physical therapy, occupational therapy,
vocational rehabilitation, psychology, nursing, and
physician - Indications for functional restoration include temporary
disability and ability to return to work following
exercise program. - Phases of rehabilitation and functional restoration include
initial reconditioning, comprehensive phase, and
follow up phase
A
- Answer: C (2 & 4)
Explanation:
Source: Cole and Herring. Low Back Pain Handbook.
Functional Restoration
Functional restoration is a comprehensive,
multidisciplinary program intended primarily to correct
disability in the patient with chronic low back pain who
has demonstrated multiple barriers to recovery, including deconditioning, lack of motivation, psychologic
dysfunction, and secondary gain issues.
An interdisciplinary approach integrates physical therapy,
occupational therapy, vocational rehabilitation,
psychology, nursing, and the physician.
Indications
Persistent disability despite completion of proper primary
and secondary work-up and treatment
Presence of barriers to recovery
Deconditioning
Lack of motivation
Psychological dysfunction
Secondary gain issues
Willingness to participate
Willingness to comply
Elements
Quantifi cation of physical function
Physical reconditioning of injured functional unit
Work simulation and whole body coordination training
Cognitive-behavioral disability management
Fitness maintenance program with outcome assessment
using objective criteria
Program Content
Initial medical evaluation
Quantifi cation of physical function
Trunk range of motion
Trunk strength
Whole body task performance
Assessment of symptom self-reports – pain and disability
Psychological evaluation
Vocational assessment
Phases of Rehabilitation
Initial reconditioning phase
Focus: improving mobility, overcoming neuromuscular
inhibition and pain sensitivity, and measuring
cardiovascular endurance·- Up to 12 appointments over 4-
6 weeks
Supervised stretching, aerobic and light work simulation
exercises for 2 hours twice/week
Comprehensive Phase
10 hours/day, 5 days/week, 3 weeks
Vigorous stretching and aerobics classes
Progressive resistive exercises twice a day under
supervision of physical therapist
Daily work – simulation of tasks, lifting drills, and
position-tolerance training exercises similar to work
hardening
Classes on goal setting, work issues, stress management,
and interpersonal skills development under direction of
psychologist
Active return-to-work planning monitored by vocational
therapist
Patient will not be permitted to complete this phase of
functional restoration without a work plan and will be
terminated if he or she refuses to make such a plan.
Follow-up Phase
1 and ½ days/week, up to 6 weeks
Reconditioning, work hardening, and vocational
counseling continue.
Allows integration of improvement and behavioral
changes generated during intense phase with return-towork
At end of follow-up, patient receives appropriate work
release from medical director with functional limitations
as indicated
Source: Manchikanti L, Board Review 2005
502
Q
- All of the following statements are true with regards
to the Controlled Substances Act of the Comprehensive
Drug Abuse Prevention and Control Act of 1970. - It is the legal foundation of the government’s fi ght
against the abuse of drugs and other substances. - It is a consolidation of numerous laws regulating the
manufacture and distribution of narcotics, stimulants,
depressants, hallucinogens, anabolic steroids and
chemicals used in the illicit production of controlled
substances. - All the substances that are regulated under existing federal
law are placed into I of V schedules. - Schedule I is reserved for the least dangerous drugs that
have the highest recognized medical use.
A
- Answer: A ( 1, 2, & 3)
Explanation:
The Controlled Substances Act (CSA), title 2 of the
Comprehensive Drug Abuse Prevention and Control Act
of 1970 is the legal foundation of the government’s fi ght
against the abuse of drugs and other substances. This law
is a consolidation of numerous laws regulating the
manufacture and distribution of narcotics, stimulants,
depressants, hallucinogens, anabolic steroids, and
chemicals used in the illicit production of controlled
substances.
All the substances that are regulated under existing federal
law are placed into I of V schedules. This placement is
based upon the substances’ medicinal value, harmfulness,
and potential for abuse or addiction.
Schedule I is reserved for the most dangerous drugs that
have no recognized medical use.
Schedule V is the classifi cation used for the least
dangerous drugs.
The Act also provides a mechanism for substances to be
controlled, added to a schedule, decontrolled, removed
from control, rescheduled, or transferred from one
schedule to another.
Source: Manchikanti L, Board Review 2005
503
Q
- Identify elements of a compliance program:
- Written standards of conduct and policies and procedures
- Occasional education and training
- Process to receive complaints and protect them
- Elimination of monitoring and auditing
A
- Answer: B (1 & 3)
Explanation:
Effective Compliance Program
Seven Minimum Elements - Standards of conduct and policies and procedures
- Chief Compliance Offi cer
- Regular effective education and training
- Process to receive complaints and protect them
- Disciplinary guidelines
- Periodic Monitoring and auditing
- Procedures to detect, respond to, and correct problems
504
Q
- The benefi ts of implementing a compliance program in a
physician practice include which of the following? - Avoiding confl icts with the self-referral and anti-kickback
statutes - The enhancement of patient care through increased accuracy
in documentation - Minimizes billing mistakes and optimizes proper payment
of claims - A cap on the amount of damages the government can
recover from the practice in a civil False Claims action
A
- Answer: A (1,2, & 3)
Explanation:
Explanation: Voluntary implementation of a compliance program can benefi t a physician practice in many ways;
however, there is no cap on damages the government can
recover.
Source: OIG Supplemental Compliance Program
Guidance for Hospitals, 70 Fed. Reg. 4858 (January 31,
2005).
Source: Erin Brisbay McMahon, JD, Sep 2005
505
Q
- The Health Insurance Portability and Accountability
Act in 1996 (HIPAA) states that to meet compliance, the
practice must: - Follow all federally mandated codes regarding billing
and collections practices - Adopt specifi c security and privacy policies
- Allow patient access to medical records
- Develop an audit trail for medical record access.
A
- Answer: C (2 & 4)
Explanation:
HIPAA is not specifi cally interested in the details of a
medical practice beyond elements of security and privacy.
The goal of HIPAA is not to either assist or impair billing
and collecting,but to hold accountable medical practices to
specifi c policy and procedures, and develop their own to
ensure medical record access, and accountability to audit,
security, and privacy. Security and privacy policies are
usually developed in conjunction with health law counsel.
The role of the EMR is to enhance compliance and
security.
Source: Hans C. Hansen, MD
506
Q
- Impairment is correctly characterized by the following
defi nition(s) - A loss, loss of use, or derangement of any body part,
organ system, or organ function - An alteration of an individual’s capacity to meet personal,
social, or occupational demands because of an
impairment. - An anatomical, physiological, or psychological abnormality
that can be shown by medically acceptable clinical
and laboratory diagnostic techniques. - A barrier to full functional activity that may be overcome
by compensating in some way for the causative
impairment.
A
- Answer: B (1 & 3)
Explanation:
Source: AMA Guides to the Evaluation of Permanent
Impairment, 2001.
Impairment Defi nitions
Guides to the Evaluation of Permanent Impairment:
A loss, loss of use, or derangement of any body part, organ
system, or organ function
World Health Organization (WHO):
Problems in body function or structure as a signifi cant
deviation or loss. Impairments of structure can involve an
anomaly, defect, loss, or other signifi cant deviation in body
structures.
Social Security Administration (SSA):
An anatomical, physiological, or psychological
abnormality that can be shown by medically acceptable
clinical and laboratory diagnostic techniques.
State Workers’ Compensation Law:
Permanent impairment” is any anatomic or functional loss
after maximal medical improvement has been achieved
and which abnormality or loss, medically, is considered
stable or nonprogressive at the time of evaluation.
Permanent impairment is a basic consideration in the
evaluation of permanent disability and is a contributing
factor to, but not necessarily an indication of, the entire
extent of permanent disability.
Source: Manchikanti L, Board Review 2005
507
Q
- A new patient evaluation, outpatient visit, requires the
following: - Initial professional services from the physician.
- Provider of same specialty belonging in same group
practice. - A patient who has not been seen in the past three years.
- An opinion or advice regarding patient condition.
A
- Answer: C
Source: Manchikanti L, Board Review 2005
508
Q
- The Social Security Administration uses a number of
criteria for determination of eligibility for disability
benefi ts. The sequential evaluation for determination
of benefi ts includes which of the following factors?
nonexertional factors (evaluation of the applicant’s
cognitive capabilities) are part of the evaluation of
residual functional capacity. - Age
- Educational background
- Previous work history
- Residual functional capacity
A
- Answer: E (All)
Explanation:
Source: AMA Guides to the Evaluation of Permanent
Impairment, 2001
To determine eligibility for Social Security funds, the
applicant must undergo a sequential evaluation process
that considers the applicant’s ability to perform work
despite any functional restrictions associated with physical
impairment. Medical and psychological variables are
considered, along with the applicant’s age, educational
background, and previous work history. The applicant
must undergo a medical evaluation to determine residual
functional capacity. Both exertional factors (evaluation of
the applicant’s ability to perform work functions in several
different work environments) and nonexertional factors
(evaluation of the applicant’s cognitive capabilities) are
part of the evaluation of residual functional capacity.
Source: Manchikanti L, Board Review 2005
509
Q
- The following statements are true to describe the
purposes of rehabilitation: - To resolve deconditioning syndrome, which is developed
from prolonged bedrest with loss of muscle strength,
decreased fl exibility, and increased stiffness. - To optimize outcome by restoring function and returning
to activity. - To minimize potential or recurrence or re-injury.
- Short periods of rest between activities helps to exacerbate
the deleterious effects of inactivity.
A
- Answer: A (1, 2 & 3)
Explanation:
Source: Cole and Herring. Low Back Pain Handbook.
Purposes of Rehabilitation
To resolve deconditioning syndrome:
Prolonged bedrest
Flexibility
Stiffness (loss of intrinsic muscle strength muscle
strength, 10-15% per week, 70% in 6 months)
Cardiovascular fi tness
Disc nutrition
Depression
Short periods of rest between activities helps to minimize
the deleterious effects of inactivity.
To optimize outcome by:
Restoring function
Returning to activity
Minimize potential recurrence or re-injury
(Rehabilitation continues beyond resolution of symptoms)
To minimize need for surgical intervention
Failure of conservative care is the most common
indication for surgery
Source: Manchikanti L, Board Review 2005
510
Q
2431.Paymdecesionent for clinical services based on
the Medicare RBRVS includes all of the following
components:
1. Physician work
2. Malpractice
3. Clinically-related practice expenses
4. Physician availability for emergency care
A
- Answer: D (4 only)
Source: Manchikanti L, Board Review 2005
511
Q
- What are the elements of a training program for needle
stick safety? - General explanation of epidemiology and symptoms of
bloodborne diseases - Explanation of modes of transmission of bloodborne
pathogens - Explanation of appropriate methods for recognizing
tasks/activities involving exposure - Explanation of methods to prevent or reduce exposure
A
- Answer: E (All)
Explanation:
12 Elements of Training Program
* Accessible copy of regulatory text and explanation of its
contents
* General explanation of epidemiology and symptoms of
bloodborne diseases
* Explanation of modes of transmission of bloodborne
pathogens
* Explanation of Employer’s Exposure Control Plan and
how employee may obtain copy * Explanation of appropriate methods for recognizing
tasks/activities involving exposure
* Explanation of methods to prevent or reduce exposure
* Information on decontamination and disposal of
personal protective equipment
* Appropriate actions and persons to contact in emergency
* Procedures to follow if exposure occurs
* Information post-exposure evaluation and follow-up
* Explanation of signs and labels and color-coding for biohazard
* Opportunity for interactive questions
512
Q
2433.Enforcement weapons against fraud and abuse may include the following: 1. Anti-kickback statute 2. Needle stick safety 3. Stark Law 4. Americans with Disabilities Act
A
2433. Answer: B (1 & 3) Explanation: Enforcement Weapons Anti-Kickback Statute HIPAA Stark Law False Claims Act Administrative Sanctions QUITAM (Whistle blower Act). State Law(s)
513
Q
- What are permitted disclosures under privacy regulation
without the individual’s permission? - Public health activities
- Judicial and administrative proceedings
- Health oversight activities and government benefi t
- A request from prosecution in a liability case
A
- Answer: A (1,2, & 3)
Explanation:
Permitted Disclosures - Without the Individual’s
Permission
* Uses and Disclosures Required by Law
* Public Health Activities
* Violence or Elder Abuse
* Health Oversight Activities and Government Benefi t
* Judicial and Administrative Proceedings
* Law Enforcement
* Disclosure to Coroners and Medical Examiners
* Organ procurement organizations
* Research purposes if IRB makes certain determinations
* Specialized government functions (military)
* Workers’ compensation
- Only to extent required by state law
514
Q
2435.True statements about Federal Health Care Offense
under HIPAA are as follows:
1. Offense of “health care fraud” added to criminal statute
2. Only Medicare
3. Fines ($10,000), forfeiture, 10 years imprisonment
4. It is synonymous with Balanced Budget Act
A
- Answer: B (1 & 3)
Explanation:
Federal Health Care Offense Under HIPAA
* Offense of “health care fraud” added to criminal statute
* Any health care program - public or private, affecting
commerce
* Fines ($10,000), forfeiture, 10 years imprisonment
515
Q
- Many provider activities during a given procedure
are integral to the procedure and termed as “generic
activities.” Some generic services integral to standard
medical/surgical services include: - Draping of the patient
- Insertion of intravenous access.
- Cleansing, shaving and prepping the skin.
- Referring the patient to a different physician.
A
- Answer: A (1,2, & 3)
Explanation:
Items 1, 2, and 3 are all considered generic services
integral to standard procedures. Referral to a different
physician may occur outside the provision of a procedure,
but is not integral to it.
Source: James A. Mirazita, MD, Sep 2005
516
Q
- Exclusion means the following for a provider:
- A prohibition from providing health care services for a
period of time - A prohibition from billing federal health programs for
items or services - A prohibition from practicing as a physician for a period
of time - A prohibition from receiving reimbursement from federal
health care programs for items or services
A
- Answer: C (2 & 4)
Explanation:
Source: Manchikanti L, Principles of Documentation,
Billing, Coding & Practice Management 2004
Exclusion means a provider is barred from receiving
reimbursement from Medicare, Medicaid or other federal
health care programs. There are two types of exclusion:
Mandatory and permissive. Under mandatory exclusion,
HHS must exclude – it has no choice. Under permissive
exclusion, HHS has some discretion.
Source: Manchikanti L, Board Review 2005
517
Q
- OIG guidance on disciplinary guidelines includes:
- Written policies which may be discriminatory
- Written scope of sanctions
- Not essential to publish standards and guidelines
- Background investigations for new employees
A
2438. Answer: C (2 & 4) Explanation: Disciplinary Guidelines * Written policies - nondiscriminatory * Scope of sanctions * Range of responsibility * Publication of standards and guidelines * Background investigations for new employees
518
Q
- The largest risks for physicians are identifi ed under the
False Claims Act surround coding and billing. Which
statement regarding coding and billing under False
Claims Act regulations are accurate? - In some regions, billing patients for “no shows”, i.e.,
billing Medicare for services which were not actually
furnished because the patients failed to keep their appointments,
is an indicator of fraud and abuse. - Duplicate bills submitted to third party payors under
the mistaken belief that the original claim has been lost
or misplaced may indicate a reckless disregard of the
problem and give rise to false claim liability. - Upcoding, or billing for a more expensive service than
the one actually performed, can lead to false claim allegations. - Clustering, which is the practice of coding and charging
one or two middle levels of service codes exclusively,
under the reasoning that some will be higher, some
lower, and the charges will average out over an extended
period, is not considered a practice
A
- Answer: A (1,2, & 3)
Explanation:
Explanation:
1) The CMS region covering Kansas, Nebraska and
Northwest Missouri specifi cally states on its website that
billing Medicare for “no shows” is an indicator of fraud
and abuse.
2) Duplicate bills are often submitted to third party payors
under the mistaken belief that the original claim has been
lost or misplaced. Although double billing can occur due
to simple error, systematic double billing may indicate a
reckless disregard of the problem and give rise to false
claim liability.
3) Upcoding can lead to false claim allegations and should
not be tolerated within the physician practice.
4) Clustering can lead to false claim allegations and
should not be tolerated within the physician practice.
Source:
See Medicare: Fraud and Abuse
(www.nebraskamedicare.com/policy/fraud.htm); see also
65 Fed. Reg. at 59439.
Source: Erin Brisbay McMahon, JD, Sep 2005
519
Q
- When the focus of treatment for an individual patient
is a medical problem, as opposed to a mental health
problem, the psychologist should use the following CPT
code: - Diagnostic interview (90801).
- Individual psychotherapy (90806).
- Individual behavioral health assessment (96150).
- Individual behavioral health intervention (96152).
A
- Answer: D (4 Only)
Explanation:
1) This response is incorrect as it is generally used for the
assessment of mental health disorders.
2) This response is incorrect, as it is generally used to
designate individual services of a psychologist whose
treatment is designed to ameliorate a mental health problem.
3) This response is incorrect, as it is generally used for a
psychosocial assessment of a medical problem.
4) This response is correct. Individual behavioral health
intervention is the code to use when the focus of a
psychologist’s services is the amelioration of an
individual’s medical problem.
CPT 2005 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY. p. 163
Source: Marsha Thiel, RN, MA, Sep 2005
520
Q
- True statements about QUI TAM (Whistleblower Act)
are as follows: - Suits are usually brought by employees
- If the government proceeds with the suit, the whistleblower
receives 50 to 60% of settlement. - Individuals can bring suit against violators of Federal
laws on their own behalf as well as the government’s - If the government does not proceed and the individual
continues, the individual receives 100% of the settlement
A
- Answer: B (1 & 3)
Explanation:
QUI TAM (Whistleblower Act)
1Suits are usually brought by employees
2 If the government proceeds with the suit, the
whistleblower receives 15 to 25% of settlement.
3 Individuals can bring suit against violators of Federal
laws on their own behalf as well as the government’s
4 If the government does not proceed and the individual
continues, he receives 25 to 30% of the settlement
Source: Laxmaiah Manchikanti, MD
521
Q
2442. A psychological assessment generally consists of the following: 1. Psychometric testing. 2. Review of the medical record 3. Diagnostic interview 4. Physical exam
A
- Answer: A (1,2, & 3)
Explanation:
Psychologist assessment generally consists psychometric
testing, review of the medical record and diagnostic
interview. Psychologists do not perform physical exams
when performing psychological assessments.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
522
Q
- Roles of a clinical psychologist within a pain clinic are
the following: - Direct services to patients
- Direct services to patients, consultation, supervision
- Direct services to patients, consultation, management
- Direct services to physicians
A
- Answer: A (1,2, & 3)
Explanation:
The roles listed are legitimate roles of a psychologist
within a pain clinic.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
523
Q
2444.Multiple factors leading to introduction of OIG Compliance Plan include: 1. Runaway healthcare costs 2. Balanced Budget Act 3. Operation Restore Trust 4. Successful Healthcare Reform
A
2444. Answer: A (1,2, & 3) Explanation: Social/Economic Climate - Fraud and Abuse Headlines - Runaway Healthcare Costs - Failed Healthcare Reform - Aging Baby Boomers - Balanced Budget Operation Restore Trust - In 1995 the DHHS OIG, DOJ and others began a demonstration project in 5 states to fi ght fraud and abuse. - Result - for every $1 spent - $23 recovered Laws - Old and New - Enforcement Weapons Source: Alan Reider, JD
524
Q
- Sedentary work is characterized by the following
criteria: - Lifting a maximum of 10 lbs.
- Carrying objects weighing up to 10 lbs.
- Requirement of occasional walking and standing, but
mostly sitting - Pushing and pulling of arm or leg controls
A
- Answer: B (1 & 3)
525
Q
- When preparing to hire a psychologist, it is essential to
determine: - How to add the psychologist to the clinic’s liability
insurance. - How much psychologist can guarantee in income
- The employment screening needs that are required by
the psychology state and provincial licensing boards. - How much profi t the clinic would make
A
- Answer: B ( 1 & 3)
Explanation:
An example of screening requirements are the following
form the state of Minnesota.
http://www.revisor.leg.state.mn.us/stats/148A/
Source: Marsha Thiel, RN, MA, Sep 2447. Answer: D (4 Only)
Explanation:
Per Medicare “There must have been a direct, personal
professional service furnished by the physician to initiate
the course of treatment of which the service being
performed by the non-physician is an incidental part”
Source: Marsha Thiel, RN, MA, Sep 2005
526
Q
2447.To ensure compliant “incident to” physician service billing in a clinical setting, it is important to keep in mind
which of the following?
1. No other procedures may be performed on the patient
in the same day as an E&M service billed incident to the
physician performing the procedure.
2. The supervising MD must be present in the same exam
room during subsequent visits
3. A modifi er must be attached to the billed code to
designate the service is being billed as incident to the
physician.
4. There must be a direct personal service furnished by the
physician to initiate the course of treatment
A
- Answer: D (4 Only)
Explanation:
Per Medicare “There must have been a direct, personal
professional service furnished by the physician to initiate
the course of treatment of which the service being
performed by the non-physician is an incidental part”
Source: Marsha Thiel, RN, MA, Sep 2005
527
Q
- You have been provided with multiple reasons to
establish a compliance plan: Choose accurate statements - Physicians and other practitioners often do not have
the financial means to employ a compliance specialist,
therefore may be more vulnerable to unintentional
violations. - Fewer errors, accurate reimbursement and less chance
of a CMS audit. - Lends weight to bill procedures
- Provides “total immunity” against any wrong doing.
A
- Answer: A (1,2, & 3)
Explanation:
WHY HAVE A COMPLIANCE PLAN?
Physicians and other practitioners often do not have the
fi nancial means to employ a compliance specialist,
therefore may be more vulnerable to unintentional
violations.
Fewer errors, accurate reimbursement and less chance of a
CMS audit.
Now Medicaid, WC, MVA and private payors
Lends weight to billing procedures
Demonstrates “good faith efforts” to perform in
accordance with the laws.
WHY OIG COMPLIANCE PLAN?
The only thing worse than not having a compliance
program, is creating a plan without implementation
The single most important step in practicing appropriately
To minimize the risk of a criminal prosecution and to
lower the risk of civil penalties
Creating an inference of good faith
528
Q
- What are true statements about criminal penalties?
- Health care fraud faces - fi nes, up to 10 years in jail, or
both. - Theft or embezzlement in connection with health care
faces - fi nes, up to 10 years in jail, or both - Obstruction of criminal investigations of health offenses
faces - fi nes, up to 5 years in jail, or both - False statements and relating to health care matters faces
- fi nes, up to 5 years in jail, or both
A
- Answer: E (All)
Explanation:
Health Care Fraud
Fines, up to 10 years in jail, or both
Theft or Embezzlement in connection with Health Care
Fines, up to 10 years in jail, or both
Obstruction of Criminal Investigations of Health Offenses
Fines, up to 5 years in jail, or both
False Statements and Relating to Health Care Matters
Fines, up to 5 years in jail, or both
Mail and Wire Fraud
Fines, up to 5 years in jail, or both
False Statements and kickbacks Involving Federal Health
Care Programs
Fines up to $25,000, up to 5 years in jail, or both
Exclusion from Participation in federal health care
programs
529
Q
- What are true statements about fraud in medicine in
U.S.A.? - Medicare fee for service error rate was 8% in 2004.
- A GAO audit reported that in the U.S. approximately
10% of every health care dollar is lost to fraud annually. - Estimated net improper payments of CMS for 2004
exceeded $50 billion - Fraud and abuse cases include 60% public and 40%
private.
A
- Answer: C (2 & 4)
Explanation:
A GAO Audit reported that in the U.S. approximately 10%
of every Health Care dollar is lost to fraud annually.
10% = $100 Billion of one Trillion or 100,000
Million
2004 - 10%= $179.3 Billion of 1.7934 of Trillion or
1,793.4 Million
2010 - 10%=$263.74 Billion of $2.6374 Trillion or
263,740 Million
Fraud and Abuse cases
Public 60%
Private 40%
Source: Laxmaiah Manchikanti, MD
530
Q
2451. Compliance offi cer is providing the annual report. What are indications of non-compliance? 1. Claim problems 2. Staff problems 3. Accounting issues 4. Your documentation had 1% error rate
A
2451. Answer: A (1,2, & 3) Explanation: Indications of Non-Compliance 1. Claim problems - paid slowly - frequent problems - problem claims unresolved - cash fl ow problems 2. Staff problems - rapid turnover - staff takes work home - poor morale - disgruntled staff - staff not loyal - staff disrespectful - staff questioning about charges 3. Accounting issues - cash fl ow - keep borrowing - no real accounting 4. 1% Error Rate is Acceptable -You are under scrutiny - by Medicare, Medicaid, Tricare - by W/C and personal injury insurances - by third party payer - your own staff - your partners or superiors
531
Q
- Possible punishments for violating the Self Referral
Laws (Stark) include . . . - Civil money penalties of up to $15,000 per claim
- Civil money penalties of up to $100,000 per scheme
- Exclusion from Medicare and Medicaid
- A term of imprisonment of not more than fi ve years
A
- Answer: A (1,2, & 3)
Explanation:
Explanation: Violations of the Self-Referral Laws are
punishable with civil money penalties of up to $15,000 per
claim, $100,000 per scheme, and exclusion from federallyfunded
health care programs such as Medicare and
Medicaid.
Source: 42 U.S.C. 1395nn.
Source: Erin Brisbay McMahon, JD, Sep 2005
532
Q
- What are the penalties under the False Claims Act?
- Three times the amount of damages suffered by the
government - A mandatory civil penalty of at least $5,500 and no more
than $11,000 per claim. - Submit 50 false claims for $50 each (liability between
$282,500 and $557,500 in damages) - Program exclusion
A
- Answer: E (All)
Explanation:
Pentalties under False Claims Act:
Three times the amount of damages suffered by the
government
A mandatory civil penalty of at least $5,500 and no more
than $11,000 per claim.
Submit 50 false claims for $50 each
- Liability between $282,500 and $557,500 in damages.
Program Exclusion
Source: Laxmaiah Manchikanti, MD
533
Q
- What are OIG identifi ed risk areas?
- Billing for items or services not actually rendered
- Providing medically unnecessary services
- Joint ventures
- Physician self-referrals
A
2454. Answer: E (All) Explanation: RISK AREAS * Billing for items or services not actually rendered * Providing medically unnecessary Services * Upcoding * DRG Creep * Unbundling * Double Billing * Duplicate Billing * Teaching physicians and residents * Hospital Incentives * Joint Ventures * Physician Self-referrals POLICIES AND PROCEDURES * Documentation - For claims and billing proper and timely documentation of services - Claims submitted only when documentation is maintained and available for audit - Legible - Appropriately organized - Diagnosis and procedures be based on documentation which is available to the coding staff * Compensation - No incentive to upcode claims
534
Q
- Identify true statements of benefi ts of coding
compliance: - Improvement of quality of data
- Creation of effi cient medical practice
- Improved and correct reimbursement
- Increased risk of fraud and abuse investigations
A
- Answer: A (1,2, & 3)
Explanation: - Improvement of quality of data
- Improvement of knowledge
- Creation of effi cient medical practice
- Improved relations between staff
- Improved and correct reimbursement
- Protection against fraud and abuse
- Availability of proper data for evaluation purposes
- Improved quality management and improvement with
enhanced availability of data. - Improved relations with public and payors
- Peace of mind and comfort with enhanced medical
practice.
Source: Laxmaiah Manchikanti, MD
535
Q
- The performance of a comprehensive baseline audit of
the practice’s operations is the initial step in developing
an effective compliance program. The steps of an audit
include: - A review of key documents
- A review of coding and billing practices
- The performance of a physician practice walk-through
- Interviews of the staff
A
- Answer: E (All)
Explanation:
The initial step in developing an effective compliance
program is the performance of a comprehensive baseline
audit of the practice’s operations. The purpose is to
ascertain whether the practice’s current practices and
procedures conform to all pertinent legal requirements.
The steps of an audit include: (1) review the key
documents, (2) review coding and billing practices, (3)
perform a physician practice walk-through, (4) interview
staff, and (5) review medical charts.
Source: 65 Fed. Reg. 59434.
Source: Erin Brisbay McMahon, JD, Sep 2005
536
Q
- What are some of the common reasons for denials?
- Arbitrary denial
- Wrong coding
- Misinterpretation of the coding
- Incorrect coding
A
2457. Answer: E (All) Explanation: * Reasons for denial - Misinterpretation of the coding - Arbitrary denial - Repeated incorrect coding leads to auditing Source: Laxmaiah Manchikanti, MD
537
Q
- Tasks performed by the EMR include:
- Transcription
- Clinical decision making and support
- Chart documentation
- Patient data retrieval for personal use
A
- Answer: B ( 1 & 3)
Explanation:
The tasks performed by the EMR do not necessarily allow
for direct patient access to the records. That is a potentially
desirable feature, but should be controlled at the front and
back offi ce. The tasks performed by the EMR include:
chart documentation, transcription, prescription writing
and database, order entry, and results reporting inpatient
reports, triage of telephone communications, and secure
messaging systems. Furthermore, the software should be
able to interface with other systems, assisting in support,
and capability of multiple users. A very strong advantage
of the EMR is remote data access.
Source: Hans C. Hansen, MD
538
Q
- The EMR stores information as:
- Text fi le
- Alphanumeric fi le
- A structured database for data retrieval
- HEDON file
A
- Answer: A (1,2, & 3)
Explanation:
A HEDON fi le is not relevant to the EMR data storage.
The advantage of an EMR is data retrieval, and the access
to understanding this data is important to the provider,
and to the front offi ce. It should be in an easily
understood
formulation.
Source: Hans C. Hansen, MD
539
Q
- What are the true statements about CPT history?
- In 1956 the fi rst edition of CPT was published
- In 1960 the fi rst edition of CPT was published
- In 1965 Health Care Financing Administration adopted
(HCFA) CPT - In 1988 AMA released minibooks
A
2460. Answer: D (4 Only) Explanation: * CPT History 1966 – First edition 1970 – Second edition 1973 – Third edition 1977 – Fourth edition 1983 – HCFA adopts CPT 1983 – CPT- editorial page 1983 – Annual updates 1988 – Minibooks Source: Laxmaiah Manchikanti, MD
540
Q
2461.What does Health Insurance Portability and
Accountability Act compliance administrative
simplifi cation do?
1. Increases costs associated with administrative and
claims related transactions
2. Establishes a national uniform standards for 8 electronic
transactions, and claims attachments
3. Eliminates unique provider identifi ers
4. Establishes protections for the privacy and security of
individual health information
A
- Answer: C (2 & 4)
Explanation:
HIPAA COMPLIANCE - Administrative Simplifi cation - Reduces costs associated with administrative and claims
related transactions
- Over $30 billion in savings over 10 years - Establishes a national uniform standards for 8 electronic
transactions, and claims attachments - Established unique provider identifi ers
- Establishes protections for the privacy and security of
individual health information
Implementation costs
- Over $500 billion over 10 years
Source: Laxmaiah Manchikanti, MD
541
Q
- What are the steps to compliance of security standards?
- Administrative safeguards
- Physical safeguard
- Technical safeguard
- Financial viability safeguard
A
- Answer: A (1,2, & 3)
Explanation:
Three steps to compliance
The new rule on the security of electronic patient records
boils down to three sets of standards that practices will
need to implement step-by-step. - Administrative safeguards
Assess computer systems
Train staff on procedures
Prepare for aftermath of hackers or catastrophic events
Develop contracts for business associates - Physical safeguard
Set procedures for workstation use and security
Set procedures for electronic media reuse and disposal 3. Technical Safeguard
Control staff computer log-in and log-off.
Monitor access of patient information
Set up computers to authenticate users. - There is no fi nancial viability safeguard
Source: Laxmaiah Manchikanti, MD
542
Q
- Identify accurate statements?
- A false claim is “knowingly” failing to make inquiry
regarding the accuracy of the claim - A false claim is prosecuted by district attorney
- A false claim is when claimant knows or should know
that the claim was false - A false-claim applies only for claims over $10,000
A
- Answer: B (1 & 3)
543
Q
- Pursuant to the Federal Anti-Kickback Law, physician
practices should not have arrangements with which of
the following entities unless the arrangement is within
a Safe Harbor? - Ambulatory surgery centers
- Clinical laboratories
- Hospitals
- Durable medical equipment suppliers
A
- Answer: E (All)
Explanation:
Many common business arrangements have the potential
to violate state or federal anti-kickback laws. Physician
practices should not have any arrangement with hospitals,
ambulatory surgery centers, durable medical equipment
suppliers, diagnostic imaging centers, clinical
laboratories, billing companies, or others that provide any
form of payment or remuneration for referrals of patients
for services that may be covered by a federally-funded
health care program, unless the arrangement falls squarely
and appropriately within one of the anti-kickback law safe
harbors.
Source: 42 CFR 1001.952 (1991).
Source: Erin Brisbay McMahon, JD, Sep 2005
544
Q
2465.What sections are utilized in Interventional Pain Management Coding? 1. Evaluation and Management Section 2. Nervous System of Surgery Section 3. Radiology Section 4. Chiropractic Section
A
2465. Answer: A (1,2, & 3) Explanation: Interventional Pain Management Coding 1. Evaluation and Management 2. Surgery General Pelvis and hip joint Nervous system Spine and spinal cord Extracranial nerves, peripheral nerves and autonomic nervous system 3. Radiology (needle placement, fl uoroscopy) Spine and pelvis Lower extremities (si joint) Other procedures 4. Medicine Physical medicine & Rehab Psychiatry Source: Laxmaiah Manchikanti, MD
545
Q
- Which of the following is a true statement with regard to
the Federal Self-Referral Law (Stark)? - Stark rules prohibit physicians from referring patients to
hospitals where physicians work. - Stark rules prohibit physicians from personally performing
the designated health service which they order
for their patients. - Stark rules prohibit investments in publicly traded companies
and mutual funds. - Stark rules prohibit physicians from making referrals to
a designated health service entity in which the physician
has a fi nancial relationship, unless an exception
applies.
A
- Answer: D (4 Only)
Explanation: - Stark Law prohibits a physician from making referrals
for certain designated health services to entities where (a)
the physician has a direct or indirect fi nancial relationship
and (b) the service is billed to Medicare or Medicaid. - Physicians who personally perform the DHS which they
order for their patients are covered by an exception to
Stark Law. - Investments in publicly traded companies and mutual
funds are protected as an exception to Stark Law. - Stark referral rules do not prohibit physician referrals
to hospitals.
Sources:
42 U.S.C. 1395nn; 42 CFR 411.355, .357.
Source: Erin Brisbay McMahon, JD, Sep 2005
