CH7- Medical Necessity

Question 1

Use CPB Chapter 7_Case 1.pdf to answer questions 1 & 2.
A 40-year-old patient is trying Botox® for her chronic migraines. According to the policy, what are the symptom parameters that must be documented?
a. The patient has chronic intractable migraines with status migrainosus.
b. The patient has chronic migraines more than 15 days per month, with headaches lasting 4 hours a day or longer.
c. A diagnosis of chronic migraines is sufficient.
d. There are no specific documentation requirements for the use of Botox® for chronic migraines.

Answer 1

b. The patient has chronic migraines more than 15 days per month, with headaches lasting 4 hours a day or longer.
Response Feedback:
When Botox® (onabotulinumtoxina) is used for the FDA approved indication of prophylaxis of headaches in adult patients with chronic migraine (> 15 days per month with headache lasting 4 hours a day or longer), the documentation must support these specific symptom parameters.

Question 2

Use CPB Chapter 7_Case 1.pdf to answer the following question.
The patient has had three injections without relief from the migraines. According to the policy in Chapter 7 Case 1, what will be considered for coverage by Medicare?
a. All three injections will be covered by Medicare.
b. Only one injection is covered by Medicare.
c. Two of the three injections are covered when the treatment fails.
d. None of the injections are covered as Botox® is not a covered condition for chronic migraines.

Answer 2

c. Two of the three injections are covered when the treatment fails.
Response Feedback:
Two of the three injections are covered when the treatment fails.
Rationale: According to the policy above, it is expected that patients will not continue to receive injections of Botox® if, after 2 consecutive injections, using maximum dose for the size of the muscle, treatment has failed.

Question 3

Case2
A 40-year-old patient has severe pain in his lower back. After multiple surgeries, physical therapy, and various medications without relief, the provider performed percutaneous epidural lysis of adhesions. An epidural catheter is placed and an epidurography is performed. A series of injections are performed over a span of 3 days. The catheter is removed.
Utilize the NCCI edits and MUE edits above. Which of the following is the correct way to report this procedure?
a. 62264
b. 62263
c. 62263, 62264
d. 62264 x 2

Answer 3

b. 62263
Response Feedback:
The procedure occurred over a three-day period. According to the NCCI edits, 62263 and 62264 cannot be reported together due to the description of the codes. According to the MUE edits, 62263 and 62264 can only be reported once per person per day. Referring to the code descriptors in the CPT codebook; 62263 is for multiple sessions for 2 or more days and 62264 is for multiple sessions over a 1-day period. This scenario has multiple injections over a three-day period making 62263 the correct code.

Question 4

Case 3
According to this excerpt from the NCCI edits, which code pair will allow the use of a modifier to bypass the edit if the documentation supports the use of the modifier?
a. 22010, 69990
b. 22010, 64530
c. 22010, 76000
d. 22010, 6452

Answer 4

c. 22010, 76000
Response Feedback:
Code pair 22010, 76000 has a CCM indicator of one which indicates a modifier may be used to bypass the edits if the documentation supports the use of the modifier.

Question 5

Case 4
According to this excerpt from the MUE table, which procedure may NOT be reported with two units on the same date of service?
a. 15740
b. 15756
c. 15760
d. 15769

Answer 5

d. 15769
Response Feedback:
Rationale: The MUE table identifies the maximum number of units a procedure can be reported on the same date of service. According to this table, 15769 may only be reported with one unit on the same date of service.

Question 6

Use CPB Chapter 7_Case 5.pdf to answer the following question.
A 50-year-old male patient is being see for his annual exam. He has hypertension, hyperlipidemia and hematuria. According to this medical policy, what parameters must be documented to cover the PSA test?
a. The patient has hematuria
b. There are no specific documentation requirement for prostate specific antigen test
c. The patient has hyperlipidemia
d. The patient has hypertension

Answer 6

b. There are no specific documentation requirement for prostate specific antigen test
Response Feedback:
Rationale: According to Policy 190.31 - The medical policy does not indicate that any specific diagnosis is to be documented to cover a PSA test. The Coverage Indications do indicate that patients with LUTS (lower urinary tract symptoms) often undergo PSA tests to differentiate between benign vs malignant disease. However, it is not mandatory for a person to have LUTS for the coverage to apply.

Question 7

Use CPB Chapter 7_Case 6.pdf to answer questions 7 & 8.
A 30-year-old female patient is being seen for a routine exam. She appears to be fairly healthy but is requesting a screening mammogram. With the increases rates of detected breast cancer, this patient wants to be tested in an effort of early detection. According to the policy, is this a covered service?

a. Screening mammograms are covered for all women regardless of age.
b. Women ages 35 and 40 are covered for annual screening mammograms.
c. Women 40 and older are covered for annual screening mammograms.
d. There is not a required age limitation for screening or diagnostic.

Answer 7

c. Women 40 and older are covered for annual screening mammograms.
Response Feedback:
According to this policy, women 40 and older are eligible for annual screening mammograms. Women between age 35-39 are eligible for one baseline mammogram. Payment may not be made for a screening mammogram performed on a woman under age 35.

Question 8

Use CPB Chapter 7_Case 6.pdf to answer the following question.
A 45-year-old female patient is being seen for a routine screening mammogram. The patient states that she does perform her own exams and has noticed a lump in her right breast. Upon review of the screening mammography, the results were inconclusive and did not warrant an additional test. The patient is still concerned and requests to have a diagnostic exam performed. According to the policy, is this a covered service?
a. This is not a covered service. The policy states an additional test has to be ordered and the radiologist is not recommending more tests.
b. This is a covered service as the patient is within the age range for a mammography to be covered.
c. This is a covered service as the patient has not had a diagnostic test performed this year.
d. There is no specific requirement on the number of mammograms that can be performed.

Answer 8

a. This is not a covered service. The policy states an additional test has to be ordered and the radiologist is not recommending more tests.
Response Feedback:
According to this policy, a diagnostic mammogram has to be ordered by a physician and the patient has to be under the care of a physician. The patient also has to have signs, symptoms or possible radiographic abnormalities detected on the screening mammography.

Question 9

Use CPB Chapter 7_Case 7.pdf to answer the following question.
A 54-year-old male patient is being seen for chest pain. During the visit he states that he smokes a pack and a half of cigarettes a day and has done so for years. Cancer does run in his family but not lung cancer. He has no signs or symptoms related to lung cancer. According to this policy, does this patient qualify for a Lung Cancer Screening?

a. Yes; he smokes more than one pack a day which makes him eligible for coverage for the lung cancer screening test.
b. No; he does not have any signs or symptoms related to lung cancer and does not qualify.
c. Yes; he has a physician’s order for the test.
d. No; he does not fall within the eligibility age criteria and does not qualify.

Answer 9

d. No; he does not fall within the eligibility age criteria and does not qualify.
Response Feedback:
According to the policy, the age eligibility criteria is 55-77. This patient is 54-years-old.

Question 10

Case 8
Patient arrives at ABC hospital with an order for MRI Brain without/with contrast. Can 70552 and 70551 be reported for the services performed?

a, No; you cannot report both 70552 and 70551 unless a modifier is applied.
b. Yes; you can always report both.
c. No; you cannot report both. CPT 70553 would apply when the test is performed without contrast followed by with.
d. These two codes can never be reported together.

Answer 10

c. No; you cannot report both. CPT 70553 would apply when the test is performed without contrast followed by with.
Response Feedback:
CPT 70553 is the most appropriate code to report as it included the test being performed without contrast followed by with.

Question 11

Case 9
A patient arrives at ABC Imaging Center with an order for CT Abdomen and Pelvis with contrast. Can 74177 be reported with 74160 for the services performed?
a. Yes; the patient is having both a CT of abdomen and also CT of pelvis.
b. Yes; you can always report both.
c. No; you cannot report both. CPT® 74177 would be the only code to report as it includes the CT of both the abdomen and the pelvis.
d. No; these two codes can never be reported together.

Answer 11

c. No; you cannot report both. CPT® 74177 would be the only code to report as it includes the CT of both the abdomen and the pelvis.
Response Feedback:
CPT 74177 would be the only code to apply as it includes the CT of both the abdomen and the pelvis.

Question 12

What does the acronym NCCI stand for?
a.
National Correct Coding Initiative

b.
National Correct Coding Institute

c.
National Coding Coverage Institute

d.
National Coding Clinic Initiative

Answer 12

a.
National Correct Coding Initiative
Response Feedback:
Rationale: NCCI is the acronym for National Correct Coding Initiative which was instituted by CMS to prevent improper payment by identifying services that should not be billed together.

Question 13

Codes that are considered bundled based on Centers for Medicare & Medicaid (CMS) standards are determined by what?
a.
NCDs

Correctb.
NCCI

c.
MUEs

d.
LCDs

Answer 13

b.
NCCI
Response Feedback:
Rationale: National Correct Coding Initiative (NCCI) is used by CMS to determine when services or procedures should be bundled, or not separately reported.

Question 14

Services that are performed for treatment or diagnosis of an injury, illness, or disease in accordance with generally accepted standards of medical practice are considered what?
a.
Medical necessity

b.
Compliance

c.
Clinical standards

d.
HIPAA

Answer 14

a.
Medical necessity
Response Feedback:
Rationale: Medical necessity is defined differently from payer to payer; however, Medicare defines it as an accepted standard of care provided to treat or diagnose injury, illness, or disease.

Question 15

A patient is scheduled for a laparoscopic procedure that is converted to an open procedure after the procedure is initiated. Which of the following would be correct coding based on CMS NCCI edits?
a. Not payable with the Column 1 code unless a modifier is permitted and submitted.
b. Not payable because they have frequency limits.
c. Payable with the Column 1 code.
d. Never payable with the Column 1 code.

Answer 15

a. Not payable with the Column 1 code unless a modifier is permitted and submitted.

Response Feedback:
Rationale: Column 2 indicates the code is not payable with the Column 1 code, unless a modifier is permitted and submitted on the claim.

Question 16

The part of National Correct Coding Initiative (NCCI) that places frequency limitations on codes that can be billed on a single date of service by a single provider is called what?
a. CCI
b. LCD
c. NCD
Correctd. MUE

Answer 16

d. MUE
Response Feedback:
Rationale: MUEs provide limitations of frequency on codes that can be billed in a single day by a single provider for a beneficiary.

Question 17

Services that are integral to the procedure for a surgery being performed – such as cleaning and prepping the skin, opening and closing the surgical site, or any cultures being taken are considered to be what?
a.
Determined individually by payer.

Correctb.
Are included and never separately billable.

c.
Are separately billable if they require additional time.

d.
Separately billable.

Answer 17

b.
Are included and never separately billable.
Response Feedback:
Rationale: Preparation, opening and closing of the surgical site, or any cultures being taken are all integral, or included and not separately billable.

Question 18

According to the NCCI table, when an excision of a pilonidal cyst or sinus, simple (11770) is performed and a simple repair (12002) is performed at a different location, how should this be reported for a commercial carrier using the NCCI edits?
a. 11770, 12002
b. 11770
c. 12002
Correctd. 11770, 12002-59

Answer 18

d. 11770, 12002-59
Response Feedback:
Rationale: In the NCCI Table, the column 2 code is included in the column 1 code. A CCM modifier of 1 allows the use of a modifier when the documentation supports it. In this case 12002 is included in 11770. If documented, they can be reported separately with a modifier. Because these were performed on different locations, modifier 59 is appropriate.

Question 19

Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include which of the following?
a. Approved CPT® codes when performing the procedure.
b. Comorbid conditions of the patient.
Correctc. Investigational or experimental procedures.
d. Diagnostic limitations for proposed procedures.

Answer 19

c. Investigational or experimental procedures.
Response Feedback:
Rationale: NCDs must be read for all guidance pertaining to certain procedures. The guidance could include, but is not limited to, CPT® codes, ICD-10-CM codes, co-morbid condition(s), place of service, and contraindications to the procedure. Medicare will never pay for investigational or experimental procedures.

Question 20

When applying an LCD to services, which of the following statements is TRUE regarding the CPT® and ICD-10-CM codes reported on a claim form?
a.
The claim should contain an approved code to be reimbursed.

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

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

d.
Documentation only needs to support the CPT® code, the ICD-10-CM code is automatically understood.

Answer 20

b.
Documentation should provide medical necessity and support the CPT® and ICD-10-CM codes reported.
Response Feedback:
Rationale: The CPT® and ICD-10-CM codes listed are not suggestions but are the codes and conditions that have been approved for payment. Documentation must support both the procedure and the diagnosis reported.

Question 21

What does the NCCI file indicate?
a.
The relative value units (RVUs) of surgical procedures.

Correctb.
It indicates specific CPT® code pairs that can be reported on the same day for the same beneficiary by the same provider.

c.
It states whether Medicare or the MAC will pay for an item or service as medically necessary.

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

Answer 21

b.
It indicates specific CPT® code pairs that can be reported on the same day for the same beneficiary by the same provider.
Response Feedback:
Rationale: The NCCI file is a Medicare file that indicates specific CPT® code pairs that can be reported on the same day for the same beneficiary by the same provider. Although the NCCI edits is a Medicare file for bundling, other payers may utilize this set of edits as well.

Question 22

Local Coverage Determinations (LCDs) are established by Medicare Administrative Contractors (MACs) for what purpose?
a. LCDs are established to override NCDs.
b. LCDs establish coding standards for certain services.
c. LCDs make coverage determinations universal throughout jurisdictions.
Correctd. LCDs are developed when no NCD is available.

Answer 22

d. LCDs are developed when no NCD is available.

Response Feedback:
Rationale: LCDs are established by the MAC when there is not an NCD available, or when the NCD needs to be defined further. Each individual MAC can establish LCDs for their jurisdiction.

Question 23

National Coverage Determinations (NCDs) were established by CMS to indicate what?
a. Services or procedures that can be provided for a Medicare beneficiary.
Correctb. Medical services or procedures that are paid by Medicare with certain limitations.
c. Services that will not be covered by CMS.
d. Medical services or procedures that are paid by Medicare.

Answer 23

b. Medical services or procedures that are paid by Medicare with certain limitations.
Response Feedback:
Rationale: NCDs are based on regulations and rulings established to determine if services or procedures will be paid by CMS, and the limitations that have been established.

Question 24

When a payer denies a procedure or service as inclusive, what steps should be taken with the denial?
a. Just add a modifier to bypass.
b. Bill the patient for the difference.
c. None, a denial is final.
Correctd. Look at NCCI edits and bundling edits for payers.

Answer 24

d. Look at NCCI edits and bundling edits for payers.
Response Feedback:
Rationale: Review of the NCCI edits and other bundling edits for commercial payers should be researched. Denials are not final and an appeal can always be made. Adding modifiers to services without making sure they are allowed or that the documentation supports the modifier could be considered bad practice or worse. Billing the patient for a service that has been denied or considered inclusive can violate a contractual agreement.

Question 25

When is the NCCI policy manual is updated?
a. Monthly
b. Semi-annually
Correctc. Annually
d. Quarterly

Answer 25

c. Annually
Response Feedback:
Rationale: The CMS updates the policy manual annually and updates edits quarterly.

Question 26

An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier?
a.
21

b.
25

c.
22

Correctd.
24

Answer 26

d.
24
Response Feedback:
Rationale: Modifier 24 tells that payer that this service is not related to the procedure and allows for payment of the E/M service. Otherwise, it could be denied as a post-op visit.

Question 27

Medicare Administrative Contractors contract with the federal government to do which of the following?
a. Adjudicate claims
Correctb. Adjudicate and process claims and protect the integrity of the Medicare program
c. Follow Medicare policies
d. Process claims

Answer 27

b. Adjudicate and process claims and protect the integrity of the Medicare program
Response Feedback:
Rationale: MACs are to adjudicate, and process claims and protect the integrity of the Medicare program.

Question 28

When are NCCI edits updated and released by CMS?
a.
Annually

b.
Weekly

Correctc.
Quarterly

d.
Semi-annually

Answer 28

c.
Quarterly
Response Feedback:
Rationale: The CMS Learning Network states that the NCCI edits are updated and loaded into the CMS billing system quarterly.

Question 29

Indicators are used to determine if modifiers are allowed or not allowed to bypass an edit. What are the indicators?
a. 2 and 3
b. 3 and 9
c. 0, 1, and 2
Correctd. 0, 1, and 9

Answer 29

d. 0, 1, and 9

Response Feedback:
Rationale: 0, 1, and 9 are used; 0 means a modifier is not allowed, 1 states a modifier can be used, and 9 means the modifier is not specified.

Question 30

When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user what?
a. The codes are not bundled and a modifier is not required.
Correctb. A modifier is not allowed.
c. The edit is not applicable to this code set.
d. A modifier is allowed.

Answer 30

b. A modifier is not allowed.
Response Feedback:
Rationale: The NCCI tables are comprised of code pairs. Modifier 1 indicates a modifier is allowed and 0 (zero) indicates that a modifier is never allowed. Supporting documentation must be in the beneficiary’s medical record.

Question 31

What modifier is required when a minor procedure is performed on the same day as an E/M service and both should be paid and not considered bundled?
a. No modifier is required
b. 57
Correctc. 25
d. 24

Answer 31

c. 25
Response Feedback:
Rationale: Modifier 25 is used to tell the payer the E/M service is separately identifiable from the minor procedure and is more than the usual.

Question 32

Modifier 59 is used to unbundle procedures with an indicator of 1. Under what circumstances would modifier 59 NOT be appropriate?
a. Destruction of a premalignant lesion on the medial side of the right ankle and a biopsy of a second lesion on the arm.
Correctb. Strapping of fracture of left ring and left pinkie finger.
c. Breast nodules removed from the right breast at 3 o’clock and at 9 o’clock.
d. A benign lesion is removed from the upper left thigh that does not need suturing. A second benign lesion is removed from the lower left thigh but needs an intermediate suture repair.

Answer 32

b. Strapping of fracture of left ring and left pinkie finger.
Response Feedback:
Rationale: Modifier 59 is used when a procedure is independent of another, or could represent a different site, organ system, separate incision, separate lesion, or a separate injury. A, B, and C all qualify for modifier 59. If one of the specific anatomic modifiers (RT, LT, E1-E4, etc.) can be assigned, it should be used instead of modifier 59. Strapping of the fingers can be billed with modifiers F3 and F4 to describe the separate locations.

Question 33

NCDs are released by which of the following entities?
a. Health and Human Services (HHS)
b. Office of Inspector General (OIG)
c. Medicare Administrative Contractors (MACs)
Correctd. Centers for Medicare & Medicaid Services (CMS)

Answer 33

c. Medicare Administrative Contractors (MACs)
Response Feedback:
Rationale: National Coverage Determinations (NCDs) are released by CMS. Local Coverage Determinations (LCDs) are released by Medicare Administrative Contractors (MACs). Both NCDs and LCDs determine if payment will be made for services based on medical necessity.