AAPC-CDEO Certified Documentation Expert Outpatient - Set 4 - Part 1

Correct Answer: Separate payment is not made

Under Medicare bundling policy, separate payment is never made for routinely bundled services and supplies. CMS may provide RVUs for them, but those RVUs are not for Medicare payment use. Option a is incorrect because "By Report" applies to services such as unusual services and team surgery, which the A/B MAC continues to pay; routinely bundled services receive no separate payment. Option b is incorrect because the technical component is one part of a diagnostic service with global, professional and technical values, and has no connection to payment for bundled services. Option c is incorrect because local relative values are set for national codes lacking national values, whereas A/B MACs may not establish their own relative values for routinely bundled services.

Correct Answer: Appropriate E/M code with no modifier

When no transfer of care occurs, occasional post-discharge services by a physician other than the surgeon are reported with the appropriate evaluation and management code. Medicare manual guidance states that no modifiers are necessary on the claim. Option a is incorrect because modifier -55 is for post-discharge care by a physician who has assumed postoperative care through a transfer of care, which has not happened here. Option c is incorrect because modifier -57 marks a visit that results in the initial decision to perform surgery, not routine follow-up care by another physician. Option d is incorrect because modifier -54 is billed by the surgeon who provides only the surgical procedure after care is transferred, not by another physician giving occasional services.

Correct Answer: Raises the score when another factor signals higher costs

Disease and Disabled Interactions allow higher risk scores for certain conditions when another disease or a demographic status, such as disabled status, indicates higher costs. These interactions are additive factors that increase payment accuracy. Option b is incorrect because the models are site neutral, so payment does not differ by site of care, and interactions do not change that. Option c is incorrect because that is the prospective model characteristic, which uses base year diagnostic information, and it does not describe what an interaction does to a score. Option d is incorrect because that describes hierarchies, which give credit for the disease with the highest severity or the one that subsumes the costs of other diseases.

Correct Answer: Do not pay the E/M code

Medicare instructs contractors not to pay CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice, regardless of documentation or medical necessity. Option a is incorrect because time or MDM governs level selection for payable E/M visits, but it does not make an unpayable provider type eligible for payment. Option b is incorrect because reducing the level addresses a visit billed higher than warranted; here the problem is the billing provider type, not the level selected. Option c is incorrect because general supervision and collaboration rules apply to NPs, CNSs, CNMs and PAs, a group that does not include therapists in independent practice.

Correct Answer: I and IV

Medicare directs that E/M level follow the CPT code definitions and applicable documentation guidelines, and that a non-physician practitioner's service be medically necessary and within State scope of practice. Statements I and IV match. Option b is incorrect because statement II contradicts Medicare, which says documentation volume should not be the primary influence on the level billed; documentation should simply support the reported level. Option c is incorrect because both statements are false, and the pair leaves out I and IV, which Medicare states directly; payment for these codes is also barred for independent therapists. Option d is incorrect because it adds statement III, yet Medicare instructs contractors not to pay CPT evaluation and management codes billed by physical therapists in independent practice.

Correct Answer: Reducing the practice's documentation volume

The statute bars payment under part A or part B for items or services not reasonable and necessary for diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Documentation volume is not a listed purpose. Option a is incorrect because treatment of illness or injury is written into the statute as one of the purposes that a covered item or service must serve. Option c is incorrect because the statute names diagnosis of illness or injury as a purpose for which an item or service must be reasonable and necessary. Option d is incorrect because the statute expressly lists improving the functioning of a malformed body member as a purpose that satisfies the reasonable and necessary standard.

Correct Answer: Volume of documentation

Medicare guidance states that the volume of documentation should not be the primary influence on the level of service billed. Documentation should support the level reported, which is selected by medical decision making or time. Option a is incorrect because medical decision making is one of the two accepted bases for choosing the visit level for most E/M visit families. Option b is incorrect because time spent by the physician or non-physician practitioner is an accepted basis for level selection, provided the full time is completed. Option c is incorrect because Medicare calls it the overarching criterion for payment, so it governs the billing decision instead of being a factor to discount.

Correct Answer: Level selection based on history and exam

Medicare requires history and exam to be performed per the code descriptors, but they do not affect level selection. For most E/M visit families, the level rests on medical decision making or time. Option b is incorrect because medical necessity is the overarching criterion for payment, applied in addition to the individual requirements of the E/M visit code, so it is a genuine requirement. Option c is incorrect because the manual directs that the service be documented during, or as soon as practicable after, it is provided, to maintain an accurate medical record. Option d is incorrect because Medicare states that for all E/M visits the history and physical exam must be performed in accordance with the code descriptors, so this is a real requirement.

Correct Answer: Provided in lieu of part of the preventive service

Medicare considers the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. The physician may then charge the beneficiary for the noncovered remainder. Option a is incorrect because the covered visit is not absorbed into a wholly noncovered service; Medicare pays for it, and only the remainder of the preventive service stays noncovered. Option c is incorrect because Medicare treats the covered visit as replacing a part of the preventive service of equal value to the visit, not as an add-on of different value. Option d is incorrect because the physician is not required to give written advance notice of noncoverage for the routine preventive part, so the visit's treatment does not hinge on that notice.

Correct Answer: his or her liability for the charges

Medicare states that the physician is responsible for notifying the patient in advance of his or her liability for the charges for services that are not medically necessary to treat the illness or injury. Option a is incorrect because the fee schedule amount is only used to pay the covered visit, as the lesser of it or the actual charge, not for patient notice. Option b is incorrect because equal value describes how the covered visit is treated as provided in lieu of part of the preventive service, not the content of notice. Option d is incorrect because actual charge is compared with the fee schedule to set Medicare payment for the covered visit; it is not what the advance notice addresses.

Correct Answer: fee schedule amount

The Medicare manual directs payment for the covered visit based on the lesser of the fee schedule amount or the physician's actual charge for the visit. The visit is treated as provided in lieu of part of the preventive service. Option b is incorrect because screening procedures during the encounter are considered individually and are noncovered when done for asymptomatic conditions, so they play no part in pricing the visit. Option c is incorrect because the physician's established charge for the preventive service is used only to work out the noncovered remainder that may be billed to the beneficiary, not to set payment. Option d is incorrect because Medicare guidance gives no role to any limit set by the beneficiary when determining payment for the covered visit.

Correct Answer: Billed under the surgeon's own provider or group number

A/B MACs flag services that fall within the global period and are billed with the same provider or group number as the surgical procedure or endoscopy, along with the other conditions in the prepayment edit rules. Option a is incorrect because services on the exclusion list are removed from the prepayment audit process and may be paid separately if usual requirements are met, not flagged. Option b is incorrect because the edits look for services billed with the same provider or group number as the surgical procedure, so a different group falls outside the condition. Option d is incorrect because the edits target services furnished within the prescribed global period of the surgical procedure, so a service after that period does not meet the condition.

Correct Answer: Consistent payment for the same services across all jurisdictions

Medicare set up the national global surgical package so that Medicare Administrative Contractors consistently pay the same services across all jurisdictions. This also prevents payment for more or less comprehensive services than intended. Option b is incorrect because the global surgical package bundles post-operative visits within the global period into the procedure payment, so each visit is not paid separately. Option c is incorrect because global surgery applies in any setting, including outpatient hospitals, ASCs and physician offices, so no inpatient limit exists. Option d is incorrect because the package was created to remove variation among Medicare Administrative Contractors, not to let each contractor set its own policy.

Correct Answer: Preventive service charge minus covered visit charge

The covered visit is considered provided in lieu of part of the preventive service of equal value. The physician may charge the amount by which the established charge for the preventive service exceeds the established charge for the covered visit. Option a is incorrect because the fee schedule amount, or the actual charge if lower, is the basis for Medicare payment of the covered visit, not the beneficiary charge. Option b is incorrect because this figure is the comparison value used for the covered visit and is subtracted from the preventive charge, not billed as the remainder. Option d is incorrect because the covered visit is treated as provided in lieu of part of the preventive service, so that part of the charge is already accounted for.

Correct Answer: Not paid separately

With a Field 16 entry of 010, A/B MACs do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. Option a is incorrect because split global-care billing rests on an agreed transfer of care between providers, and nothing in this situation describes a second provider or a transfer. Option b is incorrect because that treatment applies to a 000 entry, where visits beyond the procedure day are outside the surgery payment; an 010 entry covers related visits. Option c is incorrect because a new postoperative period starts only with a clearly distinct subsequent procedure, and a recovery visit is not a procedure.

Correct Answer: Endoscopy suite

For return-trip purposes, an operating room is a place of service specifically equipped and staffed solely for performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. Option b is incorrect because the guidance expressly lists it among places excluded from the definition, so treatment there for a complication stays within the global package. Option c is incorrect because it is not specifically equipped and staffed solely for procedures, so the guidance leaves it out of the operating room definition. Option d is incorrect because a bedside setting does not meet the definition, and the guidance names it as a location that does not count as an operating room.

Correct Answer: Billed and paid separately from the procedure

When the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment for the surgery. The provider separately bills and is paid for the follow-up visit. Option a is incorrect because the day-before count describes how the global period of major surgeries is determined, using 1 preoperative day and 90 following days, not minor procedures. Option b is incorrect because split global-care billing does not apply to procedure codes with a 0-day post-operative period, so a transfer of care agreement is not the route here. Option d is incorrect because that treatment applies to a 010 entry, where related postoperative visits within 10 days are not paid separately; a 000 entry does not carry that restriction.

Correct Answer: The surgeon and the receiving physician

Medicare global surgery guidance requires both the surgeon and the physician providing the postoperative care to keep a copy of the written transfer agreement in the beneficiary's medical record, so each record shows the transfer. Option a is incorrect because the surgeon who relinquishes care carries the same duty, so a copy kept by the receiving physician alone does not satisfy the guidance. Option b is incorrect because the guidance assigns the duty to both parties, so the physician who takes over postoperative care must also hold a copy in the record. Option c is incorrect because a group practice bills the entire global package when its providers reassign benefits, which is a different situation from a transfer between two physicians.

Correct Answer: Provide at least one service to the patient

Medicare guidance states the receiving physician cannot bill for any part of the global services until at least one service has been provided. After seeing the patient, billing may begin on the date care was assumed. Option a is incorrect because modifier -57 identifies a visit resulting in the initial decision for surgery, which is a different situation from assuming postoperative care. Option b is incorrect because the guidance requires a written transfer agreement kept in the medical record, and it states no payer authorization step before billing. Option d is incorrect because the guidance lets the receiving physician bill from the date care was assumed once the patient has been seen, not after the global period closes.

Correct Answer: Amount a single physician would have been paid

Under the global surgery rules, when more than one physician furnishes services in the global surgical package, the approved sum for all physicians may not exceed what would have been paid if a single physician provided all services. Option b is incorrect because the written agreement must be kept in the medical record, but it documents the transfer and does not cap total payment. Option c is incorrect because separate visit billing is not allowed for services in the global package, so charges do not set the limit on combined payment. Option d is incorrect because the preoperative period is only one part of the package, and the cap relates to the full global amount instead.