AAPC-CDEO Certified Documentation Expert Outpatient - Set 3 - Part 3

Correct Answer: National conversion factor

The fee schedule formula sums work, practice expense and malpractice relative values, each adjusted by its GPCI, and multiplies the total by the applicable national conversion factor. This factor is used for every fee schedule amount. Option a is incorrect because status indicators in the fee schedule database identify which codes and modifiers are paid on a By Report basis; they are not multiplied in the formula. Option b is incorrect because relative values for the global service, professional component and technical component are provided for certain codes; they are inputs, not the multiplier applied to the sum. Option c is incorrect because a flat local payment amount is an option A/B MACs (B) may choose for national codes lacking national relative values, not a formula element.

Correct Answer: The same RVUs apply as for a medical doctor

The Medicare Claims Processing Manual states there are no special RVUs for limited license physicians. Fee schedule RVUs apply to a service whether a medical doctor, doctor of osteopathy, or limited license physician performs it. Option a is incorrect because local relative values are set only for national codes lacking national values, not for services based on the practitioner's license type. Option b is incorrect because the fee schedule provides no special RVUs for limited license physicians, so no separate reduced scale exists for optometrists or podiatrists. Option d is incorrect because By Report pricing is tied to specific codes and modifiers flagged in the fee schedule database, such as team surgery, not to who performs the service.

Correct Answer: As the same physician as the surgeon

Medicare requires providers in the same group practice with the same specialty to bill and accept payment as though they are a single physician, so the partner's services fall within the surgeon's global surgical package. Option a is incorrect because the rule treats the group's same specialty providers as a single physician, so the partner does not start a separate package or period. Option b is incorrect because co-surgeons are a separate surgical payment issue with their own uniform policy, and the same group and specialty rule does not turn a partner into one. Option c is incorrect because team surgeons are also handled under their own payment policy; the excerpt tells same group, same specialty providers to bill as one physician instead.

Correct Answer: Included in the global surgical package

Medicare includes a surgeon's visits to a patient in an intensive care or critical care unit in the global surgical package. The package applies in any setting, so the unit's location does not remove the visits. Option b is incorrect because Medicare places these visits inside the package when the surgeon makes them; separate payment is treated as a distinct matter for critical care services in some situations. Option c is incorrect because a transfer of care splits post-operative payments when another provider supplies follow-up, which is a different arrangement from how the surgeon's own unit visits are classified. Option d is incorrect because global surgery applies in any setting, including outpatient hospital, ambulatory surgical center and physician's office, so an inpatient restriction contradicts the rule.

Correct Answer: To the MAC servicing each applicable jurisdiction

When parts of the global surgery package are furnished in different payment jurisdictions, each service is billed to the MAC servicing the applicable jurisdiction. The surgery goes to the surgery MAC and postoperative care to the MAC where it occurred. Option a is incorrect because this would send postoperative care to the wrong contractor, since the postoperative portion goes to the MAC for the jurisdiction where that care happened. Option c is incorrect because the provider has no choice here; the guidance fixes the destination by where each portion of the global package was furnished. Option d is incorrect because residence of the patient is not the billing criterion; the guidance directs each part of the package to the MAC for the place of service.

Correct Answer: Modifier 24

Modifier 24 reports an unrelated E/M service by the same provider during a post-operative period. It is added to the appropriate level of E/M service, and documentation must establish that the visit was unrelated to the surgery. Option a is incorrect because it applies to a significant, separately identifiable E/M service on the day of a procedure, whereas this visit occurs during an earlier procedure's post-operative period. Option b is incorrect because it reports an unrelated procedure or service by the same provider in a post-operative period, not an unrelated E/M visit, and it starts a new period. Option d is incorrect because it is used by a physician who provides post-operative care only after a transfer of care, which does not describe an unrelated visit by the surgeon.

Correct Answer: The A/B MAC (B) denies the claim

Medicare bundles payment for these services into the payment for other related services. A claim solely for a mandatorily bundled service or supply is therefore denied by the A/B MAC (B). Option a is incorrect because local relative values are for services with national codes lacking national relative values, not for services whose payment is bundled into another service. Option c is incorrect because a flat local payment amount is an option for services with national codes but no national relative values, and bundled services receive no separate payment. Option d is incorrect because By Report pricing applies to services such as unusual services and team surgery, which the fee schedule database identifies; bundled services are a separate category.

Correct Answer: Diagnostic tests and procedures

Diagnostic tests and procedures, including diagnostic radiological procedures, are excluded from the global surgical package and may be billed separately. Pain management, intensive care visits by the surgeon, and suture removal are all included services. Option a is incorrect because Medicare guidance states that surgeon visits to a patient in an intensive or critical care unit fall inside the package, whatever the setting. Option b is incorrect because this is named under miscellaneous services, which sit with dressing changes and drain removal as components of the package. Option c is incorrect because the Medicare manual lists pain management by the surgeon among the services bundled into the package, so it is covered by the global payment.

Correct Answer: Diagnostic data reflecting health status

CMS-HCC risk scores predict expenditures relative to the average beneficiary using health status, which comes from diagnostic data, together with demographics such as age and gender. With demographics equal, diagnostic data explains the difference. Option a is incorrect because that model addresses Part D benefits of prescription drug plans, and it does not explain a difference between two enrollees with the same demographics. Option b is incorrect because the guidance does not base risk scores on billed service volume; scores predict expenditures from health status and demographic characteristics. Option d is incorrect because bids are standardized for the average beneficiary, and timing is not a factor the guidance names in calculating an enrollee's risk score.

Correct Answer: Items and services excluded from Medicare coverage and never furnished to enrollees

The risk adjustment data rule lists three categories: original Medicare items and services, Medicare covered items and services where Medicare is not primary payer, and additional or supplemental benefits. Excluded items never furnished to enrollees are not listed. Option a is incorrect because the regulation names this category directly, covering services in which another payer has primary responsibility while the items remain Medicare covered. Option c is incorrect because the regulation lists these first among the categories that risk adjustment data must account for, to the extent CMS requires. Option d is incorrect because the regulation includes these benefits as a listed category, so they fall within the data an MA organization must account for.