AAPC-COC Certified Outpatient Coder - Set 2 - Part 3

Correct Answer: Report an unlisted procedure code

When other HCPCS/CPT codes do not accurately describe a service, the service shall be reported using an unlisted procedure code. These codes, generally identified as XXX99 or XXXX9, appear at the end of each section or subsection. Option b is incorrect because the policy calls this inappropriate unless the code accurately describes the service performed and all of its components were performed, which is not the case here. Option c is incorrect because excluded service codes describe services outside Medicare coverage or payment recognition, an area NCCI does not generally address, so they do not identify an undescribed service. Option d is incorrect because family codes share a common descriptor portion before the semicolon, and a code that does not accurately describe the service still cannot be reported for it.

Correct Answer: It is reportable with the third procedure

For misuse edits that allow PTP-associated modifiers, the Column Two code is misused with the Column One code but may be appropriately reported with a third procedure performed on the same date of service. Option a is incorrect because repeat testing with modifier 91 is addressed under laboratory panels, not misuse edits, and nothing here describes a repeated Column One service. Option b is incorrect because a failed approach converted to a second approach is a sequential procedure situation, where only the second approach code is reported, not a misuse exception. Option c is incorrect because initial and subsequent versions of a service illustrate mutually exclusive procedures, which cannot reasonably occur at the same encounter, so this does not justify reporting.

Correct Answer: Ambulatory Patient Classification for the date of service

The Medicare manual states that OPPS payments are based on Ambulatory Patient Classification payment for the date of service, in contrast to inpatient acute and rehabilitation PPS payment, which is based on the discharge date. Option a is incorrect because describes inpatient PPS payment for acute care and rehabilitation hospitals, which the manual ties to the discharge date rather than to outpatient services. Option b is incorrect because is one of three limits on provider payment alongside billed charge and fee schedule amount, not the OPPS classification basis. Option d is incorrect because is the method the manual assigns to hospices, not to hospital outpatient services paid under OPPS.

Correct Answer: Yearly cash deductible

Supplementary medical insurance (Part B) pays participating providers for covered services only after a yearly cash deductible is met. The beneficiary is responsible for the deductible and copayment amounts set out in the Part B rules. Option a is incorrect because the 90 days is a Part A limit on inpatient hospital payment in each benefit period, not a threshold for Part B payment. Option c is incorrect because that figure is the Part A cap on posthospital extended care in a skilled nursing facility, which does not govern outpatient Part B payment. Option d is incorrect because a prior inpatient stay was a Part A condition for home health services, and it was eliminated, so it does not gate Part B payment.

Correct Answer: Services of a certified registered nurse anesthetist

The statute excludes from inpatient hospital services the medical or surgical services of a physician, resident or intern, certified nurse-midwife and qualified psychologist, plus services of a certified registered nurse anesthetist. Those services fall outside the definition. Option b is incorrect because the statute names supplies, appliances and equipment ordinarily furnished by the hospital to inpatients as part of the definition, so these are not carved out. Option c is incorrect because the statute counts these among the related services ordinarily furnished by the hospital for the care and treatment of inpatients, so they are included. Option d is incorrect because it is the first item the statute lists as an inpatient hospital service, so it falls inside the definition rather than being excluded.

Correct Answer: Special needs plans

Special needs plans were added later, when the Medicare Modernization Act renamed Part C the Medicare Advantage program and expanded plan choices. The original four types were coordinated care plans, MSA plans, PFFS plans and Religious Fraternal Brotherhood Societies. Option a is incorrect because these plans appear in the Medicare+Choice list of four authorized types, so they were part of the original Part C design. Option b is incorrect because this was one of the four original Medicare+Choice plan types, listed alongside coordinated care, MSA and religious fraternal society plans. Option d is incorrect because the Act authorized this category, which covers HMOs, provider sponsored organizations and PPOs, as the first of the four plan types under the new Part C.

Correct Answer: Relative hospital resources used by discharges in that group

The statute directs the Secretary to assign each DRG a weighting factor reflecting the relative hospital resources used for discharges in that group compared with discharges classified within other groups. Option b is incorrect because secondary diagnoses matter for DRG assignment, but the weighting factor is defined by comparative resource use, not by a count of reported diagnoses. Option c is incorrect because preadmission services relate to the definition of inpatient operating costs, which is a separate matter from how a group's weighting factor is set. Option d is incorrect because cost-sharing is described as limited to statutory deductibles, coinsurance, and noncovered items, and it is separate from the factor that compares resource use across groups.

Correct Answer: An agreement with CMS

Under the basic requirements, participation as an ASC is limited to facilities that meet the definition and have in effect an agreement with CMS obtained in accordance with the general conditions and requirements subpart. Option a is incorrect because this is the alternative Medicare treatment for a hospital-operated facility under 42 CFR 413.65, and it is a separate route from participating as an ASC. Option b is incorrect because those conditions apply to a hospital-operated facility certified as a provider-based department, whereas an ASC must meet the ASC conditions for coverage. Option c is incorrect because hospital operation is only one possible arrangement; an ASC may also be independent, so hospital ownership is not a requirement for participation.

Correct Answer: I and II

Medicare-covered services are defined as services payable or that would be payable except for the deductible, coinsurance, and primary payer amounts, and a waiver is forgiveness of the obligation to satisfy Medicare's claim. Statements I and II are accurate. Option b is incorrect because statement III is reversed, since COBRA continuation coverage is secondary to Medicare for aged beneficiaries because it arises from COBRA law, not current employment status. Option c is incorrect because statement IV misdescribes the term, because the definition expressly counts the beneficiary's employer as a carrier when that employer is self-insured. Option d is incorrect because both of these statements contradict the MSP definitions, while the two accurate statements, I and II, are left out of this pairing.

Correct Answer: Bill the identified primary payer

Chapter 3 of the MSP Manual makes the provider responsible for gathering information to identify primary payers and for billing them before billing Medicare when MSP provisions make Medicare the secondary payer. Option a is incorrect because accepting a primary payment below charges as payment in full actually removes eligibility for a Medicare secondary payment, so providers are not directed to do this. Option b is incorrect because that notice applies only when a reduced primary payment resulted from failure to file a proper claim, so it is not a routine first step. Option d is incorrect because conditional primary payments are allowed only in limited cases, such as a denied proper GHP claim or beneficiary incapacity, so they are not the first step.