AAPC-CPB Certified Professional Biller - Set 2 - Part 2

Correct Answer: Reporting of the reduction as medical review savings

A/B MACs do not attribute fragmented-billing reductions to medical review savings, except where usual medical review recodes a service that is included in the global surgery package. The reduction is a fee schedule reduction. Option a is incorrect because Medicare instructs A/B MACs to process the claim this way when total charges for fragmented services exceed the global fee, so it is a genuine feature. Option b is incorrect because the provision does not apply to these determinations, because they are fee schedule reductions rather than denials based on medical necessity or custodial care. Option d is incorrect because on an unassigned claim for services in the global package, a nonparticipating physician may bill the beneficiary no more than the limiting charge for the surgery.

Correct Answer: Entering the surgical procedure code only

A physician who performs the surgery and furnishes all usual pre- and postoperative work bills for the global package by entering the appropriate CPT code for the surgical procedure only. Included visits and services are not billed. Option a is incorrect because visits and other services included in the global package are not allowed to be billed separately by the physician furnishing the entire package. Option b is incorrect because modifier "-54" identifies surgical care only, used when physicians agree to transfer care during the global period, not the entire package. Option c is incorrect because splitting the bills with distinguishing modifiers applies only when care is transferred between physicians, which is not the case when one physician furnishes everything.

Correct Answer: Without the multiple procedures modifier

For multiple surgeries by the same physician on the same day, the billing instructions direct reporting the more major surgical procedure without modifier -51. Additional procedures the surgeon performs that day carry the modifier. Option a is incorrect because the multiple procedures modifier is placed on the additional procedures the surgeon performs that day, not on the more major procedure. Option b is incorrect because a units entry above 1 is one way the claims system identifies multiple surgeries, but it is not how the major procedure is reported. Option d is incorrect because the instructions describe reporting all of the surgeon's procedures for that day together, and nothing calls for a separate claim for the major surgery.

Correct Answer: Single line item with modifier "-50"

When a procedure's terminology does not identify it as "bilateral" or "unilateral or bilateral," Medicare requires physicians to report it with modifier "-50" as a single line item, which differs from CPT guidelines. Option a is incorrect because modifier "-51" flags additional surgical procedures performed by the same surgeon on the same day, which are multiple surgeries rather than one procedure done on both sides. Option c is incorrect because Medicare instructs physicians to use modifier "-50" for this situation, so leaving both lines unmodified would not identify the procedure as bilateral. Option d is incorrect because Medicare calls for one line item, and it notes that this differs from CPT guidelines, which would put bilateral procedures on two lines.

Correct Answer: Full value of highest endoscopy plus difference between next highest and base endoscopy

Under the special rule for multiple endoscopies, Medicare pays the full value of the highest valued endoscopy, plus the difference between the next highest endoscopy and the base endoscopy, because the base value is built into each related procedure. Option b is incorrect because this is the standard multiple surgery approach, which Medicare replaces for endoscopies because the base endoscopy value is already built into each related procedure. Option c is incorrect because a once-per-session payment is the rule given for certain lesion destruction services, not for multiple endoscopies, where additional value above the base is still paid. Option d is incorrect because paying every line in full would pay for the shared base endoscopy repeatedly, which the special endoscopy rule is designed to prevent.

Correct Answer: Surgeons of different specialties each performing a different procedure

When surgeons of different specialties each perform a different procedure with specific CPT codes, neither co-surgery nor multiple surgery rules apply, even through the same incision. Multiple procedure rules apply only to a surgeon who performs several procedures. Option a is incorrect because the manual applies the multiple procedure rules to that surgeon's services, so multiple surgery rules do govern this situation. Option b is incorrect because this describes co-surgery, which the manual says also covers two surgeons working simultaneously on parts of a procedure, billed with modifier 62. Option c is incorrect because this is team surgery, billed by each surgeon with modifier 66 and priced by report, so it has its own rules.

Correct Answer: On a "By Report" basis

The Medicare manual states that team surgery, identified by modifier 66, is paid on a "By Report" basis. Payment is not set as a fixed percentage of the fee schedule amount. Option a is incorrect because that percentage applies to each co-surgeon billed with modifier 62, not to team surgery, which has no fixed percentage. Option b is incorrect because multiple procedure rules apply to a single surgeon who performs several procedures, not to payment for a surgical team. Option d is incorrect because full fee schedule payment is made to the first bill submitted when the database indicator shows two or team surgeon rules do not apply.

Correct Answer: Modifier -66

The Medicare manual states that when a team of surgeons, meaning more than 2 surgeons of different specialties, is required for a specific procedure, each surgeon bills the procedure with modifier -66. Option a is incorrect because is listed as surgical care only in the combinations of surgical modifiers, and the guidance gives it no role in billing team surgery. Option b is incorrect because appears in the list of surgical modifier combinations as multiple surgery, so it is not the modifier the guidance assigns to team surgeons. Option c is incorrect because is the modifier each surgeon bills when two surgeons, each in a different specialty, perform a specific procedure, which is co-surgery rather than a team.

Correct Answer: Verify the student documentation in the medical record

Medicare allows students to document, but the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and medical decision making. Verification replaces re-documenting the work. Option a is incorrect because a written attestation belongs to the primary care exception for a residency program, not to student documentation in an ordinary teaching setting. Option b is incorrect because the manual lets the teaching physician verify student documentation of the exam and decision making rather than re-documenting that work. Option d is incorrect because the manual gives the verification duty to the teaching physician; a resident cosigning is not the step it names for billing.

Correct Answer: Video equipment

The Medicare manual allows presence for certain psychiatric services to be met by concurrent observation using a one-way mirror or video equipment. Audio-only equipment does not satisfy the physical presence requirement. Option a is incorrect because viewing a procedure through a monitor in another room is addressed for endoscopy, where it does not meet the teaching physician presence requirement. Option b is incorrect because a telephone consultation is not a form of concurrent observation, and the manual names only a one-way mirror or video equipment. Option c is incorrect because the Medicare manual states audio-only equipment does not satisfy the physical presence requirement, so it cannot substitute for the teaching physician's presence.

Correct Answer: Opening and closing of the surgical field

Presence is not required during opening and closing of the surgical field unless the teaching surgeon considers those activities critical or key portions of the procedure. In that case, the teaching surgeon must be present. Option a is incorrect because the teaching surgeon decides which postoperative visits are key or critical, so presence is not required at every visit. Option c is incorrect because nurse notes may demonstrate the surgeon's presence, but they are a record of presence, not a surgical activity needing presence. Option d is incorrect because the guidance names no such review as a portion requiring presence; presence is tied to critical or key portions of the procedure.

Correct Answer: Criteria for monitored anesthesia care

When a different provider performs the diagnostic or therapeutic nerve block or injection, the anesthesiologist or CRNA may report the anesthesia service, but the service must meet the criteria for monitored anesthesia care. Option b is incorrect because general anesthesia sits at the most intense end of the anesthesia continuum, and guidance does not name it as the standard for this block scenario. Option c is incorrect because guidance applies the moderate sedation requirement when the same anesthesiologist or CRNA provides both the anesthesia and the block, which is not this situation. Option d is incorrect because local or topical anesthesia is the lowest level on the continuum, and guidance does not make it the basis for reporting anesthesia for a block.

Correct Answer: Physician continuously involved in a single case with a student nurse anesthetist

Medicare pays at the personally performed rate when the physician is continuously involved in a single case involving a student nurse anesthetist. Concurrent direction or supervision of several cases is paid at the medically directed or supervised rate. Option a is incorrect because that arrangement falls in the medically supervised category, which is a separate rate group from the personally performed rate and carries its own modifier. Option b is incorrect because directing two, three or four concurrent procedures with qualified individuals is reported as medical direction and paid at the medically directed rate, not the personally performed rate. Option c is incorrect because Medicare pays this monitored anesthesia care arrangement under the rules for the medically directed rate; the personally performed rate applies only when the physician personally performs the case.

Correct Answer: QZ modifier

The QZ modifier identifies a CRNA service without medical direction by a physician. Medicare requires the claim to report actual anesthesia time and one payment modifier, and QZ is the payment modifier for this situation. Option a is incorrect because it identifies a qualified nonphysician anesthetist service performed with medical direction by a physician, which is the opposite of the situation described here. Option b is incorrect because it is the modifier the physician uses for the single medically directed service, not one a CRNA reports for an undirected service. Option d is incorrect because it denotes monitored anesthesia care and is informational only, so it cannot serve as the required payment modifier.

Correct Answer: Payable, because the facility payment does not bundle it

Medicare pays under the physician fee schedule for technical component services in institutional settings where the service is not bundled into the facility payment. An ambulatory surgery center is the standard example. Option a is incorrect because bundling applies to settings such as hospital inpatient and outpatient care, whereas an ambulatory surgery center is the guidance's example of an unbundled setting. Option b is incorrect because the guidance places this technical component under the physician fee schedule when the facility payment excludes it; the clinical laboratory schedule is not named for it. Option c is incorrect because the service described is the technical component, a separate part of the service, and professional component payment follows its own rule.

Correct Answer: Bill the PC and TC separately

Global billing of split services is possible only when the PC and TC are furnished by the same physician or supplier entity in the same service location. If the locations differ, the PC and the TC must be separately billed. Option b is incorrect because modifier 26 identifies a professional component, so it cannot turn split services at different locations into a global claim. Option c is incorrect because the guidance requires both components to be billed, each separately, so leaving out the PC would drop a payable service. Option d is incorrect because global billing is possible only when the PC and TC are furnished by the same entity in the same service location.

Correct Answer: Not separately billable

Medicare guidance separates multiple surgeries from intra-operative services, incidental surgeries, and components of more major surgeries. Those components are not separately billable, and mandatory edits prevent separate payment for them. Option a is incorrect because the major surgery is chosen by MFSDB approved amount among separately payable procedures, and a component of a primary procedure does not qualify. Option b is incorrect because modifier "-50" identifies a procedure performed on both sides of the body, a bilateral surgery, and says nothing about component services. Option c is incorrect because modifier "-51" is reserved for additional separately payable surgeries by the same surgeon on the same day, which components are not.

Correct Answer: Nurses' notes showing the physician saw the patient

When a hospital visit is questioned, Medicare instructs reviewers to check the patient's record at the provider. An entry in the nurses' notes indicating the physician saw the patient on a given day is acceptable. Option b is incorrect because the presumption is the starting position when no contrary evidence exists, not an entry used to confirm a visit once it is questioned. Option c is incorrect because this information is placed in item 32 to determine the payment locality and says nothing about whether a visit took place. Option d is incorrect because the code identifies the setting reported on the claim for payment purposes and is not documentation that the physician actually saw the patient.

Correct Answer: Condition established after study to be chiefly responsible for the admission

The Medicare manual defines the principal diagnosis as the condition established after study to be chiefly responsible for the admission. It is reported in FL 67 even if another diagnosis is more severe. Option a is incorrect because the principal diagnosis is established after study, not simply taken from what is noted first when the patient is registered. Option b is incorrect because severity does not decide the entry; the guidance says the principal diagnosis is entered even when another diagnosis is more severe. Option c is incorrect because cost of services is not the standard; entering another diagnosis can cause incorrect DRG assignment and incorrect payment under PPS.

Correct Answer: FL 42

FL 42 is the Revenue Code field. The provider enters the appropriate numeric revenue code on the adjacent line in FL 42 to explain each charge in FL 47, and uses revenue code 0001 for the total line. Option a is incorrect because it is the non-covered charges area, which is summed on the same line as the total of charges in FL 47. Option b is incorrect because it holds the narrative description or standard abbreviation for each revenue code, assisting clerical bill review, rather than the revenue code itself. Option d is incorrect because it carries the HCPCS code for outpatient services, or the accommodation rate on inpatient hospital bills, not the revenue code.