AAPC-CPC Certified Professional Coder - Set 5 - Part 1

Correct Answer: A starting point for internal review

OIG guidance describes its list of coding and billing risk areas as not exhaustive. It is meant as a starting point for an internal review of potential vulnerabilities within the physician practice. Option b is incorrect because the OIG states the list is not exhaustive or all-encompassing, so a problem missing from it can still be a real vulnerability. Option c is incorrect because OIG guidance still calls for clear written standards and procedures communicated to all employees, so a list of risk areas cannot take their place. Option d is incorrect because the bullets name risk areas that have been frequent subjects of OIG investigations and audits, which makes them problem areas rather than endorsed practices.

Correct Answer: Clear written standards communicated to all employees

OIG guidance states that clear written standards and procedures, communicated to all employees, are important to the effectiveness of a compliance program. This ties daily coding and billing work to defined, shared expectations across the practice. Option a is incorrect because the guidance says its list of risk areas is not exhaustive and should be viewed as a starting point for internal review. Option b is incorrect because the guidance calls for written standards and procedures, and these are communicated to all employees rather than passed along verbally to one group. Option d is incorrect because the semiannual reports are one resource a practice can consult to identify risk areas; the guidance does not name them as what makes a program effective.

Correct Answer: OIG Work Plan

OIG guidance directs physician practices seeking more information on potential risk areas to the OIG Work Plan, which identifies the vulnerabilities and risk areas on which the OIG will focus in the future. Option a is incorrect because these reports identify vulnerabilities and risk areas the OIG targeted during the preceding six months, so they look backward rather than ahead. Option c is incorrect because these are internal practice documents, communicated to employees to support an effective compliance program, not an OIG resource that previews its enforcement priorities. Option d is incorrect because it lists additional risk areas a practice may want to review and fold into its own standards, but it does not announce future OIG focus.

Correct Answer: Removal of cutaneous sutures and staples

The global surgical package includes miscellaneous services furnished by the surgeon, such as dressing changes, local incisional care, and removal of cutaneous sutures, staples, lines, wires, tubes, drains, casts, and splints. Option a is incorrect because the guidance states that services by other physicians are not included in the global fee for a minor procedure, except as otherwise excluded. Option b is incorrect because when the entry is 000, visits after the day of the procedure fall outside the payment amount and receive separate payment. Option c is incorrect because the package covers complications only when they do not require additional trips to the operating room, so a return to surgery is outside it.

Correct Answer: The day of surgery plus the appropriate number of days immediately following it

For minor procedures, A/B MACs (B) count the day of surgery and the appropriate number of days immediately following the date of surgery. No separate preoperative day is counted, unlike major surgeries. Option a is incorrect because the day before surgery belongs to the major surgery count; for minor procedures, preoperative visits begin on the day of surgery. Option b is incorrect because the manual counts the day of surgery itself as part of a minor procedure's global period, so leaving it out contradicts the method. Option d is incorrect because this describes the count for major surgeries, which include a preoperative day and a 90-day postoperative period, not the count for minor procedures.

Correct Answer: 10 days after the surgery

An 010 entry in the Medicare Fee Schedule Data Base marks a minor surgery with a 10-day postoperative period. Postoperative visits or services within 10 days that relate to recovery are not paid separately. Option b is incorrect because describes the 000 entry, where postoperative visits beyond the day of the procedure are not included and are paid separately. Option c is incorrect because applies to the YYY entry, where the A/B MAC (B) determines the global period for its priced codes. Option d is incorrect because belongs to major surgeries, which carry the 090 entry and also count one day before the day of surgery.

Correct Answer: Diagnostic tests and procedures

The Medicare manual lists diagnostic tests and procedures, including diagnostic radiological procedures, among the services not included in the global surgical package. A/B MACs may therefore pay for them separately. Option a is incorrect because the manual excludes other physicians' services from the package only where the surgeon and the other physician agree on a transfer of care. Option b is incorrect because the manual says the initial evaluation is always included in the allowance for a minor surgical procedure, so it has no separate payment. Option c is incorrect because the manual states that A/B MACs do not allow separate payment for related postoperative visits within 10 days of a minor surgery with that indicator.

Correct Answer: I, III, and IV

Both bills carry the same procedure code, the receiving physician may not bill until providing at least one service, and both physicians keep the written transfer agreement. Providers need not state on the claim that care was transferred. Option b is incorrect because statement II is false, since providers need not specify on the claim that care was transferred, and this choice also leaves out true statements III and IV. Option c is incorrect because it rests on statement II, which misstates the rule; only the date care was relinquished or assumed must be shown, and statement I is also true. Option d is incorrect because it counts statement II as true when Medicare says no claim statement of transfer is needed, and it drops statement III about the receiving physician.

Correct Answer: Deny the visit

Medicare instructs A/B MACs to deny postoperative visits billed with modifier -24 or -FT without sufficient documentation. Modifier -24 must be accompanied by documentation that the visit is unrelated to the surgery. Option a is incorrect because individual consideration applies to surgeries billed with modifier -22 or -52 when the required statement and documentation are included, not to visits billed with -24. Option b is incorrect because bundling is not the described outcome here; such a visit is denied, and fragmented-billing reductions concern total charges that exceed the global fee. Option c is incorrect because the manual directs denial for postoperative visits billed with modifier -24 but without sufficient documentation; it provides no reduced-rate payment for them.

Correct Answer: I, II, and III

When different physicians in a group practice participate, the group bills for the entire global package if the physicians reassign benefits to the group, and the surgeon is shown as the performing physician. Option a is incorrect because statement III is also accurate, because the physician who performs the surgery is shown as the performing physician, so this pair leaves out a true statement. Option c is incorrect because statement I is omitted and statement IV is included, yet the group bills the whole package, and modifiers "-54" and "-55" apply to physicians who agree on transfer of care. Option d is incorrect because statement IV does not fit a group practice, since the split modifiers belong to physicians transferring care, and statement II, the reassignment condition, is missing.

Correct Answer: Appropriate E/M code, no modifier

When a physician other than the surgeon treats an underlying condition or medical complication during the postoperative period, that physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim. Option b is incorrect because modifier -54 is appended by the surgeon to the surgery code when care is transferred, not by another physician reporting E/M services. Option c is incorrect because modifier -55 identifies postoperative care only after a transfer of care, and here no transfer occurs, so the surgical code is not billed. Option d is incorrect because modifier -57 marks a visit that results in the initial decision to perform surgery, which is unrelated to managing an underlying condition afterward.

Correct Answer: Day of surgery plus 10 following days

For minor procedures, A/B MACs (B) count the day of surgery and the appropriate number of days immediately following it. An entry of 010 means 10 follow-up days, so the period is the day of surgery plus 10 days. Option a is incorrect because counting the day immediately before surgery is the method for major surgeries, which also carry 90 following days, not the minor-procedure method. Option b is incorrect because the count for minor procedures starts with the day of surgery itself, so leaving it out misstates how the period is determined. Option c is incorrect because this fits an entry of 000, where visits beyond the procedure day are not included in the payment; an entry of 010 carries 10 days.

Correct Answer: Included in the payment for the procedure

NCCI treats the decision to perform a minor surgical procedure, one with a 000 or 010-day global period, as included in the payment for the procedure. It is not reported separately as an E&M service. Option b is incorrect because modifier 57 applies to the E&M service performed to decide on a major surgical procedure with a 090-day global period, not a minor one. Option c is incorrect because NCCI states that being new to the provider is not sufficient alone to justify a same-day E&M service with a minor procedure. Option d is incorrect because modifier 24 is for postoperative visits unrelated to the diagnosis for the surgery, which is a different situation from a decision for a minor procedure.

Correct Answer: XXX

All procedures on the Medicare Physician Fee Schedule are assigned a global period, but NCCI guidance states that the global concept does not apply to XXX procedures. The other designations still operate under global rules. Option a is incorrect because its global period is defined by the MAC, so the global concept still applies to these procedures through the contractor's assignment. Option c is incorrect because these procedures are related to another procedure, and the related procedure determines the applicable global period, so the concept applies. Option d is incorrect because this designation identifies maternity procedures, which carry a global period assignment and are not exempt from the global concept.

Correct Answer: They were made, absent contrary evidence

The Medicare claims processing manual directs that, for hospital visits by physicians, visits billed are presumed made in the absence of evidence to the contrary. Record review is reserved for questionable patterns of utilization. Option b is incorrect because only a sample of physician's records is reviewed, and only when utilization patterns are questionable, not for every billed visit. Option c is incorrect because nurses' notes are only one acceptable way to confirm a visit when its occurrence is questioned, not a condition applied to every billed visit. Option d is incorrect because a beneficiary statement counts as acceptable documentation if made close to the alleged visit date, but it is not required for each claim.

Correct Answer: The GC modifier is reported for services furnished under the primary care center exception.

The GC modifier applies to teaching physician services meeting the presence requirements and is excluded when the service falls under the primary care center exception. Services under that exception carry the GE modifier instead. Option a is incorrect because Medicare requires the GE modifier on the claim for every service furnished under that exception, which makes this an accurate statement. Option b is incorrect because the billing provider who places the GC modifier on the claim is certifying compliance with the teaching physician requirements, so this statement is accurate. Option d is incorrect because the manual directs these teaching physicians to give their A/B MAC (B) an attestation that they meet the exception requirements, so the statement holds.

Correct Answer: Verify the student documentation in the record

Students may document services in the medical record, but the teaching physician must verify all student documentation or findings, including history, physical exam and medical decision making. The teaching physician may verify rather than re-document that work. Option a is incorrect because the teaching physician must verify all student documentation or findings, which rules out accepting it unreviewed. Option c is incorrect because the Medicare manual allows students to document services in the medical record, so removal is not required; verification is what the teaching physician must do. Option d is incorrect because Medicare does not pay for any service furnished by a student, so a claim cannot be filed on the student's work.

Correct Answer: Student

Medicare defines a student as an individual in an accredited educational program, such as a medical school, that is not an approved GME program. A student is never considered an intern or a resident. Option b is incorrect because a resident takes part in an approved GME program, or is a physician authorized to practice only in a hospital setting, which does not describe this individual. Option c is incorrect because a teaching physician is a physician, other than another resident, who involves residents in the care of his or her patients, which is a different role. Option d is incorrect because interns are included under the term resident because they train in approved GME programs, while this individual's program is not an approved GME program.

Correct Answer: Payable separately, starting a new postoperative period

Medicare lists clearly distinct surgical procedures during the postoperative period, which are not reoperations or treatment for complications, as services not in the global surgical package. They may be paid separately, and a new postoperative period begins. Option a is incorrect because the global package covers services related to recovery from the first surgery, and a clearly distinct procedure is listed among the services not included. Option b is incorrect because nothing requires waiting for the 90 days to end; the distinct procedure is paid separately during the period and begins its own new period. Option c is incorrect because the exclusion for a clearly distinct procedure applies to the surgeon too; transfer of care is a separate rule about services of other physicians.

Correct Answer: First-visit status alone is not sufficient to justify a separate E&M service

NCCI states that the same rules for reporting E&M services apply to a minor surgical procedure on a new patient. Being new to the provider is not sufficient alone to justify a same-day E&M service. Option a is incorrect because modifier 24 addresses postoperative visits unrelated to the surgery diagnosis, not same-day E&M services tied to a minor procedure at an initial visit. Option c is incorrect because modifier 57 applies to the decision for a major surgical procedure; for a minor procedure, the decision is included in the procedure payment. Option d is incorrect because NCCI policy states the E&M service and the minor surgical procedure do not require different diagnoses, so a diagnosis difference is not the test.