AAPC-CPC Certified Professional Coder - Set 4 - Part 2

Correct Answer: DME MAC

The Medicare manual states that DME MACs have been given the responsibility of processing durable medical equipment, prosthetic, orthotic, and supply (DMEPOS) claims, so the supplier's claim goes to the DME MAC. Option b is incorrect because it is the contractor that home health agencies bill and that pays them, so it serves HHAs rather than equipment suppliers. Option c is incorrect because it enrolls physicians and other practitioners and processes claims for other Part B services and supplies, while the manual gives DMEPOS claims to a different contractor. Option d is incorrect because it performs audit, cost report settlement and other fiscal functions for parent providers, which is a provider-side role and not DMEPOS claims processing.

Correct Answer: Item described as higher quality without exceeding its HCPCS code description

ABNs cannot shift liability for an item described as better or higher quality when it does not exceed the HCPCS code description. Upgrades with a different HCPCS code and advance determination situations do call for an ABN. Option a is incorrect because an advance determination is optional for customized items, and once the beneficiary asks for one, an ABN must be furnished first. Option b is incorrect because upgrades are defined by a different HCPCS code than the item Medicare covers, and an ABN must be given before the beneficiary receives it. Option d is incorrect because when a required advance coverage determination is missing, or says Medicare will not pay, an ABN is required before the item is furnished.

Correct Answer: The interpretation of the test

Under 42 CFR 414.40, services such as an EEG typically comprise a technical component, the taking of the test, and a professional component, the interpretation. CMS sets this as a uniform national ancillary policy. Option b is incorrect because unusual services appear among the payment modifiers, a distinct policy category, and do not divide a test into two components. Option c is incorrect because those belong to the global surgery policy, a separate ancillary policy listed beside professional and technical components in the same regulation. Option d is incorrect because this is how the regulation describes the technical component of an EEG, which covers performing the test rather than reading it.

Correct Answer: Those not usually self-administered by the patient

Medicare Part B covers services and supplies, including drugs and biologicals, furnished incident to a physician's professional service when they are not usually self-administered by the patient. Option a is incorrect because Part B payment is not made for services payable under Part A, so this describes where Part B does not apply rather than the drug coverage rule. Option c is incorrect because the Part B benefit list describes the reverse, since coverage of incident-to drugs depends on the drug not being one the patient usually self-administers. Option d is incorrect because home health visits are a separate Part B benefit area; the incident-to drug provision concerns services furnished with a physician's professional service, not home health care.

Correct Answer: Technical component and professional component

Under 42 CFR 414.40, the professional and technical components policy states that a service such as an EEG typically comprises a technical component, the taking of the test, and a professional component, the interpretation. Option b is incorrect because the regulation pairs the technical component with the professional component; unusual services appear only among the payment modifiers, so this pairing is not what the rule describes. Option c is incorrect because assistant-at-surgery and bilateral surgery are listed as payment modifier examples, not as the parts that divide a diagnostic test. Option d is incorrect because global surgery is a separate ancillary policy covering pre-operative, post-operative and intra-operative services, and it does not describe how a test like an EEG is divided.

Correct Answer: No adjustment is allowed for the modifier

Medicare manual guidance lists HCPCS modifiers such as RT and LT among those for which A/B MACs (B) may not adjust fee schedule amounts provided by CMS, so the right-side modifier triggers no payment change. Option a is incorrect because split surgical global services belong to the global surgery policy; a modifier naming a side of the body does not divide a global package. Option b is incorrect because multiple surgery is a payment modifier that CMS sets as national fee schedule policy, and a right-side modifier does not identify multiple procedures. Option c is incorrect because unusual circumstances may raise or lower payment only after medical record review, which has nothing to do with a modifier that only shows laterality.

Correct Answer: Modifier -76 (repeat procedure by same physician)

The Medicare manual section on no adjustments in fee schedule amounts lists CPT modifiers -23, -32, -47, -76 and -90, so A/B MACs (B) may not adjust fee schedule amounts for modifier -76, repeat procedure by same physician. Option a is incorrect because the no-adjustment list names only specific CPT modifiers such as -23, -32, -47, -76 and -90, and this one is not among them. Option c is incorrect because the Medicare manual places -22 under payment due to unusual circumstances, where A/B MACs (B) may increase or decrease payment after reviewing records. Option d is incorrect because it is handled in the same unusual-circumstances section as -22, which permits payment changes, and it does not appear in the no-adjustment list.

Correct Answer: Level III

The HCPCS/CPT coding system has three levels. Level III contains A/B MAC (B) specific codes not included in Level I or Level II, which is why A/B MAC (B)-unique local modifiers are Level 3 modifiers. Option b is incorrect because this level holds alpha-numeric codes primarily for items and services that CPT does not include, so it is not where A/B MAC (B) specific codes sit. Option c is incorrect because this level contains the American Medical Association's Current Procedural Terminology (CPT) numeric codes, not codes specific to an A/B MAC (B). Option d is incorrect because the coding system is described as having three levels, so a fourth level is not part of the structure.

Correct Answer: The upgrade has a different HCPCS code

CMS guidance on ABN standards for upgraded DMEPOS says upgrades involve situations in which the upgraded item or component has a different HCPCS code than the item Medicare will cover, so the notifier must issue an ABN first. Option a is incorrect because customization relates to optional advance coverage determinations, which is a separate concept from the coding difference that marks an upgrade. Option b is incorrect because certification by the managing physician appears in the guidance on diabetic shoes, not as the feature that defines an upgrade from the covered item. Option c is incorrect because the guidance assigns DMEPOS claims to DME MACs generally and does not describe upgrades as being routed to another contractor.

Correct Answer: CPT code definitions and applicable documentation guidelines

Medicare guidance states that the appropriate level of E/M service for a given encounter is determined according to the code definitions in the AMA's CPT book and any applicable documentation guidelines. Option b is incorrect because billing a non-covered service as if covered is listed as a coding and billing risk area, which concerns coverage rather than level selection. Option c is incorrect because the statute quoted in OIG guidance makes this a condition of payment, tied to the patient's documented condition, and it is separate from the CPT definitions named for level selection. Option d is incorrect because physical presence is a payment condition for resident services in teaching settings; the guidance does not use it to select the E/M level.

Correct Answer: Submitting claims for services that are not reasonable and necessary

OIG guidance identifies billing for services that are not reasonable and necessary as seeking reimbursement for a service not warranted by the patient's documented medical condition. Medicare statute bars payment for such items or services. Option a is incorrect because that risk area covers services never performed, such as laser surgery billed by a physician with no laser equipment, while this service was actually delivered. Option c is incorrect because double billing means charging for the same item or service more than once, or another party also billing for it; this claim was submitted a single time. Option d is incorrect because OIG lists this as a separate risk area, and the facts here turn on the documented condition failing to warrant the service, not on coverage status.

Correct Answer: Billing for non-covered services as if covered

OIG guidance lists billing for non-covered services as if covered as a coding and billing risk area. A claim that presents an excluded service as though the program pays for it falls under that category. Option a is incorrect because this risk area concerns services not provided or not provided as claimed, while the scenario concerns a service whose benefit status is misrepresented. Option b is incorrect because that area involves a service not warranted by the patient's documented medical condition, which is a medical necessity problem rather than a benefit-status problem. Option d is incorrect because double billing means the same item or service is billed more than once, or another party also billed it; the scenario describes one claim.

Correct Answer: Split between the physicians, within the global total

Under the Medicare global surgical package, postoperative, post-discharge care is split between physicians who agree on the transfer of care. The combined approved amount generally may not exceed what one physician providing all services would receive. Option a is incorrect because the sum approved for all physicians generally may not exceed what a single physician providing all services would have been paid, so duplicate full payments are not made. Option b is incorrect because the guidance says payment for postoperative, post-discharge care is divided between physicians who agree on the transfer, so the surgeon does not receive the whole amount. Option c is incorrect because denial or separate payment applies where no transfer of care occurs; here an agreed transfer exists, which is the basis for splitting the payment.

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

The Medicare manual states the national definition ensures payment is made consistently for the same services across all A/B MAC (B) jurisdictions, preventing payments for services more or less comprehensive than intended. Option a is incorrect because the global package bundles related postoperative visits into the surgery payment, so the national definition does not aim at paying each visit separately. Option c is incorrect because bilateral and multiple surgeries fall under other uniform payment policies established in addition to the global policy, not under the purpose of the national definition. Option d is incorrect because global periods come from the postoperative period entry in the MFSDB, or are set by the A/B MAC (B) for YYY codes, not by surgeon choice.

Correct Answer: Immunosuppressive therapy for organ transplants

The Medicare manual lists immunosuppressive therapy for organ transplants among the services not included in the global surgical package, so it may be paid separately for a procedure with the appropriate MFSDB indicator. Option a is incorrect because the Medicare manual states A/B MACs do not allow separate payment for these visits within 10 days when related to recovery from the procedure. Option b is incorrect because the manual includes same-day visits by the same physician in the procedure payment unless a significant, separately identifiable service is also performed. Option d is incorrect because the manual says the initial evaluation is always included in the allowance for a minor surgical procedure; the separate-payment policy covers only major procedures.

Correct Answer: Billable as a significant, separately identifiable service

Medicare includes same-day visits by the same physician in the minor surgery payment unless a significant, separately identifiable service is also performed. A full neurological examination for head trauma meets that standard, so the visit may be billed. Option a is incorrect because the guidance ties separate payment of a same-day visit to the service being separately identifiable, not to waiting out a postoperative period. Option b is incorrect because a transfer of care concerns dividing postoperative care among physicians, whereas this visit was furnished by the same physician on the day of surgery. Option c is incorrect because same-day visits are bundled only when no significant, separately identifiable service occurs; here a full neurological examination goes beyond identifying the need for sutures.

Correct Answer: Modifier -FT

The Medicare manual states that critical care services provided during a global surgical period must be unrelated to the surgical procedure and appended with modifier -FT, which marks an unrelated E/M visit in the global period. Option b is incorrect because it reports a surgery with services significantly less than usually required, which describes a reduced procedure rather than a critical care visit unrelated to the surgery. Option c is incorrect because it reports surgery requiring services significantly greater than usual, with a statement and operative report, so it does not mark unrelated critical care. Option d is incorrect because it is used when a physician furnishes surgical care only under a transfer of care agreement, not to identify unrelated critical care.

Correct Answer: correct coding

Medicare claims processing instructions state that A/B MACs (B) apply the correct coding edits first and then apply the global surgery edits to the correctly coded services on the same claim. Option a is incorrect because the limitation of liability provision does not apply to global surgery determinations, which are fee schedule reductions rather than medical necessity denials, so it is no edit step. Option b is incorrect because global surgery edits come second in the sequence, applied to services that have already passed through the correct coding edits on the claim. Option c is incorrect because reductions for fragmented billing are not attributed to medical review savings except when usual review recodes a service, so it does not set the order of edits.

Correct Answer: Deny the services

Medicare global surgery adjudication rules state that A/B MACs (B) do not allow separate payment for E/M services on the same day or during the postoperative period when billed without modifier "-24," "-25," "-57" or "-FT." These services should be denied. Option a is incorrect because individual consideration applies to surgeries billed with "-22" or "-52" when the required statement and documentation are included, not to unmodified E/M services. Option b is incorrect because a fee schedule reduction addresses fragmented billing of services in the global package, whereas these unmodified E/M services are denied outright. Option d is incorrect because separate payment is not allowed for these services when no qualifying modifier is billed, so payment at the fee schedule rate would be improper.

Correct Answer: The group

Under the Medicare manual's rule for physicians in group practice, the group bills for the entire global package when its physicians reassign benefits to the group. The surgeon is shown as the performing physician. Option a is incorrect because a receiving physician under a transfer of care bills with modifier "-55" for postoperative management, which is a different arrangement from group billing. Option b is incorrect because this physician is shown as the performing physician on the claim, but the billing entity for the whole package is the group. Option c is incorrect because the contractor processes claims and applies edits to them; it does not submit the bill for a global package.