AAPC-CPC Certified Professional Coder - Set 5 - Part 2

Correct Answer: Review a sample of the physician's records

Medicare presumes that hospital visits billed for were made, absent evidence to the contrary. When patterns of utilization are questionable, the guidance directs a review of a sample of the physician's records. Option a is incorrect because this ignores the exception, since questionable patterns of utilization are exactly the situation where the guidance requires a records check rather than simple acceptance. Option b is incorrect because the guidance sets the opposite starting point: absent contrary evidence, visits billed for are presumed made, and a questionable pattern only triggers further checking. Option d is incorrect because the guidance calls for examining a sample of records when patterns are questionable, not a full review of all the physician's records.

Correct Answer: Prepayment edits for separate billing

Medicare manual instructions require A/B MACs (B) to identify, on a prepayment basis, services within the global period billed with the same provider or group number and without the listed modifiers, to detect separate billing of included services. Option b is incorrect because reassignment lets a group bill the entire global package for its physicians; it is a billing arrangement, not a method for detecting included services. Option c is incorrect because the excerpt describes edits applied on a prepayment basis to claims, not an audit performed after payment to test medical necessity. Option d is incorrect because a transfer of care is an arrangement between physicians who split the global package using modifiers, not a contractor review of claims.

Correct Answer: Standard billing under CMS regulations

Non-medically directed CRNAs bill in a standard fashion under CMS regulations in the Medicare Claims Processing Manual. Supervision by an operating practitioner is not medical direction, so the medical direction route does not apply. Option a is incorrect because medical direction rules govern CRNAs and AAs practicing under an anesthesiologist, and here no anesthesiologist directed the care. Option b is incorrect because this bundling applies when the physician who furnishes the medical or surgical service also furnishes the anesthesia, which is not the situation described. Option d is incorrect because an AA always performs services under an anesthesiologist's direction, so this route cannot fit a CRNA working without medical direction.

Correct Answer: risk of adverse reactions

The anesthesia care package begins with a preoperative evaluation. Its history and physical examination must be sufficient to minimize the risk of adverse reactions, plan alternative approaches to anesthesia, and answer questions from the patient or family. Option a is incorrect because post-anesthesia recovery care is a separate component of the care package, and the evaluation is not described as reducing the need for it. Option c is incorrect because the guidance links the evaluation to patient safety and planning, and does not describe it as lowering what the surgical procedure costs. Option d is incorrect because standard preparation and monitoring services are their own component of the package, not something the history and physical examination is meant to reduce.

Correct Answer: The anesthesia practitioner

The anesthesia practitioner assumes responsibility for anesthesia and related care in the post-anesthesia recovery period, which is part of the anesthesia care package, until the patient is released to the surgeon or another physician. Option a is incorrect because family members are involved in the preoperative evaluation, where their questions about the anesthesia procedure are answered, but they do not assume responsibility for recovery care. Option b is incorrect because a billing role concerns claim reporting and has nothing to do with clinical responsibility for post-anesthesia recovery care, which belongs to the anesthesia practitioner. Option c is incorrect because the surgeon takes over only when the patient is released to the surgeon; until then the guidance places responsibility on the anesthesia practitioner.

Correct Answer: Anesthesia assistant (AA)

An AA always performs anesthesia services under the direction of an anesthesiologist. Unlike a CRNA, who may practice with or without medical direction, an AA is listed only as practicing with medical direction. Option a is incorrect because a CRNA may work independently or under the supervision of an anesthesiologist or operating practitioner, so medical direction is not required. Option b is incorrect because an operating practitioner is named only as a possible supervisor of a CRNA, not as a practitioner who gives anesthesia under direction. Option d is incorrect because an anesthesiologist may personally perform anesthesia services, and also supervises CRNAs or AAs, so no direction by another physician is required.

Correct Answer: Sedative administration

NCCI lists sedative administration by the physician performing a procedure as integral to a large number of procedures. As a component of the comprehensive service, it is not separately reportable under standard of medical/surgical practice principles. Option a is incorrect because the evaluation belongs to the anesthesia care package of the anesthesia practitioner and is not listed among services integral to many procedures. Option c is incorrect because direction of an AA is a supervisory arrangement for anesthesia services, not a component service integral to another physician's procedure. Option d is incorrect because recovery care is part of the anesthesia care package provided by the anesthesia practitioner, not a service listed as integral to a surgeon's procedure.

Correct Answer: They are not separately reportable with anesthesia

Standard preparation and monitoring are part of the anesthesia care package. NCCI states they are not separately reportable with anesthesia service codes when performed in association with the anesthesia service, regardless of the mode of anesthesia. Option a is incorrect because the anesthesia care package includes standard preparation and monitoring whether a physician, CRNA or anesthesia assistant provides the care, so the provider type does not change reporting. Option b is incorrect because modifiers 59, XE or XU apply only when the service is unrelated to the anesthesia service or follows release from postoperative care, not when it is performed in association with it. Option d is incorrect because NCCI guidance applies the bundling rule regardless of the mode of anesthesia, so regional anesthesia gets no special exception for preparation and monitoring.

Correct Answer: Local, topical or regional anesthesia

NCCI lists local, topical or regional anesthesia administered by the physician performing the procedure among services integral to a large number of procedures. As a component of the comprehensive service, it is not separately reportable. Option b is incorrect because the same list carves these out of the integral services, since CMS policy allows separate payment in specific situations. Option c is incorrect because NCCI treats such preparation, done before and apart from the anesthesia service, as an exception, so it can be reported on its own. Option d is incorrect because a service furnished after the patient is released from the anesthesia practitioner's postoperative care may be separately reportable with modifier 59, XE or XU.

Correct Answer: unrelated to

NCCI allows separate reporting, with modifier 59, XE or XU, only when preparation or monitoring is performed prior to and unrelated to the anticipated anesthesia service, or after release from the anesthesia practitioner's postoperative care. Option a is incorrect because services performed concurrently with anesthesia fall within the anesthesia care package, so this timing does not create the exception for separate reporting. Option b is incorrect because a service integral to the anesthesia care package is part of standard preparation and monitoring, which NCCI treats as included rather than separately reportable. Option c is incorrect because services performed in association with the anesthesia service are included in it and are not separately reportable, so this wording describes the bundled situation.

Correct Answer: Multiply allowable units by the anesthesia-specific conversion factor

Once the A/B MAC has the base units and the time units from reported actual anesthesia time, it multiplies the allowable units by the anesthesia-specific conversion factor for the payment area to set the fee schedule payment. Option a is incorrect because a three-base-unit limit applies only under the medically supervised rate, when more than four procedures are directed concurrently, not as a routine step. Option b is incorrect because the -51 modifier is reported by the physician when billing multiple or bilateral surgeries, so it is a billing step, not a payment step. Option d is incorrect because the QS modifier is informational for monitored anesthesia care and is reported by the provider on the claim, not added by the contractor.

Correct Answer: Reported minutes divided by 15, rounded to one decimal

The A/B MAC computes time units by dividing the reported anesthesia time by 15 minutes and rounding the result to one decimal place. Actual minutes are reported on the claim, not pre-converted units. Option a is incorrect because time units are computed in 15-minute increments and rounded to one decimal place, so neither the divisor of 10 nor whole-number rounding is used. Option b is incorrect because base units are a separate payment component tied to the anesthesia procedure, and they are not multiplied by minutes to produce time units. Option c is incorrect because the conversion factor is released annually by CMS and is applied to the sum of base and time units, not to raw minutes.

Correct Answer: Payable separately if reasonable and medically necessary

Medicare may pay under the fee schedule for specific medical and surgical services furnished by the anesthesiologist, such as Swan Ganz catheter insertion, when reasonable and medically necessary or when rebundling provisions do not preclude separate payment. Option a is incorrect because the manual says such services may be furnished as single services during the day of or the day before the anesthesia service. Option b is incorrect because modifier -51 appears in the manual for multiple or bilateral surgeries, where the anesthesia procedure with the highest base unit value is reported. Option d is incorrect because anesthesia time is the period an anesthesia practitioner is present with the patient, starting at preparation for anesthesia services, so a service on the preceding day is outside it.

Correct Answer: Practitioner begins preparing the patient in the operating room

Medicare defines anesthesia time as the period during which the anesthesia practitioner is present with the patient. It starts when the practitioner begins preparing the patient for anesthesia services in the operating room or an equivalent area. Option a is incorrect because anesthesia time is tied to the anesthesia practitioner's presence with the patient, not to the surgeon's actions, and it begins before any incision is made. Option b is incorrect because arrival alone does not start the clock; time begins when the practitioner starts preparing the patient for anesthesia services in the operating room or an equivalent area. Option c is incorrect because induction matters for the additional time unit under the medically supervised rate, but anesthesia time itself starts earlier, when preparation of the patient begins.

Correct Answer: Submit documentation with all subsequent claims before payment

Under Medicare manual instructions on medical direction, A/B MACs periodically sample claims for four or fewer concurrent procedures. A physician who cannot supply the requested documentation must submit documentation with all subsequent claims before payment will be made. Option a is incorrect because AD describes medical supervision of more than 4 concurrent procedures; it is a payment modifier, not a response to a failed documentation request. Option c is incorrect because the guidance ties payment to documentation being submitted first; nothing allows an unreduced rate to substitute for the missing records. Option d is incorrect because the A/B MAC requires documentation with every later claim until payment is made, so the physician cannot simply wait for another sample.

Correct Answer: Two concurrent cases involving residents

The Medicare manual states that the requirements for payment at the medically directed rate do not apply to two concurrent anesthesia cases involving residents, or to a single resident case concurrent with another directed case. Option a is incorrect because an anesthesiologist's assistant is listed with the qualified individuals, meaning this combination remains eligible for the directed rate under the guidance. Option b is incorrect because the guidance extends the directed-rate requirements to this pairing, so it falls inside the rule rather than outside it. Option c is incorrect because a CRNA counts among the qualified individuals who can be paired with a student nurse anesthetist case, so the requirements still apply.

Correct Answer: Receiving patients entering the operating suite

Receiving patients entering the operating suite for the next surgery is listed in Medicare guidance as an activity that does not substantially diminish the physician's control or count as a separate service, so the medically directed rate remains payable. Option b is incorrect because availability for the immediate needs of the surgical patients is required, so lacking it fails the directed-rate requirements instead of being a harmless activity. Option c is incorrect because extensive emergency time is contrasted with an emergency of short duration; it removes availability for immediate needs and disqualifies the directed rate. Option d is incorrect because leaving the immediate area for other than short durations means the physician is unavailable to the surgical patients, so the directed-rate requirements are not met.

Correct Answer: Presence during the entire viewing from insertion to removal

Anesthesia payment under the teaching physician rules requires presence during critical or key portions, immediate availability, and documentation of both. Presence for the entire viewing from insertion to removal is not the anesthesia standard; it belongs to endoscopic procedures. Option a is incorrect because the medical record must show the teaching physician's presence during those portions and the immediate availability of another teaching anesthesiologist as necessary, so this is required. Option b is incorrect because this is a stated requirement; the teaching anesthesiologist, or another anesthesiologist in the same group, must be present during all critical or key portions of the service. Option c is incorrect because Medicare states this directly; the teaching anesthesiologist, or an arrangement partner, must be able to furnish anesthesia services throughout the whole procedure.

Correct Answer: 50 percent

When a physician medically directs qualified individuals in two, three, or four concurrent cases and performs the required activities, the A/B MAC pays 50 percent of the allowance for the service performed by the physician alone. Option a is incorrect because full payment for both providers is tied to one case where the physician and CRNA each document a medically necessary service, not to concurrent directed cases. Option b is incorrect because the guidance gives no such share for directed cases; it ties payment at the medically directed rate to 50 percent of the physician-alone allowance. Option d is incorrect because this share is not given in the guidance for directed cases; the rate stated is 50 percent of the allowance for the physician alone.

Correct Answer: Three base units

Medicare guidance states that the A/B MAC may allow only three base units per procedure when the anesthesiologist is involved in more than four concurrent procedures or performs other services while directing them. Option b is incorrect because the guidance caps the base units at three per procedure in this situation, and five exceeds that stated limit. Option c is incorrect because the guidance sets the limit at three base units per procedure, so two does not match the stated allowance. Option d is incorrect because four appears in the guidance only as the count of concurrent procedures that, when exceeded, triggers the medically supervised rate; it is not the base unit limit.