AAPC-CPC Certified Professional Coder - Set 2 - Part 3

Correct Answer: Included in the more complex procedure

Under the more extensive procedure principle, the less complex service is included in the more complex service and is not separately reportable unless performed at separate patient encounters or at separate anatomic sites. Option b is incorrect because sequential procedures involve a failed first surgical approach followed by a second approach, and only the second approach is reported, not a simple and complex pair. Option c is incorrect because modifiers such as 59, XE or XS apply to "separate procedure" codes performed in unrelated areas or at separate encounters, which is not this situation. Option d is incorrect because family of codes principles direct reporting of the most comprehensive code, so component services are not reported separately alongside it.

Correct Answer: Sequential procedure principle

When an initial surgical approach fails and a second approach is used at the same patient encounter, and each approach has its own code, the procedures are sequential. Only the code for the second approach, the open procedure, is reported. Option a is incorrect because it applies to similar codes differing in complexity, such as simple versus complex, not to a failed approach followed by a second approach. Option b is incorrect because it directs selection of the most comprehensive code among related component and combination codes, but does not address a failed first approach replaced by a second. Option c is incorrect because it concerns codes whose descriptors include the term "separate procedure" being performed with a related procedure, which is not what happens in a converted approach.

Correct Answer: CMS

Under 42 CFR 414.40(a), CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. The HHS Secretary delegated this authority to CMS. Option b is incorrect because the AMA maintains CPT, the HCPCS Level I system, and republishes it annually, but the regulation gives national definition and modifier authority to another agency. Option c is incorrect because CPT Assistant is an AMA publication of coding guidelines, and CMS does not review or approve it, so it holds no regulatory authority. Option d is incorrect because the regulation sets uniform national policy, so authority over definitions, codes and payment modifiers does not rest with an individual payer's claims department.

Correct Answer: Services excluded from Medicare coverage

CMS policy states that the NCCI program does not generally address HCPCS/CPT codes describing services excluded from Medicare coverage or not otherwise recognized for payment under the Medicare program, which makes excluded services the correct category. Option a is incorrect because a comprehensive code is one whose descriptor includes other procedures, so it concerns code definition and rebundling, not services outside Medicare coverage. Option b is incorrect because the "separate procedure" designation marks a service generally included in a more comprehensive procedure, which is a bundling concept rather than a coverage exclusion. Option d is incorrect because the CPT guidance describes add-on codes as separately identifying an additional service performed in certain situations, and nothing there places them among services NCCI generally leaves unaddressed.

Correct Answer: Modifier -24

Modifier -24 reports an unrelated evaluation and management service by the same physician during a postoperative period. It is added to the appropriate E/M level, and a diagnosis clearly unrelated to the surgery supports it. Option a is incorrect because it is attached to an unrelated procedure performed in a postoperative period, so it does not fit an evaluation and management visit. Option b is incorrect because it reports a significant, separately identifiable E/M service on the day of a procedure, not an unrelated visit during the postoperative period. Option c is incorrect because it marks a surgery with services significantly greater than usually required and goes on the procedure, not on an E/M visit.

Correct Answer: 090

Codes with a 090 entry in the Medicare Fee Schedule Data Base are major surgeries. Entries of 000 and 010 are minor procedures or endoscopies, and YYY codes have a global period set by the A/B MAC (B). Option b is incorrect because also marks minor surgical procedures or endoscopies in the database, so it cannot identify the major surgery category. Option c is incorrect because is an entry assigned to minor surgical procedures or endoscopies, not to major surgeries, which carry a different postoperative period entry. Option d is incorrect because designates codes priced by the A/B MAC (B), which determines the global period of 0, 10, or 90 days, so it does not mark major surgery.

Correct Answer: Modifier -52

Medicare guidance states that surgeries for which services performed are significantly less than usually required may be billed with modifier -52. The biller must supply a concise statement of how the service differs and an operative report. Option a is incorrect because it is appended to critical care services unrelated to the surgical procedure during a global period, not to reduced surgical services. Option b is incorrect because it is used when the surgeon relinquishes postoperative care to another physician, so it addresses split care rather than a reduced procedure. Option c is incorrect because it reports surgeries where services performed are significantly greater than usually required, which is the opposite of the circumstance described.

Correct Answer: As a fee schedule reduction

Because the Medicare fee schedule amount includes all services in the global surgery package, A/B MACs (B) do not pay more than that amount. Excess charges from fragmented billing are processed as a fee schedule reduction. Option a is incorrect because the guidance says these determinations are fee schedule reductions, not denials based upon medical necessity or custodial care, so this treatment does not apply. Option b is incorrect because A/B MACs (B) do not attribute such reductions to medical review savings, except when usual medical review recodes a service already in the global package. Option d is incorrect because individual consideration applies to surgeries billed with modifier -22 or -52 when the required statement and documentation accompany the claim, not to fragmented billing.

Correct Answer: Team surgery

Medicare guidance names team surgery services among the By Report services, and the rules on multiple surgical modifiers state that A/B MACs (B) must price all claims for surgical teams by report, not from RVUs. Option a is incorrect because it is another listed adjustment to the fee schedule amount, while the By Report services named by the guidance are different ones, such as unusual services. Option b is incorrect because it appears in the list of fee schedule adjustments to the computed amount, and the guidance does not name it among the By Report services. Option c is incorrect because guidance treats it as one of the adjustments made to reach the final fee schedule amount, not as a By Report category.

Correct Answer: Report the more major procedure without modifier -51 and the additional procedure with modifier -51

For multiple surgeries by the same physician on the same day, Medicare billing instructions direct reporting the more major surgical procedure without the multiple procedures modifier -51 and each additional procedure with modifier -51. Option a is incorrect because this reverses the instruction; the modifier marks the additional procedures, while the more major procedure is reported without it. Option c is incorrect because a single surgeon performing multiple surgeries is exactly when the modifier is used on additional procedures; omitting it leaves the claim unflagged for multiple surgery adjustment. Option d is incorrect because the instructions exempt the more major procedure from the modifier, so appending it to both lines misapplies the multiple surgery billing rule.