AAPC-CPMA Certified Professional Medical Auditor - Set 4 - Part 2

Correct Answer: It cannot be safely furnished by an unskilled person

A service is skilled when it cannot be self-administered or safely and effectively furnished by an unskilled person. Furnishing by a therapist, or by an assistant under supervision, does not by itself make a service skilled. Option a is incorrect because who furnishes a service does not decide its status; a service a therapist provides still is not skilled if an unskilled person could safely and effectively furnish it. Option b is incorrect because a service is not considered skilled merely because an assistant furnishes it under direct or general supervision, so the supervision arrangement alone cannot establish skill. Option d is incorrect because Medicare coverage policy says that unavailability of a competent person for a non-skilled service, however important to the patient, does not make it skilled when a therapist provides it.

Correct Answer: Need for the skills of a therapist

Under the Medicare manual's maintenance program provision, coverage depends on whether the specialized skill, knowledge and judgment of a qualified therapist are required to design or carry out the program, not on potential for improvement. Option a is incorrect because improvement potential is the goal of rehabilitative therapy, but skilled maintenance services may be covered when they meet maintenance program criteria, so improvement is not required here. Option c is incorrect because Medicare guidance states that recovery not being possible does not necessarily mean skilled therapy is unneeded, so recovery prospects do not decide coverage. Option d is incorrect because spontaneous improvement describes a transient, easily reversible loss of function, which is not covered; it does not describe a chronic degenerative condition under a maintenance program.

Correct Answer: They are not reasonable and necessary

Under the Medicare manual on rehabilitative therapy, when expected rehabilitation potential is insignificant in relation to the extent and duration of therapy required to achieve it, the therapy is not reasonable and necessary. Option a is incorrect because a diagnosis or prognosis cannot be the sole factor in deciding whether a service is skilled, so diagnosis alone does not establish coverage. Option b is incorrect because the manual provision states no reclassification; maintenance programs are addressed in a separate subsection, and this excerpt only says the rehabilitative therapy fails the reasonable and necessary standard. Option d is incorrect because the presumption of proper supervision applies when services are of a type safely performed only by or under a qualified professional, which is unrelated to rehabilitation potential.

Correct Answer: Reasonable and necessary for diagnosis or treatment

The statute bars payment under Part A or Part B for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Option a is incorrect because participating hospitals and SNFs are described only as settings that may furnish therapy to certain inpatients, and the statute does not set that as the payment standard. Option b is incorrect because services for a transient, easily reversible loss of function that improves on its own are described as not reasonable and necessary, so they are not covered. Option c is incorrect because private practice rules are addressed separately in the Medicare manual and are not the statutory test applied to items or services generally.

Correct Answer: Mutually exclusive procedures

NCCI states that mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. Repair of an organ by two different methods is its example, since only one method can be chosen. Option a is incorrect because refers to codes whose descriptor includes the term "separate procedure", which may be reported when done in an anatomically unrelated area or at a separate encounter. Option b is incorrect because are the limited services contained within a more comprehensive code, which prohibits reporting them separately, rather than procedures that cannot be performed together. Option d is incorrect because describes a surgical approach converted to a second approach, where only the code for the second approach is reported, not two alternative repair methods.

Correct Answer: 000 or 010 days

A procedure with a global period of 000 or 010 days is defined as a minor surgical procedure. The decision to perform it is included in its payment, and E&M services on that date are generally included. Option b is incorrect because this designation identifies maternity procedures, a separate category in the global surgery scheme that is not the definition of a minor surgical procedure. Option c is incorrect because this period defines a major surgical procedure, for which only the E&M service made to decide on surgery is separately reportable. Option d is incorrect because this designation marks a procedure related to another procedure, so its global period is determined by that related procedure rather than defining minor surgery.

Correct Answer: Not separately reportable with the Column One code

When an integral component service has its own code, NCCI PTP edits place the comprehensive service in Column One and the component in Column Two. Because a component integral to the comprehensive service is not separately reportable, the Column Two code is not reportable with Column One. Option a is incorrect because having its own code is precisely the situation in which PTP edits place the component in Column Two, so a separate code confers no separate reportability. Option b is incorrect because documentation of an integral service, including dictation or transcription, is itself part of the comprehensive service and does not make a Column Two service separately reportable. Option d is incorrect because the comprehensive service is the one placed in Column One; the Column Two service is the integral component of it, not a comprehensive service.

Correct Answer: All described services were performed

The first family-of-codes principle states that a HCPCS/CPT code may be reported if and only if all services described by the code are performed. Partial performance of a descriptor does not qualify. Option a is incorrect because when no code correctly describes the procedure, the guidance directs a "not otherwise specified" code instead of the code that most closely describes it. Option b is incorrect because component service codes are not reported separately with a more comprehensive code that already includes those component services. Option c is incorrect because the guidance sets a stricter standard, since a code may be reported if and only if all of its described services are performed.

Correct Answer: duplicate payment

OIG guidance lists double billing resulting in duplicate payment among the risk areas associated with coding and billing that have been frequent subjects of OIG investigations and audits of physician practices. Option b is incorrect because OIG guidance lists this as its own bullet about billing for items or services not provided as claimed, distinct from double billing. Option c is incorrect because claims for equipment, supplies and services that are not reasonable and necessary are another listed concern, and they do not describe repeated billing. Option d is incorrect because inducements, kickbacks and self-referrals form a separate risk area in the OIG list, not the outcome of double billing.

Correct Answer: Instructions in CMS rules, manuals, and notices

Physicians must use CMS coding instructions, published in its rules, manuals, and notices, when reporting services to Medicare patients. CPT Professional codebook instructions are followed unless CMS has provided different coding or reporting instructions. Option a is incorrect because CMS does not review or approve that AMA publication, and CMS may adopt NCCI edits inconsistent with it, so it cannot override CMS. Option c is incorrect because appendix instructions sit inside the same codebook, so they give way whenever CMS supplies different coding or reporting instructions for Medicare services. Option d is incorrect because codebook chapter instructions are part of the CPT Professional codebook itself, which physicians follow unless CMS has provided different coding or reporting instructions.

Correct Answer: The contractor's local coverage determination

Medicare states that the Part B outpatient therapy benefit pays only for services that constitute therapy. When there is doubt about whether a service is therapy, the contractor's local coverage determination (LCD) shall prevail. Option a is incorrect because CPT Assistant is published by the AMA and contains coding guidelines, but CMS does not review or approve it, so it cannot settle a therapy question. Option b is incorrect because a plan of care is a condition of payment that a physician/NPP or therapist establishes and reviews; it does not decide whether a service is therapy. Option c is incorrect because payers may request documentation to validate matters such as site of service, but such a request is an information tool and not a rule of precedence.

Correct Answer: Extended HPI, extended ROS, pertinent PFSH

A Detailed history requires an extended HPI, an extended ROS and a pertinent PFSH. To qualify for a given type of history, all three elements in the chart must be met, along with a chief complaint. Option a is incorrect because it pairs a brief HPI with a problem pertinent ROS and no PFSH, which is the Expanded Problem Focused row of the chart. Option c is incorrect because a brief HPI with no ROS and no PFSH meets only the Problem Focused type, the lowest of the four types of history. Option d is incorrect because it describes the Comprehensive history, which calls for a complete ROS and complete PFSH rather than the extended and pertinent levels of a Detailed history.

Correct Answer: As related, based on the presumed causal relationship

The ICD-10-CM guideline for "with" states that the word means "associated with" or "due to" and the classification presumes a causal relationship. Such conditions are coded as related without explicit provider linkage unless documentation says they are unrelated. Option a is incorrect because no query is needed for conditions linked by "with"; explicit provider linkage is required only for conditions not linked by relational terms in the classification. Option b is incorrect because the classification presumes a causal relationship for conditions linked by "with", so missing provider linkage does not make the conditions unrelated here. Option c is incorrect because adding a symptom code has no bearing on the presumed relationship; signs and symptoms are a separate matter from the interpretation of "with".

Correct Answer: I, II, and IV

History, examination, and medical decision making are the three key components in selecting the level of E/M service. Time is the controlling factor only for visits predominantly consisting of counseling or coordination of care. Option a is incorrect because leaves out medical decision making, which is also one of the first three components named as key in selecting the level of E/M service. Option c is incorrect because includes time as a key component for every visit, yet time controls only visits consisting predominantly of counseling or coordination of care, and it omits history. Option d is incorrect because treats time as key for all visits, but time is an exception applying solely to counseling or coordination of care visits.

Correct Answer: Expanded Problem Focused Examination

Eight elements meets the expanded problem focused requirement of at least six bulleted elements. Detailed requires six systems or areas with two elements each, or twelve elements in two or more; two systems and eight elements meet neither route. Option b is incorrect because it calls for at least six organ systems or body areas, or twelve elements in two or more; two systems with eight elements meets neither route. Option c is incorrect because it expects at least nine organ systems or body areas, with at least two elements documented for each; two systems is far short of that. Option d is incorrect because it covers one to five bulleted elements, which is a lower level; the eight documented elements reach the next level up, so this is not the highest supported.

Correct Answer: Findings about 8 or more of the 12 organ systems

The documentation guidelines state that the medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems. A note covering six systems does not meet that standard. Option a is incorrect because body areas are a separate list from organ systems, and the general multi-system standard is stated in terms of organ systems, not all body areas. Option b is incorrect because that describes a single organ system examination, which is the other route to a comprehensive examination and does not define the general multi-system type. Option d is incorrect because the guideline sets the threshold higher than six systems, so a note with six systems, however detailed, falls short of a general multi-system examination.

Correct Answer: Documentation of at least one component

Elements with multiple components but no specific numeric requirement, such as "Examination of liver and spleen," require documentation of at least one component. A numeric requirement applies only when the element description states one. Option a is incorrect because the guidelines call an "abnormal" notation without elaboration insufficient, so it cannot satisfy the documentation requirement for an element. Option b is incorrect because the guidelines require only one component for such elements, not all of them; full documentation of every component is not demanded when no numeric requirement exists. Option c is incorrect because a count of two is not stated for these elements; the two-element figure appears in the level requirements for a detailed or comprehensive examination instead.

Correct Answer: Documenting that the problem is well controlled

A record of whether an established problem is improved or well controlled addresses the status of the presenting problem, not the data reviewed. Data complexity rests on tests ordered or reviewed, old records, outside history and discussion with interpreting physicians. Option a is incorrect because discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is named as an indicator of data complexity. Option b is incorrect because a decision to obtain history from sources other than the patient is stated to increase the amount and complexity of data reviewed. Option d is incorrect because the ordering physician personally viewing the image, tracing or specimen to supplement the report is described as another indication of data complexity.

Correct Answer: Low complexity

To qualify for a type of decision making, two of the three elements in the progression chart must be met or exceeded. Two limited elements meet the low complexity row, while only one element reaches moderate. Option a is incorrect because the chart ties this type to minimal elements, but two elements here are limited, which reaches the next row of the chart. Option c is incorrect because this row calls for extensive diagnoses or management options and extensive data, or high risk, and none of those elements appears in this encounter. Option d is incorrect because this type needs two of the three elements at the moderate row, yet only the risk element gets there, so one element cannot qualify it.

Correct Answer: Highest level in any one category

The Table of Risk assigns overall risk by the highest level of risk found in any one category: presenting problem(s), diagnostic procedure(s), or management options. Here the high-risk management options set the overall risk. Option b is incorrect because the presenting problem is only one of three categories, and it does not control the overall risk when another category is higher. Option c is incorrect because choosing the minimum reverses the rule, which looks to the top level reached in any category and ignores the lowest. Option d is incorrect because the guidelines do not blend the categories into a mean; one category sets the result instead of a calculated midpoint.