5 Written questions
5 Matching questions
- Modifier 22, Unusual procedural services
- Physical Exam Levels
- Starred procedures
- Modifyer -59
- a Many procedure codes also include procedures and supplies that are routinely necessary to perform the procedure
Only services not typically performed, or materials not typically used, should be billed separately
Charging for these items separately, known as "unbundling" or "fragmenting," is against the law.
- b When the service provided is > that usually required for the listed procedure (E/M - 21)
A provider excises a lesion from the crease of the neck of a very obese person. The obesity makes the excision more difficult. The provider indicates the complexity of the removal by adding 22 modifier to code. It may be helpful to include copy of operative report.
- c Procedures in which the follow-up is generally non-existent or varies with the patient's underlying condition
When billing for a starred procedure, the charge does not include any pre or post-operative care
- d "DISTINCT PROCEDURE"
Indicates that codes that usually are bundled together as a part of a global code are in this particular circumstance describing DISTINCT or SEPARATE precedures
- e Problem focused= 1-5 elements
Expanded problem focused= >6
Comprehensive= 18+ or 2 bullets in 9 systems
5 Multiple choice questions
- "MULTIPLE PROCEDURES"
List the major procedure first, with the additional lesser procedure(s) secondary with mod 51
For example, if a 100 sq. cm. knee wound is debrided, then reconstructed with a medial gastrocnemius muscle flap and split thickness skin graft, the procedure is reported:
15738 Muscle flap
15000-51 Wound preparation
The major procedure is the muscle flap and the "-51" modifier is not appended to its CPT code. The secondary procedure CPT codes take the "-51" modifier.
- Automatically running a test based on a previous test result w/o the MD/PA requesting the second test
- Billing for services not provided or not at the level billed for
False Claims Act- allows individuals to file claims against companies that they think have defrauded the government. More than $17 billion dollars have been recovered by the government since 1987
- Expensing employees or hours worked that do not exist
- International Classification Of Disease, 9th Revision, Clinical Modifications
Initially developed by the World Health Organization as a way to report morbidity and mortality statistics worldwide
Not initially meant to be used for billing purposes
Maintained and updated yearly by the National Center for Health Statistics
5 True/False questions
Lack of medical Neccessity → "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."
Brackets [ ] → Used to enclose a series of terms, each of which is modified by the statement appearing to the right of the brace.
Anesthesia → Medicare/medicaid program that aims at catching fraud
Kickbacks → a bribe or financial incentive
CPT → PROCEDURAL CODE
CPT codes account for the majority of the HCPCS coding system
Maintained/Updated by the AMA
Codes for >7,000 procedures and services
5-digit code 00100-99199
Followed by a verbal description
I= Evaluation & Management
II= Performance Measurement
III= New/emerging technology