Download Certified Coding Specialist Exam Prep: CPT & HCPCS Modifiers Q&A and more Exams Nursing in PDF only on Docsity!
Certified Coding Specialist Exam 2025/2026 – Certified
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To assign modifier ______correctly, two physicians of different ________ must have worked together as co-surgeons and each surgeon dictated his/her own operative report. - ANSWER-- 62 specialties When more than two physicians work together to complete a complicated procedure and each physician has a specific portion of the surgery to complete, they are called.... - ANSWER-co- surgeons This modifier indicates an increased service and is overused and results in an increase in payment of 20% to 30%. As such, the assignment of this modifier comes under particularly close scrutiny by third-party payers. What is this modifier? - ANSWER-- 22 When adding multiple CPT modifiers to a code, you would list the modifiers from: When adding multiple HCPCS modifiers, list in: If CPT modifiers and HCPCS modifiers are both used, list: - ANSWER-CPT- highest to lowest HCPS-ascending alphabetical order both- CPT (highest to lowest) then HCPS (ascend. alpha.)
What part of the CPT manual lists a full description for all modifiers? - ANSWER-appendix A When a CPT codes does not fully explain an unusual procedure,what should be added to the code? - ANSWER-modifier Third-Party payers require this modifier for a mandated service. - ANSWER-- 32 (like a rape test required by police, or phyiscal exam needed for workers comp; third-party payer will pay 100% for mandated services) Modifier - 47, anesthesia by the surgeon, is never added to what CPT code? - ANSWER- Anesthesia Code How many units of service may be billed when reporting the - 50 modifier (bilateral) to Medicare? - ANSWER-one unit (For medicare, just submit 27447-50 for procedure done left and right; whereas other payers want two lines 27447 and 27447-50.) When reporting - 51 modifier to indicate multiple procedure performed, which procedure should be reported first on the claim? - ANSWER-Primary Procedure Medicare considers what service to be part of the surgery and bundled payment not allowing the - 56 modifier? - ANSWER-preoperative When reporting subcutaneous hormone pellet replacement, you would code the following: - ANSWER-replacement only (This is hormone replacement therapy after menopause. The pellet is absorbed by system and doesn't have to be removed. Thus you don't code removal just replacement.)
If the closure is reported as more than simple__________ - ANSWER-simple closure and anesthesia you would code the more complicated closure using a separate code from 12031- 13160 ___________________is the separation and removal of the nail plate, preserving the root so the nail will grow back - ANSWER-avulsion blood trapped under a finger or toenail, its evacuated by puncturing the nail with an ........................needle. - ANSWER-Subungual hematoma E&M services provided the day before or the day of a major surgery are included in what package? - ANSWER-Global Day Modifier - 63 indicates procedure provided to a neonate or infant up to what weight? - ANSWER-4 kg or 8.8 lbs A surgical team consists of how many physicians? - ANSWER-More than two What is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures? - ANSWER-Operating Room How many modifier area are available on a CMS-1500 insurance claim form for one-line item charge? - ANSWER-four Describing a physician's services in radiology or pathology. - ANSWER-Professional component Describing the services provided by the facility. - ANSWER-Technical Component
Bundling together of time effort and services for a specific procedure into one code instead of reporting each component separately - ANSWER-Surgical Package Code assignments in the E/M section varies according to three factors: - ANSWER-1. place of service
- type of service
- patient status Type of service (for E/M) examples - ANSWER-consultation, admission, newborn care, office visit Six sections of the CPT manual - ANSWER-Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine Patient status (for E/M) - ANSWER-new, established, outpatient, inpatient A new patient is one who has not received a face-to-face professional service from that physician or another physician in the same practice of the same specialty for _____ years. - ANSWER-3 years Another name for the HCPCS Level II is: - ANSWER-national codes
Conditions that develop during an outpatient encounter including ER, Observation or outpatient surgery are considered ______ - ANSWER-Present on admission Where are POA guidelines found in ICD- 10 - cm - ANSWER-Appendix 1 IPPS - ANSWER-inpatient prospective payment system Under the _____ each case is categorized into a DRG - ANSWER-Inpatient prospective payment system One _____ group per admission - ANSWER-DRG MS-DRG variables - ANSWER--principal diagnosis
- secondary diagnosis
- principal or significant procedure
- age/sex
- discharge disposition modifier - 51 - ANSWER-Multiple procedures To code lesion procedures you need ..........., .............., size of ............., and whether the lesion is ...................... - ANSWER-the site, number, size of the excised lesion, and whether the lesion is malignant or benign. When coding the excision of a lesion, the size of the lesion is based on the following measurement: - ANSWER-lesion and narrowest width of margin
ingrown toenail - ANSWER-onychocryptosis electrocautery __________________is located in the sacral area and is most often caused by an ingrown hair. - ANSWER-Pylonidal Cysts These are included in which section: lesion injection, tattooing, tissue expansion, contraceptive capsule insertion/removal, and hormone implantation services - ANSWER-Introduction _____________is an elastic material formed into a sac that is then filled with fluid or air so it expands like a balloon? These are used to prepare site for .............. - ANSWER-Tissue expanders permanent impant Do not report an expander code from the Introduction category, after a ...........in which a temporary expander has been inserted. - ANSWER-mastectomy ------------requires closure of one or more layers of subcutaneous tissue and superficial (non- muscle) fascia, in addition to the skin closure. Also, if it's single layered but needs to be "extensively cleaned" the wound closure, is considered as the .............. repair - ANSWER-Intermediate repair intermediate repair
Relative weight is published in the ____ _____ and the updated _____ ____ ____ ______ regulations Oct every year - ANSWER-federal register , Inpatient prospective payment system Complication - ANSWER-is a diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifying the course of pts illness or the medical care required comorbidty - ANSWER-defined as a pre existing condition that because of its presence with a specific principal diagnosis will likely cause an increase to the pts length of stay in hospital Current MS-DRG is a _____ tiered system - ANSWER-three
- major diagnostic categories MDCs
- surgical or medical
- MS-DRGs AHIMA - ANSWER-American Health Information Management Association NCHS - ANSWER-National Center for Health Statistics ICD- 10 - CM and PCS are published by ____ _____ _____ - ANSWER-American Hospital Association ICD- 10 - CM is maintained by - ANSWER-National Centers Health statistics ICD-10 PCS is maintained by - ANSWER-CMS
Code set level 11 is a standardized coding system that is used primarily to identify products, supplies and services that are ______ included in the CPT codes - ANSWER-not Code set level 11 codes not included in the CPT codes are - ANSWER-Ambulance services, durable medical equipment, prosthetic/orthos, supplies Medicare Administrative Contractors are contracted to - ANSWER-Perform prepayment medical reviews MAC (medicare administrative contractors) calculates the - ANSWER-payment amount RAC - ANSWER-Recovery Audit Contractor Recovery Audit Contractor programs mission is to reduce medicare improper payments through
- ANSWER-- detection and collection of over payments
- identification of underpayments
- implementation of actions that will prevent future improper payments What is the difference between modifier - 26 and modifier - TC? - ANSWER-Separate payments may be made for the technical and professional components of a procedure if, for example, a facility provides the technical component of a service/procedure, while an individual physician performs the professional component. The physician bills the procedure code for that service with modifier - 26 appended (professional component), and the facility bills the same procedure code with modifier TC (technical component). if the same bone is fractured or dislocated code the _____ only - ANSWER-fracture if the question doesnt state open or closed fracture code it as a _____ fracture - ANSWER- closed
A condition that is produced by another illness or an injury and remains after the acute phase of the illness or injury is referred to as a/an _______. - ANSWER-Sequela A hospital's payment rate is based on which of the following factors? - ANSWER-Type of hospital Designation of the hospital as large urban, other urban, or rural Wage index for the geographic area where the hospital is located What does the fourth character of an ICD- 10 - CM diagnosis code capture?a. An atomic site b. Severity c. Etiology d. Supplemental information - ANSWER-C. The fourth character captures etiology. The fifth captures an atomic site. The sixth captures severity. Notes appearing under a 3-character code apply to which of the following? a. Only to category codes that are exactly three-characters long b. To all codes within that category c. Only to one specific code d. To all codes within the chapter - ANSWER-BWhen a note appears under a three-character code in ICD- 10 - CM, it applies to all codes with in that category An exception to the Excludes 1 definition is the circumstance when the two conditions
.a. Are unrelated to each other b. Are related to each other c. Will not be assigned as the principal diagnosis
d. Are injuries with external cause codes - ANSWER-a. are unrelated to each other According to CPT, a repair of laceration that includes retention sutures would be considered what type of closure? A. Simple b. Intermediate c. Complex d. Not specified - ANSWER-CComplex closure includes the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures. thrombectomy - ANSWER-removing a thrombus; use root operation EXTIRPATION which is taking or cutting out solid material from a body part judkins technique - ANSWER-The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material. For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer __________. - ANSWER-Coding Guideline I.C.12.a. notes that pressure ulcers present on admission but healed at the time of discharge are assigned the code for site and stage at time of admission. If a patient is admitted with a pressure ulcer of one stage, and it progresses to a higher stage during the same encounter, what should the coder do? - ANSWER-Report two codes for that site—one for the stage on admission and one for the highest stage during the hospitalization.
Implantable Electronic Device, Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Total Knee Replacement or Hip Replacement, Iatrogenic Pneumothorax with Venous Catheterization Which of the following status indicators indicates that the APC payment is reduced when multiple procedures with this status are reported together? - ANSWER-T - surgical service (procedures with T are usually reimbursed 50%) What is the maximum number of APCs that may be assigned per encounter? - ANSWER- unlimited Each code in the HCPCS has been assigned a(n)________ that establishes how a service, procedure, or item is paid in OPPS.A. Payment Status Indicator (SI)B. Outpatient Code Editor (OCE)C. Medicare Summary Notice (MSN)D. Remittance advice (RA) - ANSWER-Payment status indicator (SI) Each code in the HCPCS has been assigned a payment status indicator that establishes how a service, procedure, or item is paid in the OPPS. What type of data is exemplified by the insured party's member identification number? - ANSWER-Financial data Two patients were given the same health record number. This is an example of a(n): - ANSWER- overlap the ___ otherwise known as the ____, builds on the Anti-Kickback Statute and prohibits a physician from referring patients to a business with which he or she or a member of the physician's intermediate family has financial interests - ANSWER-Physician Self-Referral Law (Stark Law)
What does the Anti-Kickback Statute Prevent? - ANSWER-Prohibits offering, paying, soliciting, or receiving anything of value in induce or reward referrals or generate Federal health care program business. The Anti-Kickback Statute prohibits offering or accepting kickbacks intended to generate health care business. Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards? - ANSWER-Quality improvement maintenance of the charge description master requires expertise in: - ANSWER-coding, clinical procedures, health record/clinical documentation, and billing regulations CDM software is designed to..... - ANSWER-The software is primarily designed to continuously apply edits that point out compliance issues, validity of elements such as CPT codes and revenue codes, and identification of items priced below national reimbursement levels. The inpatient clinical documentation integrity process can be divided into three main functions:
- ANSWER-query for documentation clarification, physician education, and record review Although computer assisted coding (CAC) is used mainly for coding of the health record for reimbursement, another purpose is _____. - ANSWER-Clinical documentation integrity what does the acronym PHI stand for? - ANSWER-protected health information which of the following statements is true of the notice of privacy practices?a. it gives the covered entity permission to sue information for treatment purposes
special report - ANSWER-Additional medical documentation required to confirm the need for the use of unlisted, unusual, or newly adopted medical procedures. include: nature, extent, need, time, effort, equipment global surgery - ANSWER-Global period—number of days associated with surgical package; designated as 0, 10 (minor surgery), or 90 (major) days When the words "separate procedure" appear after the descriptor of a code, you know which of the following about that code? - ANSWER-the procedure is not reported if it is performed with a more major procedure of the same site these are minor procedures that are reported only when they are the only services performed or when they are performed with another major procedure that is unrelated Integumentary abscess incision codes are used when only - ANSWER-the skin and subcutaneous tissues are incised Musculoskeletal abscess incision codes are used when the incision - ANSWER-is deeper than the subcutaneous-to the fascia, muscle,tendons or other deep soft tissue Wound exploration codes have the following service(s) bundled into the codes: - ANSWER- Explorations, including enlargement, debridement, removal of foreign body(ies), minor vessel ligation, repair This type of graft is often taken from the mid-upper thigh area. - ANSWER-fascia lata Types of fracture treatment: - ANSWER-open closed
percutaneous Which of the following flaps describes a bone graft that is taken along with the skin and tissue that overlies the bone: - ANSWER-free osteocutaneous what hospitals are excluded from the medicare IPPS payment system? - ANSWER-Four classes of specialty hospitals (children's, psychiatric, rehabilitation, and long-term) and two types of distinct-part units in general hospitals (psychiatric and rehabilitation)
- Which of the following is NOT reimbursed according to the Medicare outpatient prospective payment system? a. CMHC partial hospitalization services b. Critical access hospitals c. Hospital outpatient departments d. Vaccines provided by CORFs - ANSWER-b. Critical access hospitals CRITICAL ACCESS HOSPITALS are paid on a cost-based payment system and are not part of prospective payment system.
- Fee schedules are updated by third-party payers: a. Annually b. Monthly c. Semiannually d. Weekly - ANSWER-a. AnnuallyThird-party payers who reimburse providers on a fee-for- service basis generally update fee schedules on an ANNUAL BASIS.
- Which of the following would a health record technician use to perform the billing function for a physician's office?
