Healthcare Compliance Quiz: Questions and Answers for 2023-2024, Exams of Public Health

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Answer :B. If documentation supports the service, have the staff contact the carrier to reprocess the claims. Code 33010 was valid for the date of service billed. Rationale: The effective dates of codes are date of service driven. New CPT® codes become effective January 1st of every year. When auditing, verify codes based on the codes that were valid during the date of service. - Quiz :In February 2020, an auditor is asked to review 10 records for date of service 12/1/2019 to make sure the claims were paid correctly. Te claims included code 33010, which was denied on all the claims. Te denial was for an invalid code. What should the auditor advise the provider? A. Code 33010 was deleted efective 1/1/2020. Determine the correct new code and have staf resubmit claims. B. If documentation supports the service, have the staf contact the carrier to reprocess the claims. Code 55450 was valid for the date of service billed. C. Code 33010 was deleted efective 1/1/2020. Tis is a valid denial. Advise the staf to write of the balance. D. Code 33010 was efective for the date of service. Advise the staf to add modifer 59 and resubmit the claim. Answer :a. Review based solely on the submitted claims and regulatory guidelines. No medical records are needed. For an automated review, no medical records are needed. Improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals. - Quiz :Recovery auditors may perform two types of reviews. What is an automated review? a. Review based solely on the submitted claims and regulatory guidelines. No medical records are needed.

b. Review based on data and potential human review of a medical record or other documentation. c. Medical records are required for the review. d. Review is based solely on denials received. Answer :b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. According to the OIG, disciplinary action should be taken based on the severity of the offense. Disciplinary actions could include oral warnings, written reprimands, probation, demotions, termination, etc. The incident should be documented with the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. - Quiz :When non-compliance is identified, what does the OIG recommended? a. Take disciplinary action and document the date of the incident, name of the person responsible for taking action, the follow-up action taken, and a list of claims that were affected by the action. b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. c. Immediately terminate employment for the party found in non-compliance, regardless of the severity of the offense, document the date of the termination, file a corrected claim on all claims affected. d. Continue to watch the employee in non-compliance until the incidents meet a federal level before taking action. Answer :d. No; the OIG does not specify the IRO to be used, but does retain the right to notify the provider if they must select a new IRO. The OIG will not endorse any particular IRO, but most CIAs include language that gives the OIG the opportunity to notify a provider that its choice of IRO is unacceptable within 30 days after the OIG receives written notice of the identity of the IRO. If the OIG has concerns regarding the quality of the review

or qualifications or independence of the IRO during the term of the CIA, it will make the concerns known and may request that the agreement with the IRO be terminated and another IRO be retained. - Quiz :In a Corporate Integrity Agreement (CIA), does the OIG specify the Independent Review Organization to be used? a. Yes; the specific IRO will be named in the CIA. b. Yes; the CIA will identify five IROs that can be used for the CIA Review. c. No; the OIG does not have any input on the IRO used under any circumstance. d. No; the OIG does not specify the IRO to be used, but does retain the right to notify the provider if they must select a new IRO. Answer :d. The provider can request a hearing before an ALJ in the HHS. If the subject receiving a demand letter from the OIG disagrees, he/she can request a hearing before an administrative law judge (ALJ) in Health and Human Services (HHS). - Quiz :What rights does a provider have if he/she disagrees with a demand letter sent by the OIG? a. The provider can choose to self-disclose once a demand letter has been received. b. The provider can send in supporting documentation for the claims to the OIG for review by certified mail. c. The provider can only respond to the demand letter with payment. d. The provider can request a hearing before an ALJ in the HHS. Answer :d. The 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. The 1995 E/M Documentation Guidelines are vague in the description of the exam whereas the 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. - Quiz :Which statement is TRUE regarding 1995 and 1997 E/M Documentation Guidelines?

a. The 1995 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. b. The 1995 E/M Documentation Guidelines are never beneficial for specialists. c. The 1997 E/M Documentation Guidelines are never beneficial for general practitioners. d. The 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. Answer :b. Hire an OIG employee to oversee the compliance efforts A comprehensive CIA typically lasts 5 years and includes requirements to: · hire a compliance officer/appoint a compliance committee; · develop written standards and policies; · implement a comprehensive employee training program; · retain an independent review organization to conduct annual reviews; · establish a confidential disclosure program; · restrict employment of ineligible persons; · report overpayments, reportable events, and ongoing investigations/legal proceedings; and · provide an implementation report and annual reports to OIG on the status of the entity's compliance activities. - Quiz :A Corporate Integrity Agreement (CIA) has core requirements. Which option is NOT one of the core requirements? a. Provide an implementation report and annual reports to OIG on the status of the entity's compliance activities. b. Hire an OIG employee to oversee the compliance efforts. c. Develop written standards and policies. d. Restrict employment of ineligible persons. Answer :a. OIG Work Plan

Rationale: The HHS OIG publishes its Work Plan on its website that lists the various projects, which are or will be addressed by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. - Quiz :Which OIG publication identifies various projects that are and will be addressed by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General? a. OIG Work Plan b. Semiannual Report to Congress c. Compendium of Unimplemented Recommendations d. OIG Compliance Plan Guidance Answer :b. The provider must apply for reinstatement. When the exclusionary period has ended, the individual or entity must apply for reinstatement and receive authorized notice from OIG that reinstatement has been granted. - Quiz :When a provider is excluded under the Exclusions Statute, what must he or she do at the end of the exclusionary period? a. The provider is automatically reinstated. b. The provider must apply for reinstatement. c. The provider cannot be reinstated once excluded. d. The provider must apply for a group provider number. Answer :a. CPT codebook and MUE (Medical Unlikely Edits) table. - Quiz :You audit a provider who is consistently reporting multiple units of CPT code

11042. What references can you use to show the provider multiple units of CPT code 11042 are not allowed and explain how it should be reported? a. CPT codebook and MUE (Medical Unlikely Edits) table. b. CPT codebook and NCCI procedure-to-procedure (PTP) edits. c. MUE table only.

d. HCPCS codebook and NCCI procedure-to-procedure (PTP) edits. Answer :c. Lincoln Law Also called the Lincoln Law, the False Claims Act (31 U.S.C. §§ 3729 - 3733) was enacted in 1863 to combat fraud by suppliers of goods to the Union Army during the U.S. Civil War. - Quiz :What is another name for the Federal False Claims Act (FCA)? a. Operation Restore Trust b. Kennedy-Kassebaum Law c. Lincoln Law d. Stark Law Answer :d. Fraud; the provider intentionally over-coded to gain financially. - Quiz :A provider consistently charges a higher level of E/M service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse, and why? a. Abuse; charging one level higher on each visit does not show intent. b. Abuse; the provider's practice is common and therefore would not be considered fraudulent. c. Fraud; any over-coding of services would be considered fraudulent. d. Fraud; the provider intentionally over-coded to gain financially. Answer :b. 15-25 percent of the money recovered - Quiz :A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes? a. 10-15 percent of the money recovered b. 15-25 percent of the money recovered c. 10-15 percent of the total claim amount d. 25-40 percent of the total claim amount

Answer :a. Submit a discussion period request within 30 days of the date of the demand letter. If the provider disagrees with the demand letter, he or she may submit a discussion period request to the Recovery Auditor within 30 days from the date of the demand letter; submit a rebuttal to the MAC within 15 days from the date of the demand letter; or, submit a redetermination request to the MAC within 120 days from the date of the demand letter. This last option is the first level of appeal. - Quiz :What can a provider do if he or she disagrees with a demand letter sent as a result of a Recovery Audit? a. Submit a discussion period request within 30 days of the date of the demand letter. b. Submit a discussion period request within 120 days of the date of the demand letter. c. Submit a request for review to the MAC within 15 days from the date of the demand letter. d. Submit a request for review to the MAC within 120 days from the date of the demand letter. Answer :d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries. - Quiz :Which of the following actions may result in false claims act violation? a. A provider submits claims to Medicare for office visits provided to Medicare beneficiaries. b. A provider accepts insurance only payments from Medicare beneficiaries. c. A provider routinely waives the copay for Medicare beneficiaries. d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries. Answer :a. Medicare's Conditions of Participation - Quiz :What is CoP? a. Medicare's Conditions of Participation

b. TriCare's Compliance of Physicians Guidance c. Medicaid's Coordination of Physician Groups d. Commercial Programs Answer :d. Self-referrals to designated health services. The Stark law bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationship. These are designated as self-referrals. The Stark law bans referrals to entities for a designated health service (DHS). - Quiz :What does the Physician Self-Referral Law (Stark Law) ban? a. Billing fraudulent claims. b. Unbundling services. c. Reporting medically unnecessary services. d. Self-referrals to designated health services. Answer :a. Failure to engage and use an IRO in accordance with the CIA. Material breach of the agreement may result in an individual or entity being excluded from participation in any Federal health care program. Material breach is considered to be: · Repeated or flagrant violation of the obligations under the corporate integrity agreement; · Failure to report any reportable event, take corrective action, and make the appropriate refunds; · Failure to respond to a Demand Letter concerning the payment of Stipulated Penalties; or · Failure to engage and use an IRO in accordance with the agreement. - Quiz :Which option is considered a material breach of a CIA? a. Failure to engage and use an IRO in accordance with the CIA. b. Failure to hire an OIG employee to oversee compliance efforts.

c. Failure to hire a full-time internal auditor to review every claim before it is submitted. d. Failure to fire auditors who do not agree with the provider's coding. Answer :a. A modifier is not allowed to bypass the NCCI edits. - Quiz :In the NCCI edits, what does modifier indicator zero represent? a. A modifier is not allowed to bypass the NCCI edits. b. A modifier may be used to bypass the edits if the documentation supports the modifier. c. Modifiers are not applicable to the edits. d. The NCCI edit is not in effect. Answer :a. An error rate that exceeds five percent. - Quiz :When a Discovery Sample is performed, what error rate requires a Full Sample to be reviewed? a. An error rate that exceeds five percent. b. An error rate that exceed ten percent. c. An error rate that exceeds 25 percent. d. An error rate that exceeds 50 percent. Answer :b. A modifier may be used to bypass the edits if the documentation supports the modifier. - Quiz :In the NCCI edits, what does modifier indicator one represent? a. A modifier is not allowed to bypass the NCCI edits. b. A modifier may be used to bypass the edits if the documentation supports the modifier. c. Modifiers are not applicable to the edits. d. The NCCI edit is not in effect

Answer :b. A person who brings a civil action for a violation for him/herself and for the US Government - Quiz :What is Qui Tam Relator? a. A person assigned to investigate accusations of fraudulent billing b. A person who brings a civil action for a violation for him/herself and for the US Government c. The defendant in a Qui Tam case d. The employer of the defendant in a Qui Tam case Answer :d. Billing for services at a higher level than provided or necessary. - Quiz :Which of the following best represents an example of fraudulent activity? a. Waiving cost-shares or deductibles. b. Billing for services that are medically necessary. c. Failure to maintain adequate medical or financial records. d. Billing for services at a higher level than provided or necessary. Answer :d. The Federal Civil Penalties Inflation Adjustment Act - Quiz :What regulation is the penalty for violating the False Claims Act (FCA) increased by? a. Anti-kickback Statute b. Stark Laws c. Medicare Physician Fee Schedule Final Rule d. The Federal Civil Penalties Inflation Adjustment Act Answer :a. Request a hearing before an HHS ALJ. The OIG will initiate the case by sending a demand letter outlining the CMP, assessment, and/or exclusions sought by the OIG, and the facts supporting the sanction. If the subject of the action disagrees, he/she can request a hearing before an HHS administrative law judge (ALJ). - Quiz :A provider received a demand letter from the OIG initiating a Civil Monetary Penalty. The provider

does not agree with the assessment from the OIG. What should the provider do? a. Request a hearing before an HHS ALJ. b. Send a letter to the OIG outlining further details and send supporting evidence. c. Gather the supporting evidence of innocence and take it to federal court. d. Leave it alone, the OIG will find the assessment is incorrect when they come investigate further. Answer :b. Coding and billing; reasonable and necessary services; documentation; and improper inducements, kickbacks, and self-referrals. - Quiz :The OIG's Compliance Program Guidance for Individual and Small Physician Group Practices identifies four risk areas affecting physician practices. What are the four risk areas? a. Claims submission; background checks for staff; HIPAA violations; audit compliance. b. Coding and billing; reasonable and necessary services; documentation; and improper inducements, kickbacks, and self-referrals. c. Coding and billing; background checks for staff; documentation; improper inducements, kickbacks, and self-referrals. d. Claims submission; HIPAA violations; audit compliance; improper inducements, kickbacks, and self-referrals. Answer :a. Header The header of an operative note is designed to identify the patient name, date of surgery, preoperative diagnosis, postoperative diagnosis, the procedures performed, primary surgeon, assistant surgeon(s), anesthesia administered, and the anesthesiologist. - Quiz :What section of an operative report typically contains the date of the surgery, preoperative diagnosis, postoperative diagnosis, and operation performed? a. Header

b. Indications c. Body d. Findings Answer :b. Objective; indicates the physical exam findings of the provider. - Quiz :In evaluation and management services, what does the O stand for in SOAP? What is included in this section? a. Operation; lists any operations performed during the visit. b. Objective; indicates the physical exam findings of the provider. c. Original; indicates any original statements made by the patient about the illness. d. Order; indicates the order of severity of the diagnoses for which the patient is being seen. Answer :a. Individually identifiable health information - Quiz :What is considered protected health information (PHI)? a. Individually identifiable health information b. Health information that is randomly gathered for research purposes c. Statistical information relating to a specific demographic area d. Provider information submitted on a claim for payment Answer :a. Assignment of benefits - Quiz :What form is used to authorize payment from the insurance carrier to go directly to the provider? a. Assignment of benefits b. Release of information c. Informed consent d. Patient registration form

Answer :b. A brief history outlining the medical necessity for the procedure. - Quiz :What is identified in the indications portion of an operative note? a. Specific details about the surgery. b. A brief history outlining the medical necessity for the procedure. c. The outcome of the surgical procedure. d. The provider and anesthesiologist performing the surgery. Answer :a. IU; because it can be mistaken for IV or the number 10. - Quiz :According to the Joint Commission (JC) Official "Do Not Use" List, what would be considered an abbreviation that should not be used in a medical record and why? a. IU; because it can be mistaken for IV or the number 10. b. HTN; because there should be more specification on the type of hypertension. c. PRN; because it may be misunderstood to be a privacy issue. d. IV; because it can be mistaken for IU. Answer :c. Reliable means to clearly identify the original content and the modified content. - Quiz :When a correction is made in an electronic health record, what must exist? a. Identity of a witness to the correction made in the electronic health record. b. The entire medical record duplicated with the corrections only made to the duplication. c. Reliable means to clearly identify the original content and the modified content. d. There are no requirements for corrections to electronic medical records. Answer :b. To provide justification for the medical necessity of treatment.

Documentation requirements for therapy services include progress reports which provide justification for the medical necessity of treatment. Information required in the progress reports should be written by a clinician. - Quiz :For therapy services, what is the reason for a progress note? a. To indicate services were performed b. To provide justification for the medical necessity of treatment c. To serve as the plan of care d. To serve as the re-certification Answer :b. Elaboration on abnormal findings - Quiz :a. All check boxes must be complete whether normal or abnormal b. Elaboration on abnormal findings c. The patient's height and/or weight to verify there was a face-to-face visit d. A family history of relevant diseases Answer :d. A health plan, healthcare clearinghouse, and any healthcare provider who transmits health information in an electronic format - Quiz :What is a covered entity? a. Any entity that transmits any information electronically b. A health care provider who sends only paper claims c. A health plan, healthcare clearinghouse, and any healthcare provider who transmits health information in any format d. A health plan, healthcare clearinghouse, and any healthcare provider who transmits health information in an electronic format Answer :b. Assessment; the provider documents an assessment of the patient's condition - Quiz :In evaluation and management services, what does the A stand for in SOAP? What is included in this section? a. Activity; documentation supports the patient's level of activity expected.

b. Assessment; the provider documents an assessment of the patient's condition. c. Action; action items the patient is to take to improve his or her conditions. d. Advice; the provider's advice to the patient. Answer :d. Assistant surgeon - Quiz :Which type of provider is not required to dictate his or her own operative report? a. Primary surgeon b. Co-surgeon c. Surgeons in a surgical team d. Assistant surgeon Answer :d. Patient registration form - Quiz :What form is used to record patient demographic information, insurance and financial information, and emergency contacts? a. Assignment of benefits b. Release of information c. Informed consent d. Patient registration form Answer :d. Department of Justice - Quiz :Which governing body is responsible for criminal prosecutions relating to the Privacy Rule? a. Office of Civil Rights b. Secretary of State c. Office of Inspector General d. Department of Justice

Answer :c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. - Quiz :When is incidental use and disclosure of PHI permitted? a. When there is authorization from the individual whose information is shared. b. When there is retribution for the use and disclosure. c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. d. When the covered entity has policies and procedures in place to identify each person who has incidentally had access to the record. Answer :b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). - Quiz :How long does HIPAA require medical records to be maintained? a. Five years from the date of its creation or the date from which it was last in effect (whichever is later). b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). c. Ten years from the date of its creation or the date from which it was last in effect (whichever is later). d. Five years past the date of death of the patient. Answer :c. The detail of the procedure can be included in the documentation for the office visit. - Quiz :When a minor procedure is performed in the office, what is the documentation requirement? a. A formal operative report must be documented. b. A reference to the operation without the detail can be included in the documentation for the office visit. c. The detail of the procedure can be included in the documentation for the office visit.

d. The surgery is not required to be documented if it is performed during an evaluation and management service. Answer :d. Informed consent - Quiz :What form is required to be obtained from the patient prior to a surgical procedure? a. Assignment of benefits b. Advanced beneficiary notice c. Release of information d. Informed consent Answer :c. The actual images must be retained. - Quiz :When referring to radiological services, what is the requirement for the images obtained? a. As long as there is a written report, the images are not important. b. They only need to be retained if abnormalities are identified. c. The actual images must be retained. d. There are no specific guidelines for images. Answer :c. Rubber Stamp - Quiz :CMS requires a legible identity for services provided/ordered. What type of signature does NOT meet the legal requirement by CMS? a. Handwritten b. Electronic c. Rubber Stamp d. All of the above are allowed by CMS Answer :c. Circle the abnormal finding and address the abnormality in the diagnosis and treatment plan - Quiz :When a laboratory report has an abnormal finding, what should be documented?

a. Initials on the lab report indicating the provider reviewed the report b. The abnormal finding should be circled c. Circle the abnormal finding and address the abnormality in the diagnosis and treatment plan d. Documentation is not necessary Answer :a. Indication for surgery - Quiz :Which section of an operative report would you expect to find the reason or medical necessity for the procedure? a. Indication for surgery b. Body of the operative report c. Findings d. In the office visit prior to the surgery Answer :a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. - Quiz :What information does a privacy practice notice contain? a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. b. Notification of each person who has access to their record and what access level they will have. c. Notification of when their payments have been received from the insurance carrier. d. Elements contained on a claim form sent to the patient's insurance carrier. Answer :b. Payment, treatment, or operations - Quiz :Under what circumstance may providers use or disclose protected health information without patient consent? a. Advertising of the entity's services b. Payment, treatment, or operations

c. Request from a spouse or another family member d. Request from a neighbor or close friend Answer :c. Subjective; patient's account of his or her symptoms and what, if anything has been done to relieve the symptoms. - Quiz :In evaluation and management services, what does the S stand for in SOAP? What is included in this section? a. Standard; indicates this is a standard format. b. Story; the provider documents the patient's story about his or her life. c. Subjective; patient's account of his or her symptoms and what, if anything has been done to relieve the symptoms. d. Symptoms; the provider documents the patient's symptoms and diagnosis that correlate with those symptoms. Answer :b. 2 points Rationale: One point is given for review and/or order (tests) in radiology section. Another point is given for review and/order of test(s) in the medicine section. The total amount of points is two. Regardless of the number of lab, radiology, and medicine procedures reviewed/ordered, only one point may be assigned for each of those areas. - Quiz :How many points are given for the MDM table Reviewed/Order Data when 3 X-rays are ordered and 3 labs are ordered? a. 6 points b. 2 points c. 1 point d. 3 points Answer :c. 99213, 99354 Rationale: This is an established patient. Two of the three key elements are required for an established patient. An expanded problem focused exam and

moderate MDM meet or exceed the requirement for code 99213. The provider spent an additional 45 minutes with the patient discussing the patient's new diagnosis. Prolonged Service codes 99354-99357 are used when provider or other qualified heath care professional provides prolonged service involving direct patient contact that is provided beyond the usual service. The codes reported based on the place of service and total time. Codes 99213 and add-on code 99354 are used to report the services. - Quiz :Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit? a. 99252 b. 99202, 99354 c. 99213, 99354 d. 99203 Answer :d. 99382 - Quiz :After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported? a. 99391 b. 99392 c. 99381 d. 99382 Answer :a. 99203

Rationale: In the CPT® Index, look for Office and/or Other Outpatient Services/Office Visit/New Patient and you are directed to codes 99201-99205. For New Patient visits, all three key components must be met. This service supports a level 3 new patient visit, 99203. - Quiz :A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritis and a history of cardiac disease. The provider performs a detailed history, comprehensive exam and a medical decision making of moderate complexity. What CPT® code is reported? a. 99203 b. 99214 c. 99204 d. 99213 Answer :c. 99397 Rationale: According to CPT® guidelines Preventive Medicine Services codes provide a means to report a routine or periodic history and physical examination in asymptomatic individuals. They include only those evaluation and management services related to the age specific history and examination provided by the provider. The patient is here for a preventive service. He did not have any complaints and the provider did not identify any new problems. In the CPT® Index look for Preventive Medicine/Established Patient. You are referred to 99382-99397. The code selection is based on age. Code 99397 is the correct code for a patient who is older than 65 years. - Quiz :A 75 year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination are performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported? a. 99215 b. 99387

c. 99397 d. 99214 Answer :d. 99222 Rationale: According to CPT® guidelines: "When the patient is admitted to the hospital in the course of an encounter in another site of service (for example hospital emergency, department, provider's office, nursing facility) all evaluation and management services provided by that provider in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." The provider admitted the infant to the hospital from his office and continued the care on the same date of service. The provider documented a comprehensive history, comprehensive exam and moderate MDM. The appropriate code is 99222. - Quiz :The provider admitted an 18 month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. A comprehensive history, comprehensive exam and moderate decision making is documented. If cultures are negative and the patient remains afebrile for 48 hours, the infant will be discharged home. What CPT® code is reported for this visit? a. 99219 b. 99238 c. 99223 d. 99222 Answer :a. 99285 Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285. - Quiz :The EMS brought a 31 year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the

provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported? a. 99285 b. 99282 c. 99283 d. 99284 Answer :c. 99367 Rationale: In CPT® Index, look for Conference/Interdisciplinary Medical Team and you are directed to codes 99367, 99368. 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code. - Quiz :A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, the pulmonologist, the oncologist, and the neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported? a. 99252 b. 99366 c. 99367 d. 99368 Answer :b. 99348 Rationale: In the CPT® Index look for Home Services/Established Patient and you are directed to code range 99347-99350. Two of three key components must be met to support a level of visit for established patient home services. 99348 is the correct code choice. - Quiz :A provider visits Mr. Smith's home monthly. Today, the provider performs a problem focused history, an

expanded problem focused examination and a medical decision making of low complexity. What CPT® code is reported? a. Home visits are no longer reportable. b. 99348 c. 99347 d. 99349 Answer :a. 99214 Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Detailed (HPI-Extended; ROS-Extended, PFSH-Complete), Exam - Detailed, MDM Moderate. 99214 is the level of visit supported. - Quiz :A 45 year-old established female patient is seen today at her provider's office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems is performed. This is a new problem. An EKG is ordered, and labs are drawn. The provider documents a moderate complexity MDM. What CPT® code is reported for this visit? a. 99214 b. 99203 c. 99215 d. 99204 Answer :b. 92950, 99291-25, 36556, 31500 - Quiz :A 5 year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider

makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported? a. 92950, 99291-25, 36556, 31603 b. 92950, 99291-25, 36556, 31500 c. 92950, 99285-25, 36556, 31500 d. 92950, 99291 Answer :c. 99291-25, 31500, 36510, 94610 - Quiz :An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded? a. 99471 b. 99291 c. 99291-25, 31500, 36510, 94610 d. 99471-25, 94610, 36510 Answer :d. 99391 Rationale: Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 25. - Quiz :Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up, she is fine. She is on breast milk;