Modifiers
Which of the following is considered an anatomic modifier?
a. 77
c. 59
b. LD
d. G0
ANS: B
Rationale: The following modifiers are identified as anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
What is the UB-04 claim form also called?
a. CMS-1500
b. CMS-1540
c. CMS-1450
d. CMS-5010
ANS: C
Rationale: UB-04 is also called a CMS-1450 and is used to report hospital services.
Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient. How are they reimbursed?
a. Capitation
b. Fee-for-service
c. Reimbursement account
d. Patient payments
ANS: A
Rationale: The physician is paid on per-patient per month method rather than a fee-for-service method.
When is the NCCI policy manual is updated?
a. Quarterly
b. Semi-annually
c. Monthly
d. Annually
ANS: D
Rationale: The CMS updates the policy manual annually and updates edits quarterly.
What is the HCPCS Level II code for Xylocaine, 10mg?
a. J2010
b. J2001
c. C9285
d. J2020
ANS: B
Rationale: Look in the HCPCS Level II Table of Drugs and Biologicals look for Xylocaine HCL which directs you to code J2001. An additional listing directs you to See Also Lidocaine HCL. Cross reference to the Tabular List to confirm complete detailed description. The selection of the code is based on the administration method and dosage units. The correct code is J2001, one unit of 10mg.
A claim is submitted for an assistant surgeon. What modifier would NOT be used for an assistant surgeon?
a. Modifier 82
c. Modifier A S
b. Modifier 80
d. Modifier 62
ANS: D
Modifier 62 is used when two surgeons are involved but they meet the definition of co-surgeons and not assistant surgeons. Modifiers 80, 82, and AS can all be used for an assistant surgeon depending on the payer and the provider. Modifier 80 is used for an assistant surgeon during the procedure. AS is used for non-physician assistant-at-surgery services for Medicare beneficiaries. Modifier 82 is used by a physician in a teaching facility when a qualified resident is not available.
On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent?
a. The frequency of care.
b. The type of care.
c. The type of facility.
d. The procedure or service.
ANS: C
Rationale: FL 4 is used for the type of bill and it’s a four-digit numerical code. The second digit identifies the type of facility.
NPI numbers have two types of entities. What are the two types?
a. Employee and Group
b. Sole proprietor and Group
c. Location and Group
d. Sole proprietor and Individual
ANS: B
Rationale: There are two types of NPI entities: Entity Type 1 and Entity Type 2.
Entity Type 1: sole proprietor/sole proprietorship, which is an individual. The individual must apply using their own Social Security Number. They will need only one number, regardless of how many locations they provide services as they are not allowed to have subparts as a type 1 entity.
Entity Type 2: group healthcare providers. These are entities with EIN numbers, whether they have one employee (just the physician) or thousands. These may include hospitals, home health agencies, clinics, and nursing homes.
Which of the following is NOT TRUE regarding MACs?
a. MACs have a specific geographic region for which they are responsible.
b. The jurisdiction of the MAC can be periodically reassigned.
c. The MAC is responsible to make coverage determinations for their jurisdiction.
d. All MACs have the same policies and coverage determinations.
ANS: D
Rationale: Each Medicare Administrative Contractor (MAC) is responsible for making coverage determinations and establishing policies for their geographical region. These policies may vary from jurisdiction to jurisdiction.
What is the HCPCS Level II code for a bathtub chair?
a. E0240
b. E0163
c. E0160
d. E0247
ANS: A
Rationale: Look in the HCPCS Level II Alphabetic Index for Chair/Bath/Shower which directs you to E0240. Cross reference to the Tabular List for complete detailed description. The correct code is E0240.
Which of the following modifiers are not used to bypass NCCI edits?
a. 76, 77
b. 24, 57
c. 59, 78
d. 27, 91
ANS: A
Rationale: Modifiers 76, Repeat procedure or service by same physician or other qualified healthcare professional, and 77, Repeat procedure or service by another physician or other qualified healthcare professional, are not NCCI-associated modifiers and cannot be used to bypass edits.
On the UB-04 claim form, FL 10 is used to record the patient’s birthdate. If the birthdate is unknown, what information is entered?
a. Leave blank
b. Enter zero for all eight digits
c. Enter zero for all six digits
d. Enter X for all eight digits
ANS: B
Rationale: When the birthdate is not available, zero is to be used for all eight digits – MM/DD/CCYY.
A claim is denied stating the provider is not credentialed with the commercial insurance. Which of the following would NOT be an option for the practice?
a. Refile the claim under any credentialed provider
b. Bill the patient for the services
c. Verify the status of the provider’s credentialing
d. Write off the balance of the encounter
ANS: A
Rationale: Billing the patient for services could be problematic if the patient was told the provider was in-network and writing-off the balance can create issues with providing free care but these could be done. It would be appropriate to verify the credentialing, as the claim could have been processed incorrectly. It is NOT appropriate to bill services to a provider that did not provide the care to the patient.
A patient is scheduled for a laparoscopic procedure that is converted to an open procedure after the procedure is initiated. Which of the following would be correct coding based on CMS NCCI edits?
a. Bill both procedures.
b. Bill only the laparoscopic procedure since that is what was scheduled.
c. Bill only the open procedure (most extensive).
d. Bill both procedures with a modifier appended to the Column 2 code.
ANS: C
Rationale: NCCI edits do not allow bypassing with a modifier when a procedure is converted from laparoscopic to open. Billing both procedures would be considered unbundling.
What is the HCPCS Level II code for high top orthotic shoe for an infant?
a. L3204
b. L3206
c. L3201
d. L3207
ANS: A
Rationale: look in the HCPCS Level II Alphabetic Index for Shoes/Orthopedic/High-top/Infant; which directs you to code L3204. The code choice is based on age of patient and style of shoe. The correct code is L3204.
Based on NCCI edits, when a procedure is bundled and has a CCM indicator of 0 – which of the following modifiers is allowed?
a. 51
b. 59
c. 25
d. Modifiers are not allowed
ANS: D
Rationale: CCM indicator 0 indicates modifiers are not allowed to report the code pair together. The referenced procedures are bundled and are not separately billable.
FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?
a. Only for inpatient services
b. Only for outpatient services
c. For all services
d. Only for ED visits
ANS: A
Rationale: FL 35 and FL 36 are used only for inpatient services and should not be completed on outpatient claims.
What is an IPO in a health organization?
a. A group of providers offering joint healthcare services
b. A corporate umbrella for management of diversified healthcare delivery systems
c. An organization that combines function of delivery of care with healthcare and administration
d. A practice formed to share economic risk, expenses, and marketing efforts
ANS: B
Rationale: An IPO is a corporate umbrella for the management of diversified healthcare delivery systems. The system may include one or more hospitals, a large group practice and other healthcare operations. Physicians practice as employees of the organization or in a closely affiliated physician group.
When looking at the NCCI Edit tables, Column 1 codes are indicated as payable. Column 2 codes contain the codes that are what?
a. Payable with the Column 1 code.
b. Never payable with the Column 1 code.
c. Not payable with the Column 1 code unless a modifier is permitted and submitted.
d. Not payable because they have frequency limits.
ANS: C
Rationale: Column 2 indicates the code is not payable with the Column 1 code, unless a modifier is permitted and submitted on the claim.
What is the HCPCS Level II code for a gas permeable bifocal contact lens?
a. V2510
b. V2502
c. V2599
d. V2512
ANS: D
Rationale: Look in the HCPCS Level II Alphabetic Index for Contact lens supplies and services/Gas permeable/Bifocal, per lens which directs you to V2512. Cross reference to the Tabular List for complete detailed description. The correct code is V2512 for gas permeable bifocal contact lens.
A commercial insurance claim was filed and denied using 99213 with M25.519 for DOS 9/12. The patient had an arthroscopy of the left knee on 8/16 (90-day global surgery) that is unrelated to the visit on 9/12. What error is identified for the claim for DOS 9/12?
a. This E/M is not a billable service and should not be reported.
b. Modifier 24 is appended to identify this as not related to the surgery.
c. Modifier 25 is appended to identify this as separately identified.
d. No modifier is required and contact is made with the payer to review the claim.
ANS: B
Arthroscopy has 90 global days, however the shoulder pain is not associated with the knee procedure. Modifier 24, Unrelated E/M by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period; is appended to the claim to allow for reimbursement.
W
hen filing professional fee (provider) claims, which code set is NOT reported on the CMS-1500 claim form?
a. CPT® codes
b. HCPCS Level II codes
c. ICD-10-CM codes
d. ICD-10-PCS codes
ANS: D
Rationale: ICD-10-PCS codes are only reported on the UB-04 claim form for facility inpatient services.
A new patient is seen for a visit with a participating commercial carrier. CPT® code 99204 is billed for $200. The contracted fee for this carrier is $153.35. The patient has a 20% co-pay after a $1000 deductible, of which $500 has been met. How much will the patient owe?
a. $200
b. $46.65
c. $153.35
d. $30.67
ANS: C
Rationale: This is a participating physician, and the contracted amount for this visit is $153.35. Since the deductible has not been met, the contracted amount will be applied toward the deductible and will be paid by the patient.
What does the NCCI file indicate?
a. The relative value units (RVUs) of surgical procedures.
b. It indicates specific CPT® code pairs that can be reported on the same day for the same beneficiary by the same provider.
c. It states whether Medicare or the MAC will pay for an item or service as medically necessary.
d. It indicates whether specific medical services, items, treatment procedures, or technologies can be paid for under Medicare.
ANS: B
Rationale: The NCCI file is a Medicare file that indicates specific CPT® code pairs that can be reported on the same day for the same beneficiary by the same provider. Although the NCCI edits is a Medicare file for bundling, other payers may utilize this set of edits as well.
What is the HCPCS Level II code for Progesterone, 100 mg IM?
a. J2675
b. J2675 x 2
c. J2675 x 100
d. J2675 x 50
ANS: B
Rationale: Look in the Table of Drugs and Biologicals for Progesterone which directs you to J2675. Cross reference to the Tabular List for complete detailed description. The choice of the code is based on the administration method, drug unit designation, and number of units administered to the patient. The unit per dose for this code is 50 mg. The correct code is J2675 x 2 to indicate that 100 mg was administered to the patient.