COBGC Compliance and Documentation 3 — Questions and Answers
Question 1: Under CMS guidelines, which time threshold must be met to bill a 99215 office visit based on total time on the date of the encounter for an established gynecology patient?
- 30–39 minutes
- 40–54 minutes (Correct answer)
- 55–69 minutes
- 20–29 minutes
Correct answer: 40–54 minutes
For 2021 and later E/M guidelines, 99215 requires 40–54 minutes of total time on the date of the encounter for an established patient.
Question 2: A gynecology patient signs a Notice of Privacy Practices (NPP) acknowledgment. What does this document legally confirm?
- The patient consents to all uses and disclosures of her PHI
- The patient was provided the opportunity to review the practice's HIPAA privacy policies (Correct answer)
- The patient waives her right to access her medical records
- The patient authorizes release of records to her insurer
Correct answer: The patient was provided the opportunity to review the practice's HIPAA privacy policies
The NPP acknowledgment documents that the patient was given the opportunity to review the notice; it is not consent to all PHI disclosures.
Question 3: Documentation of medical necessity for a GYN procedure is primarily supported by which part of the medical record?
- The CPT code selected by the coder
- The ICD-10-CM diagnosis codes linked to the procedure and the clinical notes (Correct answer)
- The patient's insurance card copy
- The operative report header only
Correct answer: The ICD-10-CM diagnosis codes linked to the procedure and the clinical notes
Medical necessity is established through the diagnosis codes that reflect the clinical condition and the supporting documentation in the physician's notes.
Question 4: Which modifier indicates that a procedure was performed by two surgeons with distinct roles during a single gynecologic operative session?
- -51
- -62 (Correct answer)
- -80
- -66
Correct answer: -62
Modifier -62 is appended when two surgeons each perform distinct portions of a procedure that requires their individual skills simultaneously or sequentially.
Question 5: An OB/GYN coder discovers a claim was submitted with an incorrect procedure code six months ago. The compliance-appropriate first step is to:
- Ignore it if the payment amount was correct
- Conduct a self-disclosure, correct the record, and refund any overpayment (Correct answer)
- Wait for the payer to request a refund before acting
- Submit a new claim with the correct code without notifying the payer
Correct answer: Conduct a self-disclosure, correct the record, and refund any overpayment
Compliance best practice—and the False Claims Act—require prompt self-disclosure, correction, and repayment of any overpayment once an error is identified.
Question 6: In obstetric coding, which antepartum visit count is required before a physician may bill the global obstetric package code 59400?
- At least 3 antepartum visits
- At least 7 antepartum visits (Correct answer)
- At least 13 antepartum visits
- Any number of antepartum visits qualifies
Correct answer: At least 7 antepartum visits
CPT defines the global OB package (59400/59510) as including 7 or more antepartum visits; fewer visits require billing individual antepartum visit codes.
Question 7: A gynecologic surgical note states the surgeon 'explored the pelvis and found findings consistent with endometriosis.' A coder should:
- Code endometriosis as confirmed based on the surgeon's intraoperative description (Correct answer)
- Query the physician because 'findings consistent with' is not a definitive diagnosis
- Code 'abnormal pelvic findings' only
- Leave the diagnosis code blank until pathology returns
Correct answer: Code endometriosis as confirmed based on the surgeon's intraoperative description
Intraoperative findings described by the surgeon during a procedure may be coded as confirmed diagnoses even before pathology confirmation, unlike outpatient suspected conditions.
COBGC Compliance and Documentation 3
Under CMS guidelines, which time threshold must be met to bill a 99215 office visit based on total time on the date of the encounter for an established gynecology patient?