Mixed Deck — All CPC Topics Flashcards

When a procedure note states 'difficult dissection due to prior surgery, procedure took 2.5× normal time,' which modifier best captures the additional work?

Answer: -22

Modifier -22 (Increased Procedural Services) is used when the work is substantially greater than typically required, and documentation must support the claim.

The suffix '-itis' at the end of a medical term indicates:

Answer: Inflammation

The suffix '-itis' means inflammation, as in appendicitis (inflammation of the appendix).

Which Medicare term describes the amount Medicare has approved for a covered service?

Answer: Medicare Fee Schedule amount

The Medicare Fee Schedule amount (approved amount) is the maximum amount Medicare will pay for a covered service based on the Medicare Physician Fee Schedule.

What is the definition of a 'new patient' for E/M coding purposes?

Answer: A patient who has not received professional services from the physician or group within the past 3 years

A new patient is one who has not received any professional services from the physician/qualified health care professional or another in the same group of the same specialty within the past 3 years.

A Qui Tam lawsuit under the False Claims Act allows which party to file a lawsuit on behalf of the federal government?

Answer: Private whistleblower (relator)

Qui Tam provisions allow private individuals (relators or whistleblowers) to file FCA suits on the government's behalf and receive a portion of any recovery.

The 'three-day payment window' rule requires that outpatient services provided within how many days before an inpatient admission must be bundled into the inpatient DRG payment?

Answer: 3 days

CMS's three-day payment window rule requires that most outpatient diagnostic services and related non-diagnostic services provided within 3 days prior to inpatient admission be included in the DRG payment.

What is an insurance claim form?

Answer: A treatment summary

An insurance claim form can be considered a type of treatment summary because it itemizes the medical services, procedures, and diagnoses provided to a patient during a specific encounter. While its primary purpose is to request reimbursement from an insurer, the form effectively summarizes the care delivered, allowing the insurance company to understand the scope of treatment for payment processing.

A procedure has an asterisk (*) next to it in the CPT manual. What does this historically indicate?

Answer: A surgical package does not apply and the procedure is billed as separate components

In older CPT editions, an asterisk indicated a starred procedure, meaning the surgical package rules did not apply and components were billed separately; this concept informs current coding practices.

A CRNA working under the medical direction of an anesthesiologist appends which modifier?

Answer: QX

QX is appended by the CRNA when working under an anesthesiologist's medical direction, paired with the anesthesiologist's QK modifier on their separate claim.

What is a claim denial in medical billing?

Answer: A request for additional treatment

While typically a refusal to pay, a claim denial can sometimes indirectly lead to a 'request for additional treatment' in specific scenarios. For example, if a claim is denied because the initial treatment was deemed insufficient or inappropriate by the payer, it might necessitate a revised treatment plan and a request for further services to address the patient's condition effectively. This interpretation links the denial to a subsequent clinical action.

Which program uses data analytics and algorithms to proactively identify potentially fraudulent Medicare claims BEFORE payment is made?

Answer: Fraud Prevention System (FPS)

The Fraud Prevention System (FPS) uses predictive analytics to flag suspicious claims for review before Medicare payment is issued, unlike RACs which review claims post-payment.

For E/M time-based coding, what must be documented to support billing based on total time?

Answer: Total time on the date of the encounter including all activities performed by the provider

Under the 2021 guidelines, total time includes all time spent by the provider on the date of the encounter, not just face-to-face time.

When a procedure is performed during the global surgical period of a prior procedure, and the new service is unrelated, which modifier should be used?

Answer: -79

Modifier -79 is used for an unrelated procedure or service by the same physician during the postoperative period.

Critical care services (99291, 99292) are typically reported when the provider spends what minimum time with the critically ill patient?

Answer: 60 minutes (first 30–74 min not separately reported)

Code 99291 covers the first 30–74 minutes of critical care; the minimum threshold before the first code can be reported is 30 minutes.

Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?

Answer: -RT

Modifier -RT (Right side) is used when a procedure is performed on the right side of a paired organ or body part.

An Advance Beneficiary Notice (ABN) is required to be given to Medicare patients when the provider believes Medicare will likely deny a service as:

Answer: Not medically necessary

An ABN must be issued when a provider believes Medicare may deny a claim for lack of medical necessity, allowing the patient to decide whether to receive and pay for the service.

In the context of E/M coding, what does the term 'undiagnosed new problem with uncertain prognosis' represent in MDM?

Answer: Moderate complexity

An undiagnosed new problem with uncertain prognosis is classified as moderate complexity in the 'problems addressed' element of MDM.

What is the correct way to report a procedure that was discontinued after the patient was prepared and taken to the procedure room but before the procedure began?

Answer: Report the procedure code with modifier -73

Modifier -73 is used when a procedure is discontinued after the patient has been prepped and brought to the procedure room but before anesthesia is administered or the procedure starts.

In medical coding compliance, 'query fatigue' refers to the risk that:

Answer: Physicians begin agreeing to queries without carefully reviewing them to avoid repeated requests

Query fatigue occurs when physicians, overwhelmed by frequent queries, begin rubber-stamping responses without proper review, potentially leading to inaccurate documentation.

What does the combining form 'cardi/o' refer to?

Answer: Heart

Cardi/o is the combining form for the heart, as in cardiology (study of the heart).