CPC Compliance and Regulatory Rules 5

Question 1

A coder bills an established patient office visit and a separate E/M code for a preventive medicine service performed on the same day by the same physician. Which modifier allows separate billing of both services?

Accepted Answer

Modifier 25

Answer

Modifier 25 is appended to a significant, separately identifiable E/M service performed on the same day as a preventive medicine service.

Question 2

The Deficit Reduction Act of 2005 requires states to enact false claims laws in order to receive an enhanced Medicaid reimbursement. What percentage increase does a state receive?

Accepted Answer

10%

Answer

States that enact qualifying false claims laws receive a 10% increase in their share of any Medicaid fraud recoveries.

Question 3

Which Medicare administrative contractor (MAC) function involves reviewing claims before payment is made to determine if coverage criteria are met?

Accepted Answer

Prepayment review

Answer

Prepayment review allows MACs to examine claims before issuing payment to ensure all coverage criteria are met.

Question 4

A physician documents a 30-minute E/M visit but the coder bills a 60-minute code based on typical visit length for that diagnosis. This is an example of:

Accepted Answer

Upcoding based on diagnosis

Answer

Billing a higher-level code based on assumptions rather than actual documented time or medical decision-making constitutes upcoding.

Question 5

Which of the following actions would be appropriate when a compliance audit reveals a pattern of overcoding E/M services?

Accepted Answer

Conduct education, perform a corrective action plan, and consider a voluntary repayment

Answer

Appropriate responses to audit findings include education, corrective action plans, and voluntary repayment of identified overpayments.

CPC - Certified Professional Coder Practice Test

CPC - Certified Professional Coder Practice Test

CPC Compliance and Regulatory Rules 5