CRCR Charge Capture and Coding 5 — Questions and Answers
Question 1: Which of the following coding practices violates the False Claims Act?
- Querying physicians for clarification on unclear documentation
- Deliberately assigning codes that maximize reimbursement beyond what documentation supports (Correct answer)
- Using encoder software to verify code assignments
- Updating the CDM annually to reflect new CPT codes
Correct answer: Deliberately assigning codes that maximize reimbursement beyond what documentation supports
Intentionally assigning codes to maximize payment beyond what is documented and clinically appropriate constitutes a false claim and violates the False Claims Act.
Question 2: A revenue cycle analyst notices that multiple DRGs are being 'optimized' by consistently adding a CC code that appears in very few records compared to national benchmarks. This pattern suggests:
- Excellent clinical documentation improvement program outcomes
- Potential upcoding or DRG manipulation requiring a compliance review (Correct answer)
- Accurate coding of a high-acuity patient population
- Effective use of NCCI modifiers
Correct answer: Potential upcoding or DRG manipulation requiring a compliance review
A statistical outlier in CC/MCC rates compared to benchmarks is a red flag for upcoding, inappropriate query practices, or documentation inflation.
Question 3: Under CPT guidelines, an Evaluation and Management (E/M) visit on the same day as a procedure is generally:
- Always billed separately with no restrictions
- Bundled into the procedure unless a separately identifiable service is documented and modifier -25 is appended (Correct answer)
- Billed with modifier -59 appended to the procedure code
- Not payable under any circumstances
Correct answer: Bundled into the procedure unless a separately identifiable service is documented and modifier -25 is appended
A same-day E/M service is payable separately only when it is significant, separately identifiable, and documented beyond the decision to perform the procedure, requiring modifier -25.
Question 4: Which of the following accurately describes a 'soft coding' environment?
- Codes are assigned by clinical documentation improvement specialists only
- Coding is performed after the bill drops without physician input
- Codes are suggested by an encoder and reviewed/approved by a coding professional before billing (Correct answer)
- Only ICD-10 codes are assigned, with CPT codes entered separately
Correct answer: Codes are suggested by an encoder and reviewed/approved by a coding professional before billing
In a soft coding environment, computer-assisted or encoder-suggested codes are reviewed and validated by a credentialed coder before claim submission.
Question 5: A patient undergoes a bilateral knee arthroscopy. How should CPT coding typically reflect this?
- Report the unilateral arthroscopy code once
- Report the unilateral arthroscopy code twice with modifier -50 (Bilateral Procedure) (Correct answer)
- Report the procedure with modifier -51 only
- Use a separate bilateral CPT code that exists in the code set
Correct answer: Report the unilateral arthroscopy code twice with modifier -50 (Bilateral Procedure)
When a procedure is performed bilaterally and no specific bilateral code exists, the unilateral code is reported with modifier -50 to indicate bilateral performance.
Question 6: What is the role of Clinical Documentation Improvement (CDI) specialists in charge capture?
- They assign final billing codes to all claims
- They concurrently review records and query physicians to ensure diagnoses and procedures are fully documented to support accurate coding and reimbursement (Correct answer)
- They manage accounts receivable and follow up on unpaid claims
- They negotiate reimbursement rates with commercial payers
Correct answer: They concurrently review records and query physicians to ensure diagnoses and procedures are fully documented to support accurate coding and reimbursement
CDI specialists bridge the gap between clinical documentation and coding by identifying documentation gaps and querying providers to ensure complete, accurate, and specific records.
Question 7: A facility is audited and found to be consistently missing charges for contrast media used during CT scans. The most likely root cause is:
- Coders are intentionally omitting the charges
- A CDM or charge capture workflow gap where contrast is not triggering a separate charge entry (Correct answer)
- Radiologists are not documenting the use of contrast
- Payers are automatically denying contrast charges
Correct answer: A CDM or charge capture workflow gap where contrast is not triggering a separate charge entry
Missing charges for supply or drug items like contrast media most often result from a workflow or CDM configuration issue where the item is not linked to an automatic charge trigger.
CRCR Charge Capture and Coding 5
Which of the following coding practices violates the False Claims Act?