Medical Billing Software Medical Billing Software Coding & Documentation 2 — Questions and Answers
Question 1: What are Evaluation and Management (E/M) codes used to report in medical billing?
- Laboratory and pathology procedures
- Provider assessment and management of a patient's health, including office visits and consultations (Correct answer)
- Durable medical equipment dispensed to patients
- Inpatient surgical procedures performed by surgeons
Correct answer: Provider assessment and management of a patient's health, including office visits and consultations
E/M codes (CPT 99202–99499) report the clinical work involved in evaluating and managing a patient's condition during encounters such as office visits, hospital visits, and consultations.
Question 2: Under the 2021 AMA E/M guidelines, which two elements primarily determine the level of an office or outpatient E/M service?
- History and Physical Examination
- Medical Decision Making or Total Time (Correct answer)
- Chief Complaint and Review of Systems
- Number of diagnoses and amount of data reviewed
Correct answer: Medical Decision Making or Total Time
The 2021 AMA E/M revisions base office and outpatient visit levels on either Medical Decision Making (MDM) complexity or total time spent on the date of the encounter.
Question 3: What is the role of a charge description master (CDM) in hospital billing?
- A list of all patients admitted over a fiscal year
- A comprehensive database linking billable services to their corresponding charges and revenue codes (Correct answer)
- A schedule of contracted reimbursement rates by payer
- A repository of clinical protocols for common diagnoses
Correct answer: A comprehensive database linking billable services to their corresponding charges and revenue codes
The CDM (also called a chargemaster) is a hospital's master list of all services, procedures, and supplies with associated charges and revenue codes used to generate itemized bills.
Question 4: What coding guideline applies when a condition is documented as 'probable' or 'suspected' in an outpatient setting?
- Code the probable diagnosis as if confirmed
- Code the presenting signs and symptoms rather than the unconfirmed diagnosis (Correct answer)
- Leave the diagnosis field blank and resubmit after confirmation
- Use an ICD-10 'Z' code as the primary diagnosis
Correct answer: Code the presenting signs and symptoms rather than the unconfirmed diagnosis
In outpatient coding, uncertain diagnoses documented as 'probable,' 'suspected,' or 'rule out' should not be coded; instead, the signs and symptoms prompting the encounter are reported.
Question 5: Which modifier is appended to indicate that a procedure was performed on the left side of the body?
- -RT
- -LT (Correct answer)
- -51
- -59
Correct answer: -LT
Modifier -LT (Left Side) is appended to a procedure code to indicate that the service was performed on the left side of the body, as required by many payers for laterality.
Question 6: What is the primary function of the ICD-10-PCS code set?
- Reporting diagnoses for outpatient office visits
- Reporting inpatient hospital procedures performed on patients (Correct answer)
- Identifying durable medical equipment for Medicare billing
- Classifying professional services for physician fee schedule claims
Correct answer: Reporting inpatient hospital procedures performed on patients
ICD-10-PCS (Procedure Coding System) is used exclusively by hospitals to report inpatient procedures for reimbursement and data analysis.
Medical Billing Software Medical Billing Software Coding & Documentation 2
What are Evaluation and Management (E/M) codes used to report in medical billing?