NHA Medical Billing & Coding (CBCS) — All Questions

Modifier 57 is appended to an evaluation and management service that resulted in:

• a.a minor procedure performed on the same day in every billing situation without exception
• b.the decision to perform a major surgery, typically the day of or day before✓
• c.a reduced service
• d.an unrelated postoperative visit

Modifier 57 marks an E/M service that led to the decision for a major surgery, usually the day of or the day before. Modifier 25 is used with minor procedures instead.

Modifier 80 is used to report the services of a(n):

• a.assistant surgeon✓
• b.surgical team of three or more surgeons
• c.second primary surgeon of a different specialty
• d.resident supervised by a teaching physician

Modifier 80 reports assistant surgeon services. Modifier 62 identifies co-surgeons, modifier 66 identifies a surgical team, and modifier 82 is used when a qualified resident is not available.

Modifier 62 is reported when:

• a.a service is reduced from the usual
• b.a procedure is repeated by the same surgeon in every billing situation without exception
• c.one surgeon is aided by an assistant
• d.two surgeons work together as primary surgeons on distinct parts of one procedure✓

Modifier 62 identifies co-surgeons, where two surgeons each perform a distinct part of the same procedure. Each surgeon reports the same procedure code with modifier 62.

Modifier 90 is appended to a laboratory code when:

• a.only the interpretation is billed
• b.a test is repeated on the same day
• c.the test is performed by an outside reference laboratory✓
• d.the specimen is collected at the patient's home in every billing situation without exception

Modifier 90 identifies a reference (outside) laboratory that performed the test billed by the ordering provider. Modifier 91 covers a medically necessary repeat of the same lab test on the same day.

Modifier 91 is correctly used when a clinical diagnostic laboratory test is:

• a.repeated on the same day to obtain subsequent, medically necessary results✓
• b.sent to an outside reference laboratory
• c.repeated because of a testing or equipment error in every billing situation without exception
• d.performed as part of a defined panel

Modifier 91 reports a medically necessary repeat of the same lab test on the same day, such as serial glucose readings. It is not used for re-runs due to specimen or equipment problems.

Modifier 22 indicates that a procedure required:

• a.an unrelated E/M service
• b.substantially greater work than typically required, supported by documentation✓
• c.reduced or eliminated services in every billing situation without exception regardless of what the medical record documents
• d.a bilateral surgical approach

Modifier 22 identifies increased procedural services due to unusual difficulty. Documentation must justify the additional work, which may support higher payment on manual review.

HCPCS Level II codes beginning with the letter 'J' are used primarily to report:

• a.drugs administered by injection or infusion, other than oral✓
• b.orthotic and prosthetic devices
• c.ambulance and transport services in every billing situation without exception
• d.durable medical equipment items

J codes report non-orally administered drugs, such as injectable or infused medications. The units billed must reflect the dosage amount stated in the code description.

When billing a HCPCS 'J' drug code, the number of units reported must reflect:

• a.the number of vials opened during the visit in every billing situation without exception
• b.the total minutes the drug was infused
• c.the dosage in the code description relative to the amount administered✓
• d.the patient's body weight in kilograms

Units are reported based on the code's defined dosage increment compared with the amount given. For example, if a code represents 10 mg and 30 mg is administered, three units are billed. Miscounting units is a common billing error.

The HCPCS Level II modifiers LT and RT are used to identify:

• a.the professional and technical components in every billing situation without exception
• b.assistant surgeon services
• c.a reduced service
• d.the left or right side of the body for a procedure or item✓

LT and RT designate laterality, left or right, for procedures and durable medical equipment. Some payers prefer LT and RT on separate lines rather than modifier 50 for bilateral items.

HCPCS Level II modifiers such as FA and F1 through F9 are used to identify:

• a.specific toes on the foot in every billing situation without exception
• b.the eyelids
• c.specific fingers on which a procedure was performed✓
• d.the coronary arteries

FA and F1 through F9 identify individual fingers; TA and T1 through T9 identify toes; and E1 through E4 identify eyelids. These anatomic modifiers support billing for distinct sites.

The HCPCS modifier GA indicates that:

• a.the service is statutorily excluded from Medicare
• b.a required Advance Beneficiary Notice of Noncoverage is on file✓
• c.the provider expects the service to be paid in full in every billing situation without exception
• d.the service was performed bilaterally

Modifier GA shows that a signed ABN is on file for a service Medicare is expected to deny. Modifier GZ means no ABN was obtained, and GY means the service is statutorily excluded.

For CPT office E/M coding, a patient is considered 'new' when he or she has not received professional services from the physician, or another physician of the same specialty and group, within the past:

• a.three years✓
• b.five years
• c.one year
• d.six months

A new patient is one who has not received a face-to-face professional service from the physician, or a same-specialty physician in the same group, within the prior three years. Otherwise the patient is established.

Under current office E/M guidelines, the level of medical decision making is determined by the number and complexity of problems, the risk of complications, and:

• a.the total charge for the visit
• b.the number of body systems examined
• c.the amount and complexity of data reviewed and analyzed✓
• d.the length of the history of present illness in every billing situation without exception

Medical decision making has three elements: the problems addressed, the data reviewed and analyzed, and the risk. Two of the three drive the level. History and exam no longer determine the level for office visits.

Under current office E/M guidelines, which activity performed by the physician on the date of the encounter may count toward total time?

• a.Travel time to a different facility
• b.Reviewing the patient's outside test results and documenting in the record✓
• c.Time spent caring for a different patient
• d.Time spent by clinical staff rooming the patient in every billing situation without exception

Total time includes the physician's face-to-face and non-face-to-face work on the date of the encounter, such as reviewing records, ordering tests, counseling, and documenting. Staff time and unrelated work do not count.

A CPT consultation code requires a request from another provider, the consultant's opinion, and:

• a.a second surgical opinion only
• b.a referral of the patient to a hospital
• c.a transfer of the patient's care to the consultant in every billing situation without exception
• d.a written report of the findings back to the requesting provider✓

A consultation requires a request, the rendering of an opinion or service, and a written report back to the requesting provider. If the consultant assumes ongoing care, it becomes a transfer of care.

CPT critical care codes are reported based on:

• a.the place of service alone
• b.a flat rate per hospital admission
• c.the total time the physician spends providing critical care✓
• d.the number of organ systems that are failing in every billing situation without exception

Critical care codes are time-based. The first code covers the first 30 to 74 minutes, and an add-on code covers each additional 30 minutes of critical care for a critically ill or injured patient.

CPT preventive medicine service codes are selected based on:

• a.the severity of the presenting complaint in every billing situation without exception
• b.whether the patient is new or established and the patient's age✓
• c.the total counseling time only
• d.the number of chronic problems managed

Preventive medicine codes are chosen by new or established status and the patient's age group. If a significant separate problem is also addressed, a problem-oriented E/M with modifier 25 may be reported.

When coding an excision of a skin lesion in CPT, the size measured for code selection is the:

• a.length of the incision line
• b.size of the specimen after fixation in the lab
• c.diameter of the lesion only, excluding margins in every billing situation without exception
• d.greatest diameter of the lesion plus the narrowest surgical margins✓

The excised diameter equals the lesion's greatest diameter plus the narrowest margin on each side, measured before excision. Whether the lesion is benign or malignant and its site also affect code choice.

In CPT, the choice between a benign and a malignant lesion excision code is based on:

• a.the age of the patient
• b.the nature of the lesion, typically confirmed by the pathology report✓
• c.the surgeon's contracted fee schedule in every billing situation without exception
• d.the size of the incision only

Selecting a benign or malignant excision code depends on the nature of the lesion, best confirmed by pathology. Coders may need to wait for the pathology report before finalizing the code.

When multiple wounds of the same complexity and same anatomical group are repaired, CPT directs the coder to:

• a.add the lengths together and report a single code for the summed length✓
• b.use an unlisted repair procedure code
• c.report a separate code for each individual wound in every billing situation without exception
• d.report only the single longest wound

Repairs of the same classification and anatomic grouping are summed by length and reported with one code. Repairs of different classifications or different anatomic groups are reported separately.

A wound repair that requires layered closure of deeper subcutaneous tissue and superficial fascia is classified in CPT as:

• a.complex repair
• b.an unlisted repair
• c.simple repair
• d.intermediate repair✓

Simple repair is a superficial, one-layer closure. Intermediate repair involves layered closure of deeper tissue. Complex repair goes beyond layered closure, such as scar revision or extensive undermining.

The CPT global obstetric package for routine maternity care generally includes antepartum care, delivery, and:

• a.all newborn care after delivery
• b.postpartum care✓
• c.any unrelated surgery during pregnancy
• d.infertility treatment before conception

The global obstetric package bundles routine antepartum visits, delivery, and postpartum care into one code. Complications or unrelated care are reported separately.

A CPT code identified as a 'separate procedure' should be reported:

• a.with every related major procedure it accompanies in every billing situation without exception
• b.only when performed independently, not as an integral part of a larger procedure✓
• c.as an add-on code to a primary procedure
• d.only on inpatient hospital claims

A separate procedure code is bundled when performed as part of a larger service. It is reported alone only when performed independently, at a different site, or in a different session, where modifier 59 may apply.

When a diagnostic endoscopy leads to a surgical endoscopy in the same session, the coder generally reports:

• a.only the diagnostic endoscopy
• b.an unlisted endoscopy code
• c.only the surgical endoscopy, since the diagnostic scope is included✓
• d.both the diagnostic and the surgical endoscopy separately in every billing situation without exception

A diagnostic endoscopy is included in a surgical endoscopy performed at the same site and session, so only the therapeutic procedure is reported. Endoscopy families have specific bundling rules.

Anesthesia payment under CPT is commonly calculated using base units, time units, and:

• a.any applicable modifying units✓
• b.the facility's revenue code
• c.the surgeon's assistant fee
• d.the number of diagnoses reported

Anesthesia payment uses the formula of base units plus time units plus modifying units, multiplied by a conversion factor. Physical status modifiers and qualifying circumstances can add modifying units.

The anesthesia physical status modifier 'P3' describes a patient with:

• a.brain death, with organs removed for donation
• b.a mild systemic disease
• c.no systemic disease, a normal healthy patient
• d.a severe systemic disease✓

Physical status modifiers range from P1, a normal healthy patient, to P6, a declared brain-dead donor. P3 identifies a patient with a severe systemic disease.

When a child receives a vaccine, CPT coding generally requires reporting:

• a.only the administration code
• b.a single combination code for both in every billing situation without exception
• c.a code for the vaccine product and a separate code for its administration✓
• d.only the vaccine product code

A complete immunization service is billed with two components: the vaccine or toxoid product code and the immunization administration code, which may include counseling for younger patients.

Modifier 33 is appended to identify a service as:

• a.an assistant surgeon service
• b.a repeat clinical laboratory test in every billing situation without exception regardless of what the medical record documents
• c.a preventive service, which may waive patient cost-sharing under applicable rules✓
• d.a reduced service

Modifier 33 flags a preventive service, such as one recommended by the U.S. Preventive Services Task Force, so that patient cost-sharing may be waived under the Affordable Care Act.

In medical terminology, the suffix '-ectomy' means:

• a.surgical removal or excision✓
• b.creation of a new opening
• c.surgical repair of a structure
• d.surgical incision into a structure

The suffix -ectomy means excision or removal, as in appendectomy. In contrast, -otomy means incision, -ostomy means creating an opening, and -plasty means surgical repair.

The suffix '-ostomy' differs from '-otomy' in that '-ostomy' refers to:

• a.removing an organ or structure
• b.cutting into a structure without leaving an opening
• c.creating a new, often permanent, opening✓
• d.suturing a structure closed

The suffix -ostomy means surgically creating an opening or stoma, such as a colostomy. The suffix -otomy means a simple incision, such as a laparotomy, and -ectomy means removal.

The suffix '-itis' in a diagnostic term indicates:

• a.surgical repair
• b.inflammation✓
• c.the study of a subject
• d.an abnormal condition

The suffix -itis means inflammation, as in appendicitis or arthritis. In contrast, -osis means an abnormal condition, -ology means the study of, and -pathy means disease.

The prefixes 'hyper-' and 'hypo-' respectively indicate:

• a.within and outside in every billing situation without exception
• b.above or excessive, and below or deficient✓
• c.fast and slow
• d.before and after

Hyper- means excessive or above, as in hyperglycemia, and hypo- means deficient or below, as in hypoglycemia. Tachy- and brady- mean fast and slow, and intra- and extra- mean within and outside.

In surgical terminology, the suffix '-rrhaphy' means suturing, while '-pexy' means:

• a.recording or producing an image
• b.visual examination of a cavity
• c.surgical fixation or suspension of a structure✓
• d.surgical crushing of a structure in every billing situation without exception

The suffix -rrhaphy means suture or repair, as in herniorrhaphy, and -pexy means surgical fixation, as in nephropexy. The suffix -tripsy means crushing, and -scopy means visual examination.

In medical terminology, a combining vowel, usually the letter 'o', is generally used to:

• a.replace the suffix of a term
• b.connect a root to a consonant-starting suffix, or to connect two roots✓
• c.always separate a prefix from a root in every billing situation without exception
• d.indicate the plural form of a word

A combining vowel links a root to a suffix that begins with a consonant, or joins two roots, as in gastroenterology. It is usually dropped before a suffix that begins with a vowel, as in gastritis.

In anatomy, the term 'distal' describes a location that is:

• a.toward the front of the body
• b.toward the head of the body
• c.nearer to the midline of the body in every billing situation without exception
• d.farther from the point of attachment or origin of a structure✓

Distal means farther from the trunk or origin; the fingers are distal to the wrist. Proximal means nearer. Medial and lateral refer to the midline, and superior and inferior mean above and below.

The anatomical plane that divides the body into anterior and posterior portions is the:

• a.coronal (frontal) plane✓
• b.sagittal plane
• c.midsagittal plane
• d.transverse plane

The coronal or frontal plane divides the body into front and back. The sagittal plane divides it into left and right, and the transverse plane divides it into upper and lower portions.

The thoracic cavity primarily contains the:

• a.stomach and intestines
• b.brain and spinal cord
• c.urinary bladder and rectum
• d.heart and lungs✓

The thoracic cavity houses the heart, lungs, and major vessels. The abdominal cavity holds digestive organs, the pelvic cavity holds the bladder and reproductive organs, and the cranial and spinal cavities hold the central nervous system.

When abstracting a procedure code from an operative report, the coder should rely primarily on the:

• a.preoperative diagnosis listed at the top in every billing situation without exception
• b.anesthesia record alone
• c.body of the operative report describing what was actually performed✓
• d.scheduling note created before the case

The detailed body of the operative report, describing the findings and steps actually performed, governs code assignment, because the planned procedure may differ from what was done. The postoperative diagnosis is usually more accurate than the preoperative one.

A Medically Unlikely Edit (MUE) differs from an NCCI procedure-to-procedure edit in that an MUE limits:

• a.the maximum units of a single code reportable for one patient in one day✓
• b.the diagnosis codes that are allowed
• c.which two codes may be billed together in every billing situation without exception
• d.the timely filing period for the claim

MUEs cap the units of service for a single code per patient per day, while procedure-to-procedure edits identify code pairs that should not be reported together. Both are components of the National Correct Coding Initiative.

ICD-10-PCS procedure codes, as distinct from CPT codes, are used to report procedures in the:

• a.ambulance transport setting
• b.inpatient hospital setting✓
• c.physician office setting
• d.retail pharmacy setting

ICD-10-PCS codes report procedures in the inpatient hospital setting, while CPT and HCPCS codes report physician and outpatient procedures. Each system has its own structure and guidelines.

In the medical billing revenue cycle, the step that occurs first, before a claim can be created, is:

• a.posting of the insurance payment
• b.patient registration and insurance verification✓
• c.adjudication of the claim by the payer in every billing situation without exception
• d.appeal of a denied claim

The revenue cycle begins at the front end with scheduling, registration, and insurance verification, before charge capture, coding, claim submission, adjudication, and payment posting.

Claim 'adjudication' is the process by which:

• a.the clearinghouse formats the claim
• b.the provider assigns the diagnosis codes in every billing situation without exception
• c.the patient selects an insurance plan
• d.the payer reviews the claim and decides to pay, deny, or reduce it✓

Adjudication is the payer's determination that applies benefits, edits, and medical-necessity rules to pay, deny, or adjust each claim line. The results are reported on the remittance advice.

The HIPAA electronic transaction used to submit institutional (facility) claims, corresponding to the UB-04, is the:

• a.837I✓
• b.270 eligibility inquiry
• c.835 remittance
• d.837P

The 837I is the institutional claim transaction that corresponds to the paper UB-04. The 837P is the professional version for the CMS-1500, and the 835 is the electronic remittance advice.HIPAA

The HIPAA 835 transaction is used to transmit:

• a.electronic remittance advice and payment information from payer to provider✓
• b.a prior authorization request
• c.the professional claim from provider to payer in every billing situation without exception
• d.an eligibility and benefit inquiry

The 835 is the electronic remittance advice, detailing payments and adjustments. It is often paired with electronic funds transfer for automated payment posting.HIPAA

The paired HIPAA transactions 270 and 271 are used respectively for:

• a.an eligibility inquiry and the payer's response✓
• b.a prior authorization request and response
• c.a claim status request and response
• d.a claim and its remittance advice

The 270 is an eligibility and benefit inquiry and the 271 is the payer's response. The 276 and 277 handle claim status, and the 278 handles prior authorization.HIPAA

To electronically check the status of a submitted claim, a provider uses the HIPAA:

• a.270 and 271 transactions
• b.276 inquiry and 277 response transactions✓
• c.820 premium payment transaction in every billing situation without exception
• d.834 enrollment transaction

The 276 is a claim status request and the 277 is the response. The 834 handles enrollment, and the 820 handles premium payments.HIPAA

The HIPAA 278 transaction is used for:

• a.electronic remittance advice
• b.prior authorization and referral requests and responses✓
• c.enrollment of members in a health plan in every billing situation without exception
• d.submission of a professional claim

The 278 is the health care services review transaction, used for prior authorization and referral certification requests and responses.HIPAA

The current HIPAA-mandated standard format governing electronic health care claim transactions is known as:

• a.ASC X12 version 5010✓
• b.the National Drug Code
• c.CPT Category III
• d.ICD-10-CM

HIPAA electronic transactions use the ASC X12 version 5010 standards. Code sets such as ICD-10-CM and CPT populate the data, but the transaction format itself is X12 5010.HIPAA

On the CMS-1500 (02/12) claim form, Item 21 requires an ICD indicator to show:

• a.the number of service lines on the claim
• b.the billing provider's NPI
• c.the place of service
• d.which diagnosis code set is being reported✓

Item 21 holds the diagnosis codes plus an ICD indicator that identifies the code set version, such as ICD-10-CM, and can list up to twelve diagnoses.

Item 24 of the CMS-1500 claim form is where the biller enters:

• a.the dates of service, procedure codes, modifiers, charges, and units✓
• b.the patient's insurance policy number in every billing situation without exception
• c.the referring provider's name
• d.the notice of privacy practices

Item 24 contains up to six service lines with dates of service, place of service, procedure codes, modifiers, diagnosis pointers, charges, and units.