Chapter 14 — Exercises

Items marked † have worked solutions in Answers to Selected Exercises, along with every odd-numbered item. All scenarios are constructed; verify all modifier rules against current CPT guidance and payer policy.

A. Recall and vocabulary

14.1 State, in one sentence, what a modifier is. Then state the question a coder must be able to answer about every modifier they append.

14.2 Distinguish CPT modifiers from HCPCS Level II modifiers by format and maintainer. May a HCPCS Level II modifier be appended to a CPT code?

14.3 † Name the four audiences that read a modifier and what each reads it for. Which one requires no chart review?

14.4 Distinguish payment from informational modifiers. State the sequencing rule and its two complications.

14.5 † State what modifier 25 asserts. Name the two things it requires and the one thing people wrongly believe it requires.

14.6 Distinguish modifier 25 from modifier 57 by the global period of the procedure involved.

14.7 † State the modifier 59 last-resort rule. Name the four X{EPSU} modifiers and what each says.

14.8 Give four reasons modifier 59 attracts more scrutiny than any other modifier.

14.9 † Distinguish modifier 51 from modifier 59 by what each asserts and by which direction each moves the payment.

14.10 State the three rules governing modifiers 26 and TC. What determines which entity bills the technical component?

14.11 † Name the five global-period modifiers and what each describes. State the distinction that decides most questions between two of them.

14.12 Distinguish modifier 52 from modifier 53. Which is generally not used for outpatient hospital or ASC reporting, and what replaces it?

14.13 † Name the four liability modifiers. Which one is an admission, and what does it admit?

14.14 Why would an organization ever report the modifier in 14.13?

B. Select the modifier

For each, name the modifier and the reasoning. Some require none.

14.15 † A patient presents for a scheduled joint injection. The provider examines the joint, confirms the plan, and injects. An E/M is on the claim.

14.16 A patient presents for three chronic conditions, mentions new shoulder pain, is evaluated, and receives an injection. All four problems are assessed with plans.

14.17 † A surgeon evaluates a patient and decides to perform a procedure with a 090-day global period the following morning.

14.18 A radiologist at a hospital interprets a chest radiograph and dictates a report. The hospital owns the equipment.

14.19 † A surgeon performs a planned second-stage reconstruction six weeks after the first stage.

14.20 A patient returns to the operating room eighteen hours after surgery because of bleeding.

14.21 † During the postoperative period of a knee procedure, the same surgeon treats the patient for an unrelated laceration of the hand.

14.22 During the postoperative period of a knee procedure, the same physician sees the patient for an unrelated upper respiratory infection.

14.23 † A procedure was terminated after anesthesia induction because the patient became unstable. Physician office setting.

14.24 A laboratory test is repeated four hours later to obtain a subsequent value for a patient on a heparin drip.

14.25 † A normally covered service is expected to be denied as not reasonable and necessary. An ABN was obtained.

14.26 The same situation, and the ABN was not obtained.

C. Read the document

14.27 † An office note documents: a scheduled injection, an examination of the joint injected, a discussion of the procedure, consent, the procedure, and post-procedure instructions. An E/M code with modifier 25 is on the claim. Evaluate.

14.28 An office note documents four assessed problems with individual plans, two tests ordered, and a minor procedure. The diagnosis for the procedure is one of the four. Is modifier 25 supported? Address the misconception directly.

14.29 † A billing system appends modifier 59 to every claim carrying a specific code pair. Write the three questions from §14.1's compliance callout and describe what you would do with the answers.

14.30 An operative report documents two procedures. The coder appends modifier 59 to the second. Describe exactly what you would look for in the report before agreeing.

D. Judgment and process

14.31 A colleague says modifier 25 requires a different diagnosis. Correct them, and cite what supports your correction.

14.32 † A practice's modifier 25 rate is far above its specialty peers. Describe the investigation, in order, and name the three possible findings.

14.33 Your billing system appends modifier 51 automatically and one of your payers applies it during adjudication. Is this a problem? What would you check?

14.34 † A denial arrives for bundling. A colleague suggests appending modifier 59 and resubmitting. Give the response, and describe the correct sequence.

14.35 Design the pre-submission check a coder should perform before appending any modifier. Maximum five steps.

E. Certification-style questions

14.36 † Modifier 25 is appended to:

  • A. the procedure code
  • B. the evaluation and management code
  • C. both
  • D. neither

14.37 Modifier 25 requires:

  • A. a different diagnosis for the E/M and the procedure
  • B. an E/M service above and beyond the usual pre- and post-procedure work
  • C. a major surgical procedure
  • D. prior authorization

14.38 † The E/M that resulted in the decision for major surgery takes:

  • A. modifier 25
  • B. modifier 57
  • C. modifier 58
  • D. modifier 24

14.39 Modifier 59 should be used:

  • A. whenever two procedures are performed
  • B. only when no more descriptive modifier is available
  • C. on every E/M billed with a procedure
  • D. to indicate multiple procedures

14.40 † Modifier 51 indicates:

  • A. distinct procedural service
  • B. multiple procedures
  • C. a bilateral procedure
  • D. reduced services

14.41 A planned, staged procedure during the postoperative period takes:

  • A. modifier 58
  • B. modifier 78
  • C. modifier 79
  • D. modifier 24

14.42 † An unplanned return to the operating room for a related procedure during the postoperative period takes:

  • A. modifier 58
  • B. modifier 78
  • C. modifier 79
  • D. modifier 76

14.43 Modifier 26 reports:

  • A. the technical component
  • B. the professional component
  • C. the global service
  • D. a repeat procedure

14.44 † A service expected to be denied as not reasonable and necessary, for which no ABN was obtained, is reported with:

  • A. GA
  • B. GX
  • C. GY
  • D. GZ

14.45 Modifier 51 is never appended to:

  • A. surgical codes
  • B. add-on codes and modifier-51-exempt codes
  • C. E/M codes
  • D. bilateral procedures

F. Write it

14.46 † Write the 120-word correction you would give a colleague who believes modifier 25 requires a different diagnosis.

14.47 Draft the modifier decision card from §14.12, reduced to fit on one side of an index card.

14.48 Write the two-sentence standard your practice should adopt governing when modifier 59 may be appended.

G. The Encounter

14.49 † State what each of the two modifiers on Account 10-4471 asserts, who reads it, and what happens if it is missing. Be specific about the dollar consequence of one of them.

14.50 Apply §14.4's test to Q1: for each element modifier 25 asserts, quote the documentation that supports it. Then state which element is supported by evidence that has nothing to do with the knee.

14.51 † The chapter answers Q1 "yes" and immediately gives two qualifications. State both, and explain why answering "yes" without them would be misleading.

14.52 Line 2 carries RT. Suppose it were omitted. State the immediate consequence, the delayed consequence, and the consequence that has nothing to do with payment.

14.53 Chapter 4 §4.10 identified a gap: the note never states the decision to inject was made during this visit. Explain how that gap and modifier 25 interact, and what Chapter 30 will have to do about it.

14.54 Update your Encounter Workbook (Appendix C): record both modifiers, the Q1 analysis, and the four elements with their documentary support.