Chapter 14 — Quiz

Twenty-four questions.

Multiple choice

1. A modifier:

  • A. changes the definition of a code
  • B. reports that a service was altered by a specific circumstance without changing its definition
  • C. replaces a code
  • D. is optional in all cases

2. Modifier 25 is appended to:

  • A. the procedure code
  • B. the E/M code
  • C. both codes
  • D. the diagnosis code

3. Modifier 25 requires:

  • A. a different diagnosis
  • B. an E/M above and beyond the usual pre- and post-procedure work
  • C. a 090-day global procedure
  • D. an ABN

4. The E/M leading to the decision for major surgery takes:

  • A. 25
  • B. 57
  • C. 58
  • D. 79

5. Modifier 59 should be used:

  • A. routinely on second procedures
  • B. only when no more descriptive modifier is available
  • C. on all E/M codes
  • D. to request a payment reduction

6. Which is not one of the X{EPSU} modifiers?

  • A. XE
  • B. XS
  • C. XR
  • D. XU

7. Modifier 51 asks the payer to:

  • A. pay more
  • B. apply the multiple-procedure reduction
  • C. override a bundling edit
  • D. split a global service

8. Modifier 59 asks the payer to:

  • A. apply a reduction
  • B. pay two services an edit would otherwise bundle
  • C. split a global service
  • D. deny the claim

9. Modifier 26 reports:

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

10. There is no professional component without:

  • A. a signed order
  • B. a written interpretation and report
  • C. prior authorization
  • D. a facility fee

11. A planned, staged procedure during the postoperative period takes:

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

12. An unplanned return to the OR for a related procedure takes:

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

13. An unrelated E/M during the postoperative period takes:

  • A. 24
  • B. 25
  • C. 57
  • D. 79

14. Modifier 22 requires:

  • A. nothing additional
  • B. documentation and a special report, and triggers manual review
  • C. prior authorization
  • D. an ABN

15. Modifier 91 is used for:

  • A. a repeat test because of equipment failure
  • B. a repeat test to obtain subsequent results
  • C. an inadequate specimen
  • D. a repeat procedure by a different physician

16. A statutorily excluded service is reported with:

  • A. GA
  • B. GY
  • C. GZ
  • D. no modifier

17. A service expected to be denied as not reasonable and necessary, with no ABN obtained:

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

18. Modifier 51 is never appended to:

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

Short answer

19. State the question a coder must be able to answer about every modifier they append.

20. Name the four audiences that read a modifier. Which one needs no chart review, and what does that imply?

21. State the modifier 25 misconception and correct it.

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

23. (Chapter 5) A system appends a modifier automatically on a rule. Name the statutory concept implicated and the three questions that address it.

24. (Chapter 4) Account 10-4471 carries modifier 25 on line 1. Name the four elements supporting it and say which three have nothing to do with the knee.

Answer key **1.** B. **2.** B — modifier 25 goes on the **E/M**, not the procedure. **3.** B. **4.** B. **5.** B. **6.** C — there is no XR. **7.** B. **8.** B. **9.** B. **10.** B. **11.** A. **12.** B. **13.** A. **14.** B. **15.** B. **16.** B. **17.** D. **18.** B. **19.** **"Where in the documentation is the thing this modifier says?"** A modifier is a factual assertion on a document that carries a certification, and appending one without being able to point at its support is the failure mode this entire chapter is about. **20.** The payer's **claim system** (whether to pay, reduce, or override); a **medical reviewer** (whether the documentation supports the assertion); an **auditor** (patterns and frequency); and a **future reader of the record**. **The auditor needs no chart review** — modifier frequency is visible in claims data alone. **The implication:** a practice whose modifier rate is far above its peers is visible long before anybody requests a chart, and the outlier is identified without anyone forming a judgment about a single claim. **21.** **The misconception: that modifier 25 requires a different diagnosis for the E/M and the procedure.** It does not. CPT's own guidance says so. **The test is whether the E/M was significant and separately identifiable** — above and beyond the usual pre- and post-procedure work — and a shared diagnosis is entirely compatible with that. A different diagnosis makes the case easier to see; it is not the test. **22.** **It is the only modifier whose sole function is to defeat a control.** **It is applied by the party that benefits from it.** **It is easy to apply and hard to check** — two characters against an operative note somebody has to read. **And its use is measurable without any chart review**, so outliers surface from claims data alone. **23.** **Reckless disregard**, the second and third prongs of "knowingly" under the False Claims Act (Chapter 5 §5.3) — an unexamined default operating at volume on a question that determines whether claims are true. **The three questions:** which modifiers does the system append and on what conditions; who configured each rule, when, and why; and when did anyone last read a sample of the output. **24.** **(1)** Three chronic conditions each individually assessed with a plan. **(2)** Prescription drug management — three medications reviewed and continued. **(3)** Two laboratory tests ordered, each with a stated clinical reason. **(4)** A new problem with its own history, examination, and independent management decision. **Elements 1, 2, and 3 have nothing to do with the knee**, and that is the entire modifier 25 argument — the E/M work stands on its own and would have been performed and documented whether or not the injection happened.