Chapter 16 — Exercises

How to use these. Chapter 15 taught the scoring. This set is about the setting, so most items turn on a fact about who, where, or when rather than on the MDM grid. Where an item does ask for a level, use Chapter 15's grid — it has not changed.

Section H is the two-claim set and it is the one most students have never seen before. Do it.

Section A — Initial versus subsequent (items 1–8)

State the code family and whether the service is initial or subsequent, with the reason.

A.1 A hospitalist admits a patient on Monday and sees them Monday.

A.2 The same hospitalist sees the patient Tuesday.

A.3 The hospitalist's partner, same group, same specialty, covers Wednesday.

A.4 A cardiologist is asked to see the patient Wednesday and does so for the first time.

A.5 The cardiologist's partner, same group, sees the patient Thursday.

A.6 A nephrologist sees the patient Thursday for the first time.

A.7 A hospitalist sees a patient in the office Monday morning and admits them Monday afternoon, seeing them again on the floor. What is reported for Monday?

A.8 An emergency physician sees a patient at 9 p.m.; a hospitalist admits at 11 p.m. and evaluates the patient at 11:30 p.m. What does each report?

Section B — Observation and status (items 9–16)

B.9 Define observation status in one sentence. Is it inpatient or outpatient?

B.10 State the two-midnight benchmark. Is it applied prospectively or retrospectively?

B.11 A physician documented an expectation of a three-day stay with the reasoning. The patient improved and went home the next morning. Was the inpatient admission appropriate?

B.12 A physician wrote "admit" with no further statement. The patient stayed four days. What is the documentation problem, and what is at risk?

B.13 A patient spends three nights in a hospital bed under observation and is discharged to a skilled nursing facility. What happens to the skilled nursing facility coverage, and why?

B.14 The same patient's hospital bill includes charges for the blood pressure medication she takes at home. Explain how that happened.

B.15 Utilization review determines on hospital day 2 that an inpatient admission should have been outpatient. The patient has not been discharged. What mechanism applies, and what does it require?

B.16 The same determination is made three days after discharge. What is different?

Section C — Discharge day management (items 17–20)

C.17 A discharge summary describes the final examination, instructions, prescriptions, and follow-up arrangements, and does not state a time. What do you report?

C.18 The same summary ends with "Total discharge day time: 45 minutes." Now what?

C.19 The attending discharges the patient on Thursday, having done most of the discharge planning Wednesday. For which date is the service reported?

C.20 A consultant sees the patient on the discharge date. May the consultant report a discharge day management service? What should they report?

Section D — Concurrent care (items 21–24)

D.21 Four professionals see a hospitalized patient on the same date. Is that permissible? State the requirement.

D.22 A cardiologist's daily note reproduces the hospitalist's assessment nearly verbatim. What is the likely claim outcome and is it defensible?

D.23 A hospital-based group experiences a steady trickle of duplicate denials among physicians who practice as hospitalists. Coding review finds no errors. Where should you look next, and why?

D.24 Name the claim-level element, other than the code, that most quickly signals to a payer that two same-date services are distinct.

Section E — Consultations (items 25–32)

For each, state whether a consultation may be reported and why.

E.25 A primary care physician documents a request for a cardiology opinion. The cardiologist sees the patient and sends a written report back.

E.26 The patient calls the cardiology office directly and schedules an appointment.

E.27 A surgeon requests an opinion. The consultant sees the patient, renders an opinion, and never writes back.

E.28 A consultant renders an opinion and also starts a medication.

E.29 A primary care physician sends the patient to a specialist to take over management of the condition.

E.30 All three Rs are met. The payer is Medicare. What do you report?

E.31 All three Rs are met. The payer recognizes consultation codes. The setting is the office and the service is level 4. What do you report?

E.32 Which two of the three Rs fail most often, and what does each failure look like in a record?

Section F — Emergency department (items 33–38)

F.33 Is the ED family new/established? Is there a time option? State both answers and the reason for each.

F.34 A patient presents with chest pain. The workup is negative and the diagnosis is reflux. Does the final diagnosis determine the level? What does?

F.35 For the same patient, score the risk element given documentation that admission was considered and declined with return precautions.

F.36 An ED physician evaluates an undiagnosed new problem, orders one test, and prescribes a medication. Score all three elements and give the code.

F.37 The same encounter, but the physician recommends an over-the-counter analgesic instead. Now what?

F.38 Which ED code may not require the presence of a physician or other qualified health care professional, and what office code is its analogue?

Section G — Critical care (items 39–44)

G.39 A stable patient is in the intensive care unit. Is this critical care? Explain.

G.40 A critically ill patient is in the emergency department. Is this critical care?

G.41 25 minutes of critical care are documented. What do you report?

G.42 95 minutes of critical care are documented, including 20 minutes performing a separately reportable central line placement. What do you report?

G.43 A physician bills 99291 and separately bills pulse oximetry. What happens, and why?

G.44 A patient is seen in the morning for a routine subsequent hospital visit, deteriorates in the afternoon, and receives 45 minutes of critical care. May both be reported? What identifies it?

Section H — The two claims (items 45–52)

H.45 Name the form and transaction for the professional claim and for the facility claim.

H.46 An ED encounter carries 99284 on both claims. Explain how each level was determined.

H.47 A facility's ED level matches the physician's level on every claim in a sample. What does that suggest?

H.48 List the five characteristics facility acuity leveling criteria are expected to have. Which one is the practical test, and why?

H.49 A facility remittance shows a pharmacy line with charges and zero allowed. Is this a denial? What is it, and what should the billing office do with it?

H.50 What does a revenue code tell you that a CPT code does not?

H.51 A hospital-owned clinic bills a professional claim and a facility claim for what looks to the patient like an office visit. Name the arrangement and its consequence for the patient.

H.52 Write the three sentences you would say to a patient who calls asking why they received two bills for one visit. Then write the sentence you would not say.

Section I — Integration (items 53–58)

I.53 (Chapter 15) In §16.10's counterfactual, Account 10-4471's three chronic conditions score nothing. State the rule and quote the phrase that governs.

I.54 In the same counterfactual, one change moves the professional claim from 99283 to 99284. Name it, and say which MDM element it moves.

I.55 Compare the office encounter and the ED counterfactual on four measures: number of claims, allowed amount, patient responsibility, and whether the knee was treated. State the conclusion in one sentence.

I.56 The chapter argues the counterfactual is not an argument that the patient did something wrong. Explain the argument it is making, and name one plan-design feature that exists because of it.

I.57 (Chapter 14) Which modifier identifies a separate E/M reported on the same date as critical care, and what must the documentation show?

I.58 (Chapter 3) Observation is generally paid under which part of Medicare? Name two consequences for the patient that follow from the answer.