Chapter 16 — Quiz

26 questions. Answers and explanations are in the instructor guide.

1. Since 2023, hospital, observation, ED, nursing facility, and home services are leveled by:

  • A. Their own separate scoring systems
  • B. History, examination, and medical decision making
  • C. The same MDM framework introduced for office visits in 2021
  • D. Facility acuity criteria

2. A single facility encounter generally produces:

  • A. One claim
  • B. Two claims — professional and facility — with two patient balances
  • C. Two claims, but only one patient balance
  • D. One claim with two sections

3. "Initial" hospital inpatient or observation care means:

  • A. The service on the date of admission
  • B. The first face-to-face service of the stay by that professional or their same-specialty group partner
  • C. The first service by any professional
  • D. The service performed by the admitting physician only

4. A cardiologist first sees a hospitalized patient on day four of the stay. The cardiologist reports:

  • A. Subsequent care, because the admission was days ago
  • B. Initial care, because it is their first service
  • C. A consultation, always
  • D. Nothing; the attending reports for the group

5. A hospitalist sees a patient in the office in the morning and admits them that afternoon. For that date the hospitalist reports:

  • A. An office visit and an initial hospital care service
  • B. An office visit only
  • C. An initial hospital care service only; the office work rolls into it
  • D. A consultation

6. Observation is:

  • A. An inpatient service
  • B. An outpatient service
  • C. Inpatient after 24 hours
  • D. Determined by which floor the patient is on

7. The two-midnight benchmark turns on:

  • A. The actual length of stay
  • B. The physician's documented expectation at the time of the decision
  • C. Whether the patient occupied an inpatient bed
  • D. A utilization review determination made after discharge

8. A patient spends four nights in a hospital bed under observation and is discharged to a skilled nursing facility. Medicare's skilled nursing facility coverage:

  • A. Applies, because the patient was hospitalized four nights
  • B. Applies at a reduced rate
  • C. Generally does not apply, because observation days do not count toward the three-day inpatient requirement
  • D. Applies only if the physician certifies it

9. Condition Code 44 may be used:

  • A. At any time after discharge
  • B. Only before the patient is discharged, following utilization review with physician concurrence
  • C. Only by the payer
  • D. Only for Medicare Advantage patients

10. Discharge day management is reported:

  • A. Once per stay, by the attending, for the date of the actual discharge
  • B. By each professional who saw the patient that day
  • C. For the date the discharge planning was performed
  • D. Once per admission and once per transfer

11. 99239 (more than 30 minutes) requires:

  • A. Only that the discharge be complex
  • B. Documentation of the time
  • C. A separate discharge summary
  • D. A physician signature within 24 hours

12. Concurrent care by several professionals on the same date is:

  • A. Prohibited
  • B. Permissible when each service is reasonable and necessary and the record shows what each professional managed
  • C. Permissible only for different specialties in different groups
  • D. Permissible only with modifier 59

13. A consultant's daily note reproduces the attending's assessment nearly verbatim. The most likely consequence is:

  • A. Nothing; duplication is normal in a shared record
  • B. A denial of one of the two claims, which is defensible
  • C. A request for records only
  • D. An automatic upcode

14. A steady trickle of unexplained duplicate denials among physicians in a hospital-based group, with no coding errors found, most often indicates:

  • A. A clearinghouse problem
  • B. A specialty enrollment problem
  • C. A modifier problem
  • D. A timely filing problem

15. The three Rs of a consultation are:

  • A. Refer, review, report
  • B. Request, render, report
  • C. Request, review, refer
  • D. Render, review, reply

16. Medicare and consultation codes:

  • A. Medicare pays them at a reduced rate
  • B. Medicare has not recognized them since 2010; report the setting-appropriate E/M instead
  • C. Medicare pays only inpatient consultations
  • D. Medicare requires modifier 32

17. A consultant renders an opinion and also initiates treatment. The service:

  • A. Becomes a transfer of care
  • B. Is still a consultation if the three Rs are met
  • C. May not be reported
  • D. Requires a second request

18. Emergency department E/M codes:

  • A. Use the new/established distinction
  • B. Offer a time-based selection option
  • C. Have neither a new/established distinction nor a time option
  • D. Are leveled by facility acuity criteria

19. An ED patient with chest pain is ultimately diagnosed with reflux. The level is determined by:

  • A. The final diagnosis
  • B. The medical decision making documented, including what was ruled out
  • C. The length of stay in the department
  • D. The facility's acuity criteria

20. Critical care requires:

  • A. That the patient be in an intensive care unit
  • B. A critically ill or injured patient and high-complexity decision making, regardless of location
  • C. At least 24 hours of care
  • D. A ventilator

21. Twenty-five minutes of critical care are documented. You report:

  • A. 99291
  • B. 99291 with modifier 52
  • C. The appropriate E/M service for the setting; under 30 minutes is not critical care
  • D. 99292

22. Which is bundled into critical care and may not be reported separately?

  • A. Central venous catheter placement in a separately documented procedure note
  • B. Pulse oximetry
  • C. Endotracheal intubation
  • D. Cardiopulmonary resuscitation

23. A patient is seen for a routine subsequent hospital visit in the morning, deteriorates, and receives critical care in the afternoon. Both services:

  • A. May not both be reported
  • B. May be reported, with modifier 25 on the E/M, when the documentation shows the sequence
  • C. May be reported with modifier 59
  • D. Are combined into a single critical care code

24. Facility emergency department levels are determined by:

  • A. The same MDM grid the physician uses
  • B. A national leveling system published by CMS
  • C. The facility's own written criteria, based on resources consumed
  • D. The patient's diagnosis

25. A facility remittance line shows charges and zero allowed for supplies. This is:

  • A. A denial requiring appeal
  • B. Packaging — payment included in the primary service
  • C. A clearinghouse rejection
  • D. A contractual write-off error

26. In §16.10's ED counterfactual, Account 10-4471's three chronic conditions contribute nothing to the level because:

  • A. The ED does not code chronic conditions
  • B. They were not addressed by the emergency physician
  • C. Chronic conditions never count in the ED
  • D. They were coded on the facility claim instead