Chapter 21 — Exercises

How to use these. Section E — the override decision — is the chapter. Everything before it is vocabulary you need in order to do it.

For every override item, run all four steps in order and say where you stop. An answer that jumps to "yes, use modifier 59" has skipped the two steps that matter.

Section A — What the edits are (items 1–8)

A.1 State the problem an edit file solves that CPT cannot solve for itself.

A.2 Are NCCI edits published in advance? What follows from the answer?

A.3 What does it cost to access them?

A.4 A practice receives an NCCI denial it says it could not have anticipated. Evaluate that claim.

A.5 In a PTP edit, what is Column One? What is Column Two?

A.6 Is the direction of an edit reversible? Explain what that means for a claim reporting both codes.

A.7 Name the two separate PTP edit files CMS publishes. What happens if you use the wrong one?

A.8 Name the six fields in a PTP edit row that matter, and say which one decides whether an override is even possible.

Section B — The modifier indicator (items 9–14)

B.9 State what indicator 0 permits.

B.10 State what indicator 1 permits. State what it does not.

B.11 State what indicator 9 means.

B.12 A claim with an indicator-0 edit is denied. The biller appeals. The appeal denies. Was the appeal poorly written?

B.13 (Chapter 20) Which of the four reasons a valid code does not pay is an indicator-0 denial?

B.14 A practice overrides one indicator-1 edit on 94% of occurrences. What has it asserted, and how would a payer see it without any charts?

Section C — MUEs (items 15–22)

C.15 What does an MUE limit?

C.16 Name four things MUE values are based on.

C.17 State what MAI 1 means and what response it calls for.

C.18 State what MAI 2 means and what response it calls for.

C.19 State what MAI 3 means and what response it calls for.

C.20 A claim reports 8 units of a code whose MUE is 3. Give all three correct responses, by MAI.

C.21 Why are some MUE values unpublished? Does that change what you report?

C.22 A biller has spent three weeks appealing MAI-2 denials. What should they have done instead, and what should they do now?

Section D — Policy and principles (items 23–32)

D.23 What is the NCCI Policy Manual? Who publishes it, how often, and what does it cost?

D.24 How is it organized?

D.25 Name three reasons to read the governing section before overriding an edit.

D.26 State the standards-of-medical-and-surgical-practice principle in one sentence.

D.27 Name six services integral to essentially any procedure.

D.28 A lesser procedure is attempted and a greater one is performed at the same site. What do you report?

D.29 (Chapter 18) A laparoscopic procedure is converted to open. Name the general principle from this chapter that governs it.

D.30 (Chapter 17) Account 10-4471's lidocaine. Which principle in this chapter keeps it off the claim, and how many chapters have now given a reason?

D.31 Distinguish comprehensive/component from mutually exclusive.

D.32 What question does each invite? Why does a distinctness modifier answer only one of them?

Section E — The override decision (items 33–42)

For each, run all four steps and say where you stop.

E.33 A lesion excision and a simple repair at the same site, same session. Indicator 1.

E.34 A lesion excision on the left forearm and an intermediate repair of a separate laceration on the right forearm. Indicator 1.

E.35 Closed and open treatment of the same fracture, same session. Indicator 1.

E.36 Two arthroscopic procedures. The operative note documents debridement in the subacromial space, "anatomically distinct from the repair site," for symptomatic bursitis. Indicator 1.

E.37 The same two procedures. The note documents "debridement performed." Indicator 1.

E.38 The same two procedures. The note documents debridement of the structures that were repaired. Indicator 1.

E.39 Two services with indicator 0. The surgeon states they were performed at separate sessions.

E.40 An E/M and a minor procedure on the same date. The E/M documentation includes three chronic conditions assessed with plans, prescription drug management, and two tests ordered, none related to the procedure.

E.41 In E.36, which modifier? Justify the choice over the alternative.

E.42 In E.37, a coder proposes querying the surgeon eighteen months later. Evaluate that proposal.

Section F — The shoulder claim (items 43–48)

F.43 Account 31-2245 has three lines. Which one requires no edit lookup at all, and why?

F.44 Run the pair for line 3. Give Column One, Column Two, and the indicator.

F.45 What does the Policy Manual say about arthroscopic debridement in the same anatomic region as a repair?

F.46 At which step does the override fail? State precisely why "there was no supporting sentence" is not the right answer.

F.47 What was the correct claim for the thirty-one cases? For the eleven?

F.48 Which modifier for the eleven, and why not 59?

Section G — The False Claims Act angle (items 49–54)

G.49 (Chapter 5) State the three ways the Act defines "knowingly." Which one does not looking at a public file fall under?

G.50 Name the four features of unbundling that make it a comfortable False Claims Act theory.

G.51 What distinguishes an error from a case?

G.52 (Chapter 5) An organization discovers a macro like Account 31-2245's and does not repay. What has changed about its position?

G.53 What is a qui tam action?

G.54 You notice a code pair carrying modifier 59 on 94% of your organization's claims. State exactly what you do, in three parts, and one thing you do not do.

Section H — Non-NCCI edits and appeals (items 55–60)

H.55 Name the three categories of edits a payer may apply.

H.56 Is a correct NCCI override a guaranteed payment? Give the example from this book.

H.57 A line denies as incidental and you cannot find an NCCI edit. What are you probably looking at, and what four questions do you ask?

H.58 What should you not say on that call, and why?

H.59 List the six edit-denial categories and which are worth appealing. How many say do not appeal?

H.60 What should a billing office do with the effort it saves by not appealing three of the six?

Section I — The Encounter (items 61–64)

I.61 Run the edit for 99214 + 20610. Give Column One, Column Two, and the indicator.

I.62 What does the Policy Manual say about an E/M on the same date as a procedure? Whose test is that identical to?

I.63 Which documentation elements satisfy step 3? How many of them concern the knee?

I.64 The override was correct at every step and the payer denied it on day 17. Explain how both are true, and say what makes the day-59 appeal succeed.