Chapter 21 — Quiz

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

1. NCCI edits are:

  • A. Proprietary to each Medicare Administrative Contractor
  • B. Published by CMS, free, and updated quarterly
  • C. Available by subscription only
  • D. Confidential to prevent gaming

2. In a procedure-to-procedure edit, Column Two is:

  • A. The payable code
  • B. The code that is not separately payable when reported with Column One
  • C. The higher-valued code
  • D. The code listed first on the claim

3. CMS publishes separate PTP edit files for:

  • A. Each specialty
  • B. Practitioner services and outpatient hospital services
  • C. Each state
  • D. Commercial and government payers

4. A modifier indicator of 0 means:

  • A. No edit applies
  • B. A modifier may override with documentation
  • C. No modifier will override this edit under any circumstances
  • D. The edit was deleted

5. A modifier indicator of 1 means:

  • A. The edit should be overridden
  • B. A modifier may override if the circumstances justify it and documentation supports it
  • C. Modifier 59 is required
  • D. One modifier is permitted per claim

6. The chapter describes indicator 1 as:

  • A. An authorization
  • B. A permission, not an authorization
  • C. A recommendation
  • D. A default

7. A claim with an indicator-0 edit denies. The appeal also denies. This means:

  • A. The appeal was poorly written
  • B. There is nothing to appeal to
  • C. A different modifier was needed
  • D. The claim should be resubmitted

8. A medically unlikely edit limits:

  • A. Which codes may be reported together
  • B. The maximum units of service for a code, per beneficiary, per date
  • C. The dollar amount of a claim
  • D. The number of lines on a claim

9. MAI 2 means the edit is:

  • A. A claim line edit that can be split across lines
  • B. A date-of-service edit, policy-based, that cannot be exceeded
  • C. A clinical benchmark appealable with documentation
  • D. Advisory only

10. Which MAI value should NOT be appealed?

  • A. 1
  • B. 2
  • C. 3
  • D. All are appealable

11. A claim reports 8 units of a code whose MUE is 3, with MAI 1. The appropriate response is:

  • A. Appeal with documentation
  • B. Report 3 units and write off the rest
  • C. Report the additional units on additional lines with appropriate modifiers, where clinically justified
  • D. Do nothing; the edit is absolute

12. Some MUE values are unpublished because:

  • A. They change too often
  • B. A published maximum invites billing up to it
  • C. They are proprietary
  • D. They apply only to facilities

13. The NCCI Policy Manual is:

  • A. A commercial publication
  • B. Published by CMS, free, updated annually
  • C. Available only to Medicare contractors
  • D. Identical to the edit files

14. The standards of medical and surgical practice principle holds that:

  • A. All procedures require documentation
  • B. Services integral to a procedure are included in it and not separately reportable
  • C. Only physicians may report procedures
  • D. Modifiers must be sequenced by value

15. Which is NOT separately reportable with a procedure?

  • A. An unrelated procedure at a different session
  • B. Local anesthesia administered by the operating physician
  • C. A significant, separately identifiable E/M service
  • D. A complication requiring a return to the operating room

16. A procedure is attempted by one approach, abandoned, and completed by another. You report:

  • A. Both
  • B. Only the attempted procedure
  • C. Only the completed procedure
  • D. The attempted procedure with modifier 53

17. A comprehensive/component edit invites the question:

  • A. "Did both of these actually happen?"
  • B. "Was this separate?"
  • C. "Which code pays more?"
  • D. "Is this medically necessary?"

18. A mutually exclusive edit invites the question:

  • A. "Was this separate?"
  • B. "Did both of these actually happen?"
  • C. "Which modifier applies?"
  • D. "What is the global period?"

19. In the override decision, step 3 requires documentation that is:

  • A. Obtainable by query
  • B. Already written and already signed
  • C. Summarized in the claim narrative
  • D. Attested to by the coder

20. Account 31-2245's line 3 fails the override at step 3 because:

  • A. No supporting sentence exists
  • B. The note affirmatively documents debridement of the structures that were repaired
  • C. The indicator was 0
  • D. Modifier 59 was the wrong modifier

21. For the eleven genuinely distinct cases, the correct modifier would have been:

  • A. 59
  • B. 51
  • C. XS
  • D. 22

22. Unbundling fits the False Claims Act's "knowingly" standard partly because:

  • A. Intent to defraud is presumed
  • B. The edits are public, so not looking is deliberate ignorance
  • C. Coders are personally liable
  • D. Modifiers are prohibited

23. False Claims Act penalties attach:

  • A. Per audit
  • B. Per claim
  • C. Per provider
  • D. Per year

24. A qui tam action is one in which:

  • A. A payer sues a provider
  • B. A private party brings an action on the government's behalf and shares in the recovery
  • C. A provider appeals a denial
  • D. CMS revokes enrollment

25. A correct NCCI override:

  • A. Guarantees payment
  • B. Does not guarantee payment; other payers apply their own edits
  • C. Cannot be reviewed later
  • D. Eliminates the need for documentation

26. Of the six edit-denial categories in §21.11, how many say "do not appeal"?

  • A. One
  • B. Two
  • C. Three
  • D. Five