Chapter 22 — Exercises

How to use these. Section G — coded wrong versus never going to be covered — is the chapter's whole point. Everything before it teaches you enough to tell the difference.

For every denial scenario, say which of the two you are in before you say what you would do.

Section A — The distinction (items 1–8)

A.1 Distinguish a clinical determination of need from a coverage determination.

A.2 Give an example of a service that is necessary and not covered.

A.3 Give an example of a service that is covered and not necessary for this patient.

A.4 Is a physician's opinion that a service was necessary the criterion? What is?

A.5 An appeal letter opens with "the physician determined this service was medically necessary." Evaluate that opening.

A.6 Rewrite it.

A.7 (Chapter 20) Which of the four reasons a valid code does not pay is this chapter about?

A.8 Why is it the only one of the four where the medical record can change the answer?

Section B — The statutory standard (items 9–12)

B.9 Where does "reasonable and necessary" come from? Cite the provision.

B.10 Is it written as a grant of coverage or as an exclusion? Why does the answer matter?

B.11 The phrase covers services "for the diagnosis or treatment of illness or injury." What category of service does that structure exclude, and which chapter covers the consequence?

B.12 Does the statute define "reasonable and necessary"? Where does the content come from?

Section C — NCDs, LCDs, and articles (items 13–22)

C.13 What is an NCD? Are they numerous?

C.14 Name the three shapes an NCD takes. Which is most operationally important and why?

C.15 What is coverage with evidence development, and what does it impose on a claim?

C.16 What is an LCD? What does "jurisdictional" mean in practice?

C.17 Can an LCD contradict an NCD?

C.18 What is a billing and coding article, and what does it contain that the LCD does not?

C.19 Which document contains the list of diagnoses that support a service?

C.20 Name the six stages of the LCD public process.

C.21 Which document produced by that process is the best preparation for a future appeal, and why?

C.22 Describe the LCD reconsideration process. Why does the chapter call it "the only door in this book"?

Section D — Finding the policy (items 23–28)

D.23 State the five steps for finding the policy governing a claim.

D.24 Your payer is commercial. Which step do you skip to?

D.25 You search and find no NCD and no LCD. What does that mean, and what is the normal case?

D.26 State the two-search shortcut in §22.5's 🔢 Code It.

D.27 Your diagnosis is not on the article's list. State the fork and both branches.

D.28 Under what circumstance does finding a different diagnosis represent correct coding rather than something else?

Section E — Linkage (items 29–34)

E.29 What carries the linkage between a service and its diagnosis on a professional claim?

E.30 A supporting diagnosis appears on the claim but is not pointed at the service line. What happens?

E.31 Name the two ways linkage fails. Which is fixable?

E.32 State the "tell is direction" test in your own words.

E.33 (Chapter 4) Figure 4.2's first documented gap. What is it, where is the information actually located, and why does its location matter?

E.34 Can a coder fix E.33? What is the correct handling, and which chapter owns it?

Section F — Frequency and ABNs (items 35–46)

F.35 Name five shapes a frequency limitation can take.

F.36 Last service December 20. Under "once per calendar year," is January 5 payable? Under "once every 12 months"?

F.37 Same facts. Is December 19 of the following year payable under each rule?

F.38 From what does the clock run? Why might your system not know?

F.39 Is "the patient says they haven't had one" verification? What is?

F.40 Name the four requirements of a valid ABN.

F.41 Name the three ABN options. Who selects one?

F.42 Which option preserves appeal rights? Which destroys them? Which is almost always better for the patient?

F.43 Name two circumstances in which giving an ABN is improper, and explain the structural reason.

F.44 Is an ABN required for a statutorily excluded service? What modifiers apply?

F.45 Why is a defective ABN worse than no ABN?

F.46 A patient calls saying they signed nothing and are being billed. Give both correct answers and say what determines which applies.

Section G — Coded wrong versus never covered (items 47–56)

For each: which of the two, and what do you do?

G.47 A service is supported by a diagnosis the patient has and documented, and the claim reported a different one.

G.48 A policy requires six weeks of documented conservative therapy. The record documents four.

G.49 A policy lists supporting diagnoses. The patient's condition is not among them and no other documented condition is either.

G.50 A service was performed twice in eight months under a 12-month frequency limitation.

G.51 A claim denied because the diagnosis pointer was omitted.

G.52 A prior authorization was obtained for one code and a different procedure was performed.

G.53 In G.48, a biller has written three appeals. Evaluate that approach.

G.54 In G.48, what actually fixes it? Name all three parts.

G.55 Write the sentence you would say to the referring office in G.48.

G.56 Write the sentence that would not work, and say why.

Section H — Commercial and prior authorization (items 57–60)

H.57 What does a commercial medical policy do, and what Medicare documents does it correspond to?

H.58 Is a prior authorization a payment guarantee? Name three things it does not confirm.

H.59 What is a peer-to-peer review? Who conducts it, and what is the coder's role?

H.60 Why does a conversation frequently resolve what a written appeal does not?

Section I — The Encounter (items 61–64)

I.61 (Q3) Should an ABN have been obtained for the March 14 injection? Give both independent reasons.

I.62 The day-17 denial was CO-97 with RARC N19. Was it a medical necessity denial? What was it, and would an ABN have addressed it?

I.63 (Q5) Imaging obtained after March 14 supports M17.11. Was M25.561 wrong on March 14? State the rule.

I.64 What do Q3 and Q5 have in common? State the principle in one sentence.