Chapter 22 — Quiz

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

1. "Medical necessity," as used in billing, refers to:

  • A. A clinician's judgment that a patient needs a service
  • B. A payer's determination, under published criteria, that it will pay
  • C. The standard of care
  • D. Whether a service is listed in CPT

2. Which is possible?

  • A. A service that is necessary and not covered
  • B. A service that is covered and not necessary for this patient
  • C. Both
  • D. Neither

3. "But the doctor ordered it" is ineffective in an appeal because:

  • A. Physicians' opinions carry no weight
  • B. The payer already knows; the question is whether the record contains what the policy requires
  • C. It must be stated by the patient
  • D. It requires notarization

4. "Reasonable and necessary" comes from:

  • A. CPT's guidelines
  • B. The Social Security Act, § 1862(a)(1)(A)
  • C. The False Claims Act
  • D. HIPAA

5. The statutory provision is written as:

  • A. A grant of coverage
  • B. An exclusion from payment
  • C. A definition
  • D. A penalty

6. A national coverage determination is:

  • A. Advisory to contractors
  • B. Binding nationwide
  • C. Applicable only to Medicare Advantage
  • D. Issued by each state

7. Most services:

  • A. Have an NCD
  • B. Have no NCD
  • C. Have both an NCD and an LCD
  • D. Are governed only by CPT

8. Coverage with evidence development means a service is covered:

  • A. Without conditions
  • B. Only when the beneficiary participates in an approved study or registry
  • C. Only after appeal
  • D. Only in hospitals

9. An LCD is issued by:

  • A. CMS centrally
  • B. A Medicare Administrative Contractor, for its jurisdiction
  • C. The state Medicaid agency
  • D. The AMA

10. Which document contains the ICD-10-CM codes that support medical necessity for a service?

  • A. The NCD
  • B. The LCD
  • C. The billing and coding article
  • D. The CPT guidelines

11. Which document published with a final LCD is the best preparation for a future appeal?

  • A. The proposed LCD
  • B. The response to comments
  • C. The notice period announcement
  • D. The contractor's fee schedule

12. LCD reconsideration may be requested by:

  • A. CMS only
  • B. The contractor only
  • C. Anyone, with supporting evidence
  • D. Specialty societies only

13. You search and find no NCD and no LCD for a service. This means:

  • A. The service is automatically covered
  • B. The service is automatically denied
  • C. No published criteria govern; the general standard applies and the record's clinical rationale supports it
  • D. You must request an NCD

14. A supporting diagnosis appears on the claim but is not pointed at the service line. The line:

  • A. Pays, because the diagnosis is present
  • B. Will deny
  • C. Pends for review
  • D. Pays at a reduced rate

15. Linkage fails in two ways. Which one is fixable?

  • A. The diagnosis is right and does not support the service
  • B. The diagnosis is wrong and a supporting, documented diagnosis exists
  • C. Both
  • D. Neither

16. Reading the covered-diagnosis list and then going looking in the record is:

  • A. Efficient coding
  • B. Coding to the policy rather than to the record
  • C. Required by the LCD
  • D. Standard appeal practice

17. Last service December 20. Under "once every 12 months," a service on January 5:

  • A. Is payable
  • B. Denies
  • C. Is payable with a modifier
  • D. Requires an ABN

18. An ABN must include all of the following EXCEPT:

  • A. The specific item or service
  • B. A specific reason denial is expected
  • C. A cost estimate
  • D. The referring physician's signature

19. An ABN given to every patient for every service as a matter of policy is:

  • A. Best practice
  • B. Improper
  • C. Required by CMS
  • D. Optional but recommended

20. Which ABN option preserves the beneficiary's appeal rights?

  • A. Option 1 — furnish and bill Medicare
  • B. Option 2 — furnish, do not bill Medicare
  • C. Option 3 — do not furnish
  • D. All three

21. Who selects the ABN option?

  • A. The practice
  • B. The beneficiary
  • C. The physician
  • D. The payer

22. For a statutorily excluded service:

  • A. An ABN is required
  • B. No ABN is required; report GY, and GX if a voluntary notice was given
  • C. Report GZ
  • D. The patient may not be billed

23. A defective ABN is worse than no ABN because:

  • A. It carries a penalty
  • B. The practice reports GA, asserting a valid notice that is not valid, and bills on paper that shifts nothing
  • C. It voids the claim
  • D. It requires a refund with interest

24. A prior authorization:

  • A. Guarantees payment
  • B. Confirms medical necessity criteria as presented, but not eligibility, benefits, or that the service matched
  • C. Is required for all services
  • D. Replaces the need for documentation

25. Account 10-5502's MRI denial. The claim was:

  • A. Coded wrong
  • B. Never going to be covered on that record
  • C. Denied in error
  • D. Missing a modifier

26. Imaging obtained after March 14 supports M17.11. M25.561 on March 14 was:

  • A. Wrong and should be corrected
  • B. Correct; a diagnosis established later does not reach backward
  • C. Correct only if the payer agrees
  • D. Correct only for the professional claim