Chapter 34 — Exercises
How to use these. Sections B and C are the reasoning core — status indicators and packaging — and they are where outpatient facility coders are actually made; drill them until you can predict a claim's fate line by line before you look at the remittance. Section D is arithmetic and should be drilled until weight × conversion factor and the discounting rule are automatic. Items marked † have worked solutions in the answers appendix. No answers appear in this file.
Every rate, weight, conversion factor, status-indicator assignment, and payment percentage in these exercises is a constructed teaching figure. The real ones live in the current year's Outpatient Prospective Payment System (OPPS) addenda and final rule and change every January 1; the Outpatient Code Editor (OCE) and the National Correct Coding Initiative edits change quarterly; ICD-10-CM changes October 1 and CPT® January 1. Verify every real-world value at the source before it touches a claim.
Section A — Neither one thing nor the other (items 1–4)
A.1 In one sentence each: what is the unit of payment under OPPS, under the Medicare Physician Fee Schedule (Chapter 23), and under the Inpatient Prospective Payment System (Chapter 33)? Then state which of the three systems lets the diagnosis codes set the price, and what the diagnosis codes do on the other two.
A.2 † An outpatient facility claim carries a \$318.00 medical/surgical supply line that everyone in the building knows will allow \$0.00. Give the two independent reasons the charge belongs on the claim anyway — one prospective, one internal — and name the chapter that made the same argument about charges on an inpatient claim.
A.3 Name three categories of service a hospital outpatient department furnishes that OPPS does not price, and give the single status indicator that announces "right building, different machine."
A.4 State the type of bill that carries a hospital outpatient claim, and name the two code fields that must both be present and consistent on a line before OPPS can price it. Which of the two maps to the ambulatory payment classification (APC)?
Section B — Status indicators and APCs (items 5–10)
B.5 † Status-indicator reasoning drill I. A hospital outpatient claim carries six lines. For each indicator below, state (a) whether the line is paid separately under OPPS, packaged, paid under a different system, or not payable in this setting; and (b) what the biller does with that line when the remittance arrives.
line 1 V clinic or emergency department visit
line 2 T significant procedure, discounting applies
line 3 N unconditionally packaged
line 4 Q1 conditionally packaged
line 5 A paid under a different fee schedule
line 6 C inpatient-only procedure
B.6 Status-indicator reasoning drill II. Claim one carries two status S procedures; claim two carries two status T procedures; everything else about the two claims is identical. State what differs in the payment, name the rule, and state — in words, not dollars — how much of the second procedure's rate survives on each claim.
B.7 A venipuncture and a basic metabolic panel (80048) appear on two claims from the same hospital on the same date. Claim one also carries a surgical procedure; claim two carries nothing else. Explain how the identical two lines can pay differently, name the family of status indicators that produces the result, and state the reading discipline it forces on anyone working an outpatient facility claim.
B.8 † Define the two-times rule in one sentence, and state the visible consequence it has on the structure of the APC system. Then explain precisely what the phrase "a level 4 gastrointestinal endoscopy APC" asserts about 45385 relative to the family's base code, 45378.
B.9 Status indicator C. State what it means, what it does to a surgical episode billed on an outpatient claim, and — precisely — at which desk the failure must be prevented. Explain in one sentence why the coder is the wrong control for this particular error.
B.10 Which single code on an outpatient facility line determines the APC? State what the revenue code contributes and what the diagnosis contributes, and name the chapter and section that first taught the pairing.
Section C — Packaging and the zero-dollar line (items 11–15)
C.11 † Read the facility claim from Chapter 1's emergency department visit [Account 22-7788].
Reproduce its five lines with charges and allowed amounts, foot both columns against the totals, and
then explain to a new biller — in three sentences, without using the word "denial" — why two lines
allowed exactly \$0.00 and the claim still paid.
C.12 A colleague proposes removing the supply and pharmacy charges from future emergency department claims "since they never pay anything and they just inflate the bill the patient sees." Give the two-part response: what it would do to the hospital's future payment rates, and what it would do inside the building.
C.13 A packaged line arrives on a remittance carrying a bundling reason code from the CO-97 family. On Account 10-4471, a code from that same family on the E/M line was worth appealing, and the appeal won. State the one test that tells a biller which situation they are looking at, and name what the test is actually asking about.
C.14 † Name five categories of item or service that OPPS packages. For one of them, state the annually set fact that can flip an individual item from packaged to separately payable — or back — without any change in how the item is used.
C.15 State what the \$318.00 supply line generated in patient responsibility on Account 22-7788, and why. Then state the general principle relating packaging to patient cost-sharing, and one sentence on why it complicates the estimate Chapter 32 §32.2 requires.
Section D — Comprehensive APCs, composites, and the arithmetic (items 16–20)
Use the chapter's constructed OPPS conversion factor of \$85.00 and its constructed labor share of 60% throughout this section. Every figure here is a teaching figure.
D.16 † Compute the payment for a clinic-visit APC with relative weight 1.4000: (a) the unadjusted national payment; (b) the wage-adjusted payment at a wage index of 1.0500, splitting labor and non-labor and showing the check that the two portions sum to the unadjusted amount; (c) the beneficiary's coinsurance and the program's share at 20% of the unadjusted amount, with the check.
D.17 † A hospital outpatient claim carries three status T procedures whose constructed APC rates are \$1,020.00, \$450.00, and \$260.00. Compute the claim's total OPPS payment, state the rule that decides which one pays in full, and then state what the total would have been if all three had carried status S instead. Show every check.
D.18 Modifiers 73 and 74: state the assertion each makes about a discontinued facility procedure, and the payment consequence of each. Then compute both outcomes on a procedure whose constructed APC rate is \$1,020.00. Finally, name the two professional-side modifiers that must not be confused with them and state, in one sentence, why keeping the pairs apart is an audit matter and not just an exam matter.
D.19 † A claim carries a status J1 service, a laboratory test, a low-cost drug, a recovery-room charge, an adjunct procedure, and a surgical pathology technical component. State what pays, what packages, and what a complexity adjustment is. Then name the one service associated with this encounter that is not on this claim at all, and say which claim carries it.
D.20 Composite APC versus comprehensive APC: state the unit of payment each uses in a single phrase, give the classic composite example, and name the status indicator that marks a composite member.
Section E — The Outpatient Code Editor, and working what comes back (items 21–24)
E.21 State the Outpatient Code Editor's two jobs, its update cycle, and the one thing it never does. Then name the inpatient-side counterpart from Chapter 33 that fails in exactly the same way for exactly the same reason.
E.22 † Work this remittance. Three lines on a Medicare outpatient facility account show zero
payment [constructed teaching example]:
(a) rev 0270 med/surg supplies charge 402.00 allowed 0.00
remark: benefit included in the payment for another service
(b) rev 0320 radiology 73090 4 units, charge 700.00, allowed 0.00
line item denial — units exceed the medically unlikely edit value
(c) the entire claim, returned to provider by an editor edit,
no adjudication, no payment, no reason code on any line
For each: state the correct disposition — appeal, correct and resubmit, or post and move on — say which of the three carries appeal rights, and say which one is quietly running out of calendar and why. Then, for the one that carries appeal rights, outline the two-paragraph argument you would make if the documentation supports it, and state what you would do instead if it does not.
E.23 † Audit this claim. A hospital outpatient facility claim, Medicare, one date of service
[constructed teaching example — this is not Account 22-7788]:
TOB 131
FL 42 REV DESCRIPTION FL 44 HCPCS UNITS CHARGE
0450 Emergency room 99284 1 2,610.00
0270 Med/surg supplies — 1 402.00
0300 Laboratory 80048 1 243.00
0320 Radiology — diagnostic 73090 4 700.00
0636 Drugs requiring detailed coding — 1 118.00
0001 TOTAL 4,073.00
FL 67 first-listed: a symptom code; no additional diagnoses reported
Find every defect. For each, state whether it will be caught by the Outpatient Code Editor, by the payer after adjudication, or by nobody at all — and for the one nobody catches, name what an auditor would have to ask for. Then name the one line on this claim that looks like a defect and is not.
E.24 Why is a claim returned to provider more dangerous to a work queue than a denial is? Answer in terms of the calendar, and name the chapter and section that has held this distinction since Part V.
Section F — Two claims, one encounter (items 25–27)
F.25 The same emergency department visit produces 99284 on the facility claim and 99284 on the professional claim. State what each of the two codes levels, who writes the rules for each, and the one thing an auditor should ask to see on the facility side. Then state what a payer analyst comparing the two levels for "mismatch" has misunderstood.
F.26 † G0463. State what it is, why Medicare created it, what the physician reports for the same clinic visit, and what the arrangement tells you about the relationship between CPT's vocabulary and Medicare's payment policy — naming the chapter and section that taught that relationship.
F.27 Write the patient explanation. A patient calls about two statements that arrived eleven days apart for one afternoon in a hospital outpatient clinic: one from the hospital, one from the physician group. She believes she has been billed twice for the same visit. Write the explanation you would give on the phone — four to six sentences, no jargon, no defensiveness — that (a) tells her what each statement is for, (b) tells her honestly that the arrangement costs her more than the same service in an independent office would have, and (c) tells her what you can do for her next.
Section G — The ambulatory surgery center and the three-site problem (items 28–30)
G.28 † Three sites, one procedure. Using the chapter's constructed figures — a level 4 gastrointestinal endoscopy APC relative weight of 12.0000, a hospital outpatient conversion factor of \$85.00, and an ambulatory surgery center (ASC) conversion factor of \$42.50 — compute the facility payment at each of the two facility sites and the beneficiary's coinsurance at each at 20%. State the difference to the patient and show the check. Then name the third site, state what facility claim it generates, and state in one sentence what the patient can see of any of this from the waiting room.
G.29 Which claim format does an ASC use to bill Medicare for its facility fee, and which format do many commercial payers want instead? Name the place-of-service code and the type of bill involved, and state what happens to a biller who assumes either format is universal.
G.30 Name two structural adjustments built into the ASC payment system, and state in one sentence each what problem each one solves. Then state what the ASC payment generally includes and the one thing it never includes.
Section H — The payment window and condition code 44 (items 31–33)
H.31 † The three-day payment window's mechanics, in full: how far back it reaches and from what starting point; the different window for hospitals excluded from the Inpatient Prospective Payment System; which entities beyond the admitting hospital it covers; the two classes of service and the different test that applies to each; the condition code that carries the attestation; and what happens operationally to an outpatient claim that has already gone out.
H.32 List condition code 44's four requirements in the order they must occur, name who must participate in each, and state what the hospital's remaining path is when the status problem is discovered after the patient has been discharged. Then state, in one sentence, why utilization review works concurrently rather than retrospectively.
H.33 A physician practice wholly owned by the admitting hospital furnishes a related service inside the window. Name the modifier that goes on the professional claim, state what it does to that claim's payment and to the technical resources, and then explain why this failure is a corporate-structure problem applied by billing software rather than a coding problem — naming the chapter whose Case Study 2 is built on the same clause.
Section I — Account 22-9107 and the converted screening (items 34–36)
I.34 Code this chart. [constructed teaching example]
"Screening colonoscopy. Medicare beneficiary, 68, asymptomatic. History of an
adenomatous polyp removed on a prior examination; the patient is on a shortened
surveillance interval on that basis. Colonoscope advanced to the cecum; prep
adequate. No polyps or masses identified. Normal examination."
(a) Which HCPCS Level II screening code does this encounter anticipate, and why not the other one? (b) What is first-listed, and what additional diagnosis establishes the shortened interval? (Where this book names no specific code, give the category and say why that is the correct answer rather than a hedge.) (c) Now change one fact: a 7 mm polyp is found in the sigmoid colon and removed by snare. State every code and modifier that changes, and every one that does not. (d) Finally: if the polyp had been in the transverse colon instead, state what changes about the code you look up — and what does not change about anything else.
I.35 † Complete the claim. Build Account 22-9107's facility claim, field by field: the type of bill in FL 4; each service line's revenue code (FL 42), HCPCS code and modifier (FL 44), and charge (FL 47); the first-listed diagnosis and the additional diagnosis in FL 67 as they stand at the time of service; and the change that the pathology report makes to the final coded record. Then mark every line that you expect to allow \$0.00, and state in one sentence why you expect it.
I.36 † Using the chapter's constructed facility payment rate of \$1,020.00 for the converted screening: compute the beneficiary's share and the program's share at the historic 20%, then at the chapter's illustrative phase-down percentage of 15%, showing both checks. State what the step is worth to this patient, state what happens to her deductible in both cases, and name the single thing a biller must verify before quoting any of these numbers to anybody.
Section J — Judgment, the exam, and the Encounter (items 37–40)
J.37 The ethics dilemma. After a screening colonoscopy converts to a snare polypectomy, a scheduler asks the coding supervisor to "just bill the G-code, so she still gets her free screening — she only came in because we told her it was free, and it isn't her fault the doctor found something." Identify (a) what is genuinely sympathetic in the request, (b) exactly what would be false about the resulting claim, (c) the mechanism the payment system actually provides for the problem the scheduler is trying to solve, and (d) the two sentences you say back. Then state what you would put in writing, and to whom, if the request came from someone senior to you.
J.38 Certification-style. A hospital outpatient claim carries a clinic visit, a drug whose per-day cost sits well below the annual packaging threshold, a surgical supply, and one surgical procedure. Which line or lines will generate beneficiary coinsurance? (A) all four · (B) the visit and the procedure only · (C) the procedure only · (D) all four, because every line carries a charge. Choose, and say in one sentence each why the other three fail.
J.39 † Certification-style. Which of the following is true of a claim returned to provider by the Outpatient Code Editor? (A) it is a denial with appeal rights at the first level · (B) it was adjudicated and may be appealed only after correction · (C) it was never adjudicated, has no appeal rights, and must be corrected and resubmitted · (D) it stops the timely filing clock until the correction is made. Choose and defend in two sentences, then state which of the wrong answers is the most expensive one to believe and why.
J.40 † The Encounter extension. Take this chapter's checkpoint — Account 10-4471's March 14 visit furnished in a hospital outpatient department under the Chapter 26 §26.9 counterfactual — and write the facility coder's line-by-line prediction: for the visit, the injection, the drug, and the venipuncture, name the status-indicator family each line meets, state whether it pays separately or packages, and state which lines can generate patient coinsurance and which cannot. Then state what the Medicare version of the visit line would be instead, and name the three different cost-sharing arithmetics this book has now applied to the same injection in the same room. Finally, state in two sentences why this checkpoint cannot price the claim from any published rate table.