Chapter 34 — Quiz

26 questions: multiple choice and short answer, in the style of the Certified Outpatient Coder (COC) and Certified Coding Specialist (CCS) exams where the material is exam-relevant. The answer key is in the collapsed block at the bottom. All dollar figures, weights, conversion factors, and status-indicator assignments are this book's constructed teaching figures; the real ones are in the current year's OPPS addenda and final rule and change every January 1.

1. The Outpatient Prospective Payment System went live on:

  • A. October 1, 1983
  • B. August 1, 2000
  • C. October 1, 2007
  • D. October 1, 2015

2. Under OPPS, the unit of payment is:

  • A. The encounter
  • B. The stay
  • C. The service, grouped to an ambulatory payment classification
  • D. The revenue code

3. On an outpatient facility claim line, the code that maps to the APC is:

  • A. The revenue code
  • B. The HCPCS code
  • C. The first-listed diagnosis
  • D. The type of bill

4. An outpatient claim carries a separately payable clinic visit, a separately payable joint injection, and a separately payable X-ray on the same date. The number of APC payments this claim can produce is:

  • A. One — the encounter groups once
  • B. One — the highest-weighted service absorbs the rest
  • C. Up to three — one per separately payable service
  • D. None — outpatient claims are paid per diem

5. Status indicator N means the line is:

  • A. Denied for medical necessity
  • B. Not covered by Medicare in any setting
  • C. Unconditionally packaged — never separately payable on its own line
  • D. Paid under the clinical laboratory fee schedule

6. Status indicator Q1 means the line is:

  • A. Always packaged
  • B. Packaged when billed with an S, T, or V service on the same date, and otherwise separately payable
  • C. Paid through a composite APC
  • D. Returned to the provider

7. A procedure carrying status indicator C appears on a hospital outpatient claim. The result is:

  • A. The procedure is paid at a reduced rate
  • B. The procedure is repriced to the ASC rate
  • C. The procedure is not paid under OPPS in any amount, and as a rule the surgical episode's payment fails with it
  • D. The claim is paid and the patient is retroactively admitted

8. Status indicator A on an outpatient hospital line means:

  • A. The service is not payable
  • B. The hospital furnished the service, but a payment system other than OPPS prices it
  • C. The service is an add-on
  • D. The service requires an Advance Beneficiary Notice

9. A comprehensive APC — status indicator J1 — makes one payment for:

  • A. The primary service only
  • B. The primary service and every other service furnished that calendar year
  • C. The designated primary service and virtually everything else on the same claim, with narrow excepted categories
  • D. Two imaging studies of the same family on the same date

10. Status indicator J2 wraps a single comprehensive payment around:

  • A. Brachytherapy sources
  • B. A qualifying observation encounter
  • C. Pass-through devices
  • D. Any claim with more than five lines

11. On a claim with two status T procedures, OPPS pays:

  • A. Both in full
  • B. The highest-rated in full and the second at 50%
  • C. The first billed in full and the second at 50%
  • D. Both at 50%

12. Status S procedures differ from status T procedures in that status S procedures:

  • A. Are always packaged
  • B. Are exempt from multiple-procedure discounting
  • C. Are paid under the physician fee schedule
  • D. May not appear with a visit code

13. At a constructed conversion factor of \$85.00, an APC with relative weight 1.4000 pays, before any wage adjustment:

  • A. \$85.00
  • B. \$119.00
  • C. \$122.57
  • D. \$140.00

14. A claim carries two status T procedures with constructed APC rates of \$1,020.00 and \$450.00. The claim's total OPPS payment is:

  • A. \$1,470.00
  • B. \$1,245.00
  • C. \$1,020.00
  • D. \$735.00

15. A facility procedure discontinued after the patient received anesthesia is reported with modifier 74 and pays:

  • A. Nothing
  • B. 50% of the APC rate
  • C. The full APC rate
  • D. The ASC rate

16. Short answer: name the two OPPS addenda a coder uses to look up a status indicator, and say what each one contains.

17. The Outpatient Code Editor updates:

  • A. Annually, with the OPPS final rule
  • B. Quarterly
  • C. Every October 1
  • D. Continuously

18. A Medicare outpatient claim is returned to provider by an OCE edit. This means:

  • A. The claim was denied and may be appealed
  • B. The claim was never adjudicated; there is nothing to appeal, and it must be corrected and resubmitted
  • C. The claim was suspended for contractor review
  • D. The timely filing clock has stopped

19. Short answer: state the two jobs the Outpatient Code Editor performs on every outpatient facility claim.

20. The facility's 99284 on an emergency department claim is leveled by:

  • A. The national medical decision making rules
  • B. Total time on the date of the encounter
  • C. The hospital's own internal criteria, applied consistently
  • D. The physician's documentation of the professional service

21. For a Medicare hospital outpatient clinic visit, the facility reports:

  • A. 99202–99215, leveled the same way as the physician's claim
  • B. G0463, one flat code for a clinic visit of any level
  • C. No visit code at all
  • D. A revenue code only, with no HCPCS code

22. For Medicare, an ambulatory surgery center bills its facility fee on:

  • A. A UB-04, type of bill 131
  • B. A UB-04, type of bill 831
  • C. A CMS-1500/837P, place of service 24
  • D. A CMS-1500/837P, place of service 22

23. Under the three-day payment window, diagnostic outpatient services furnished by the admitting hospital in the window are:

  • A. Bundled into the inpatient claim, with no relatedness test
  • B. Bundled only if the hospital attests that they are related
  • C. Billed separately under OPPS
  • D. Bundled only when furnished by the hospital itself and never by an owned entity

24. Short answer: a hospital wants to bill a non-diagnostic outpatient service furnished in the window separately from the admission. What must it do, what code carries the assertion, and what must stand behind it?

25. Short answer: list condition code 44's four requirements.

26. On Account 22-9107 — the Medicare beneficiary's screening colonoscopy during which a 7 mm sigmoid polyp was snared — the procedure reported is:

  • A. G0121, because the encounter was scheduled as a screening
  • B. 45378, because the scope reached the cecum
  • C. 45385 with modifier PT
  • D. 45385 with no modifier, because the deductible is waived automatically
Answer key 1. **B** — August 1, 2000, under the Balanced Budget Act of 1997's mandate. 2. **C** — the service, mapped through its HCPCS code to an APC. Contrast the DRG (the stay) and the fee schedule (the service, priced individually rather than grouped). 3. **B** — the HCPCS code. The revenue code categorizes and the diagnosis justifies (Ch. 26 §26.5). 4. **C** — up to three, one per separately payable service. On an inpatient claim the same three services produce no separate payment at all (Ch. 33 §33.4). 5. **C** — unconditionally packaged. It is the most misread letter in the set, and it is not a denial. 6. **B** — conditional packaging: the line's fate is decided by its neighbors, which is why an outpatient facility claim must be read as a whole document. 7. **C** — the inpatient-only list. Not reduced, not repriced: unpayable, and the failure is preventable only at scheduling. 8. **B** — right building, different machine: the clinical laboratory fee schedule, the therapy rules, ambulance, or another schedule, each with its own rules riding along. 9. **C** — the claim, not the line, becomes the unit of payment, with narrow excepted categories per the current rule. 10. **B** — the comprehensive observation APC: a qualifying visit, eight or more hours of observation, and no surgical J1/T service driving the encounter. 11. **B** — the highest-**rated** in full, each additional status T at 50%. The pricer ranks by payment rate, not by billed order or by charge. 12. **B** — exemption from discounting is the entire S-versus-T distinction. 13. **B** — 1.4000 × 85.00 = \$119.00. (\$122.57 is the wage-adjusted figure at index 1.0500, which the question excluded.) 14. **B** — 1,020.00 × 1.00 = 1,020.00; 450.00 × 0.50 = 225.00; total \$1,245.00. Predicting \$1,470.00 produces a wasted underpayment follow-up. 15. **C** — the full rate: the facility's resources were committed. Modifier 73, before anesthesia, pays 50%. 16. **Addendum B** lists every HCPCS code with its status indicator and APC assignment; **Addendum D1** defines the status indicators themselves. Both are published with each year's OPPS final rule, both are free, and both expire every January. 17. **B** — quarterly, in step with the code sets and edit files it enforces. OPPS weights, rates, and packaging rules change annually by rule; the editor turns over four times a year. 18. **B** — a return to provider is a disposition, not a decision. Nothing was adjudicated, so nothing is appealable — and for filing purposes the claim has not been successfully submitted (Ch. 27 §27.7). 19. It **edits** the claim (validity, coding, units, combinations, setting — including the hospital National Correct Coding Initiative edits and the medically unlikely edits) and it **assigns** the status indicator, the APC, and the payment flags that drive the pricer. 20. **C** — CMS has never published national facility E/M leveling criteria; each hospital maintains its own and must apply them consistently, with resource use reasonably related to levels. 21. **B** — G0463, because CMS concluded facility clinic-visit resources did not vary enough by E/M level to price five ways. The physician still reports 99202–99215. 22. **C** — the professional claim format, place of service 24. Many commercial payers instead want the institutional format at type of bill 831; assuming either is universal manufactures rejections. 23. **A** — diagnostic services in the window are always bundled: no relatedness test, no attestation, no exceptions by argument. Non-diagnostic services are *presumed* related. 24. It must **attest the unrelatedness on the claim** using **condition code 51**, and the attestation must be defensible from the record — it is the only thing standing between the claim and the presumption. Applied by configuration rather than by review, it is a false statement repeated at volume. 25. (1) The change is made **before discharge**, while the patient is still a patient; (2) the **inpatient claim has not yet been submitted**; (3) the **utilization review committee, with physician membership, determines** the admission was not medically necessary as an inpatient stay **and the practitioner responsible for the patient's care concurs**, both documented in the record; (4) the **patient is notified**, because the status change changes the patient's benefit picture. 26. **C** — 45385 with modifier PT. G0121 describes a screening that stayed a screening; the moment the snare came out, the service stopped matching its descriptor. Modifier PT keeps the screening benefit's cost-sharing protections attached to the diagnostic code. Commercial plans generally look for modifier 33 instead.