Chapter 35 — Exercises

How to use these. Sections B through G are one specialty each, and each contains at least one "code this chart" task built from constructed documentation. Work them in any order — but do Section A first and Section J last, because the intake in A and the method in J are what make the middle six transferable rather than memorized. Items marked † have worked solutions in the answers appendix. No answers appear in this file.

All accounts, notes, records, fees, base units, conversion factors, and criteria sheets in these exercises are constructed teaching material. Every real-world value expires: ICD-10-CM changes each October 1, CPT each January 1, HCPCS Level II and the NCCI edits quarterly, and payer policy continuously. Verify everything at the source before it touches a real claim.

Section A — What specialty coding actually is (items 1–3)

A.1 In one sentence each, name the five things that are genuinely specialty-specific (§35.1), and state which one of the five produces errors on every claim rather than on one.

A.2 † You are starting Monday in a specialty you have never coded. Write the five-question intake as you would actually answer it — not the questions, the answers you would go looking for — for anesthesia, and name the document or report you would obtain to answer each.

A.3 A colleague says: "Specialty coding is a different skill set; nothing from the general work transfers." Give the two-part response: what does transfer (name at least five things, with chapters), and what specifically does not.

Section B — Cardiology (items 4–8)

B.4 State what decides among the three electrocardiogram codes — the global service, the interpretation and report only, and the tracing only — and explain why the answer is a fact about a business arrangement rather than about the patient.

B.5 † Code this chart. (Constructed.) A cardiology group owns its office equipment and employs the technician who runs it. A patient presents for a follow-up visit; a twelve-lead tracing is obtained in the office and the cardiologist dictates a signed interpretation with findings and a conclusion, filed in the chart. Which electrocardiogram code applies, and why? Then state what changes if the identical clinical service happens with the tracing produced in a hospital emergency department.

B.6 A practice reads three hundred tracings a month. The cardiologists initial each tracing and write a two-word impression on it; no separate dictated interpretation exists. What is the coding consequence, which two earlier chapters established the same principle for other services, and what is the fix?

B.7 † Code this chart. (Constructed catheterization report, condensed.) "Right femoral arterial access. Catheter advanced retrograde across the aortic valve; left ventricular pressures recorded. Selective coronary angiography performed of the left main, left anterior descending, circumflex, and right coronary arteries with cine acquisition. Findings dictated vessel by vessel. No intervention. Plan: medical therapy, office follow-up in four weeks." Give the code, name the three component services a coder might be tempted to report separately, and state the authority that says not to.

B.8 93306 describes a complete transthoracic echocardiogram with spectral and color flow Doppler. A report documents a study that examined three of the required elements and stops. State the two possible situations behind that report, the correct action in each, and which chapter owns the mechanism for resolving the second.

Section C — Orthopedics (items 9–13)

C.9 State the fracture-care fork in two sentences (Chapter 17 §17.7), then state what §35.3 adds: which part of the note decides it, and who makes the decision.

C.10 † Code this chart. (Constructed office note, plan section only.) Two patients, one afternoon. Note A: "Nondisplaced fifth metatarsal fracture, acceptable alignment. Post-op shoe dispensed. Will follow in this office at 2 and 6 weeks with repeat films; anticipate 6–8 weeks." Note B: "Comminuted, displaced. Splinted for comfort. Patient will be seen by the orthopedic group near her home; records and images released. No follow-up here." For each: which side of the fork, which global period, whether the immobilization application is separately reportable, whether the supply is, and what — if anything — you must still query before selecting a code.

C.11 Build the modifier table from memory and then check it: for a patient inside a 090-day global period, name the modifier for (a) an unrelated E/M service, (b) a planned staged return to the operating room, (c) an unplanned return for a related complication, and (d) an unrelated procedure by the same physician — and state which one restarts the global period and which one does not.

C.12 † Audit this claim. A practice's system appends modifier 24 to every evaluation and management service that falls inside a global period. Last quarter it produced 214 such claims and all 214 paid. (a) Explain why the payment rate is not evidence of correctness. (b) Name what each of those claims asserts. (c) Name the earlier instances of this same mechanism in this book. (d) Describe the control — one report, one reviewer — that would catch it, and say what makes it a control rather than a report.

C.13 Name three places an orthopedic practice routinely leaves money on the table, with the chapter and section that governs each, and state for each whether the error is a coding error or a charge-capture error.

Section D — Obstetrics and gynecology (items 14–17)

D.14 State what 59400 and 59510 each include. Then list six categories of service that fall outside the package, and mark which one of the six depends on a word only a provider may write.

D.15 † Work this episode. (Constructed.) A practice provides antepartum care from 9 weeks. At 31 weeks the patient relocates and delivers with another group. (a) What does your practice report? (b) What does it not report? (c) Name the single piece of information the claim depends on, who should have been recording it and when, and what happens to accuracy if it is reconstructed from the chart in month nine. (d) Name the one front-end check that should have run more than once during the episode and cite the chapter that owns it.

D.16 A patient in the practice's global obstetric package is seen four times during the pregnancy for a condition the record describes as "elevated blood pressures, monitoring." Explain precisely what must be true before those visits are reportable outside the package, who must make that true, and what a coder may not do to make it true.

D.17 † A well-woman visit includes a preventive examination and, at the patient's mention, the evaluation and management of a new problem with its own assessment and plan. (a) What is reported? (b) What documentation standard governs the second code and which chapter set it? (c) Predict what the patient's explanation of benefits will most likely say, and write the two sentences you would say at check-out to prevent the phone call.

Section E — Pediatrics and preventive services (items 18–22)

E.18 State the two facts that select a preventive medicine service code, and name two things that do not select it. Then state what makes Medicare's treatment of a routine physical different, and which code family carries it.

E.19 † Code this chart. (Constructed.) A 6-year-old new patient presents for a school physical. The note documents a comprehensive age-appropriate history and examination, vision and hearing screening, anticipatory guidance, and immunization status reviewed. Two vaccines are administered by the nurse from practice-purchased stock; the note documents no counseling by the physician. No acute problem is addressed. Give every code on the claim, in order, with your reasoning for each — and state what a coder must confirm outside the medical record before submitting it.

E.20 Explain why a claim carrying a vaccine administration code and no product code may be entirely correct, what fact makes it correct, and what harm a biller does by "fixing" it.

E.21 † Run the numbers. A practice administers 900 doses of a vaccine in a season at a constructed administration allowed amount of \$24.80. An audit finds the administration line missing on 7% of those encounters. Compute what was not billed, show your checks, and then answer the harder question: name every report in an ordinary practice management system on which this loss would appear, and what that tells you about how it must actually be found.

E.22 Transitional care management. Name the three requirements that decide whether 99495 or 99496 may be reported at all, state which of the three is most often missed and why, state what distinguishes the two codes, and explain why the face-to-face visit is not separately reported.

Section F — Emergency medicine (items 23–26)

F.23 State the two structural facts that make 99281–99285 unlike every other E/M family, and explain what the second one removes from the coder's toolkit.

F.24 † Score this chart. (Constructed, using Figure 35.3's criteria sheet.) An emergency department nursing record documents: triage and initial vital signs; three repeat vital sign sets; continuous cardiac monitoring; an intravenous line established; two intravenous medications; specimen collection; and discharge teaching with a follow-up appointment. Using the point values in Figure 35.3, compute the score and assign the facility level. Then state what you can and cannot conclude about the physician's level from your answer.

F.25 A payer's analyst reports that a hospital's emergency department has a "mismatch rate" of 38% between facility and professional visit levels and asks the hospital to explain. Write the response in five sentences: what the two levels measure, who writes each rulebook, what correlation is expected, what the analyst should have asked for instead, and what the hospital should be able to produce.

F.26 † A hospital's facility level distribution is heavily weighted toward levels 4 and 5. (a) Name the two explanations the distribution alone cannot distinguish. (b) Name the document that decides which. (c) State the response that is not appropriate and say precisely why it is worse than doing nothing. (d) Name the earlier chapter whose metric had the identical two-explanation problem.

Section G — Anesthesia (items 27–30)

G.27 Name the source document for an anesthesia claim, and list four facts that live on it and on no other document in the record.

G.28 † Compute the claim. (Constructed; conversion factor \$22.00, 15-minute increments, truncation.) The anesthesia record reads: patient into room 13:20; anesthesia start 13:26; incision 13:44; surgery end 15:01; anesthesia end 15:09; patient out of room 15:14. The anesthesia code carries 9 base units; the patient is P3, which this payer recognizes at 1 additional unit. (a) Compute anesthesia time and the units. (b) Compute the charge. (c) Recompute using room time and state the difference in dollars. (d) Recompute anesthesia time under a round-to-nearest rule and state the difference. (e) Explain, in one sentence each, why (c) and (d) are not the same kind of difference.

G.29 A surgeon performs three procedures under one anesthetic. How many anesthesia codes are reported, which one, and what is the rule?

G.30 † An organization bills medical direction. Name the schedule-level fact that must be true for the arrangement to be permissible, name the documented steps that must have been performed, and state what an auditor would ask to see for a single case. Then state who may assign the physical status modifier and what a coder may never do with it.

Section H — Time-based codes and behavioral health (items 31–33)

H.31 † Name the four time conventions in this book, the chapter that owns each, and the documentation each requires. Then, for each of the following, name the correct convention: an anesthesia case; 22 minutes of therapeutic exercise plus 9 minutes of manual therapy; a 38-minute psychotherapy session; an office visit selected on total time.

H.32 A therapist provides, on one date, 8 minutes of one timed service and 8 minutes of another. State the units under the Medicare methodology, state the answer produced by converting each service separately, and explain in one sentence why the shortcut survives in practices for years before it is found.

H.33 † Audit this documentation. A behavioral health practice's note template carries a session-duration field defaulted to 50 minutes. Over one year, 94% of the practice's notes read "session duration: 50 minutes." (a) Name what each of those notes asserts and who is asserting it. (b) Explain why this is worse than the equivalent error on a claim. (c) Name three remedies, at least one of which is a report the practice can run against two systems it already owns. (d) Name the thread in this book this belongs to and one earlier instance of it.

Section I — Telehealth (items 34–35)

I.34 State what place of service 02 and place of service 10 each mean, explain why two codes exist for what feels like one situation, and state what modifier 95 asserts.

I.35 † A practice has billed telehealth the same way for two years: place of service 11 plus modifier 95, for every payer. (a) Name three distinct things that could be wrong with that. (b) Name the payment mechanism that makes the place of service field consequential, and cite the chapter. (c) Describe the artifact the practice should build instead, including the one field on it that most practices omit.

Section J — The method, judgment, the exam, and the Encounter (items 36–40)

J.36 † Build the plan. You start in an obstetrics and gynecology practice in ten days. Write the two-week plan as a dated list of tasks with a named deliverable for each — the four things you obtain beforehand, the artifacts you build in week one, the work of week two — and state, honestly, the three things the two weeks will not have bought you.

J.37 The judgment item. A practice's physician-owner tells you that the specialty society's coding guidance says a service is separately reportable, while the largest commercial payer's published medical policy says it is not. State what governs the claim you are about to submit, what the society's guidance is genuinely useful for, and what you would do next — in order, naming at least two chapters.

J.38 Certification-style. A cardiologist reviews and dictates a signed interpretation of an electrocardiogram tracing performed on hospital equipment in the hospital's emergency department. The cardiology group owns no equipment there. Which is reported by the group? (A) 93000 · (B) 93010 · (C) 93000 with modifier 26 · (D) nothing; the hospital bills the service. Choose, and say in one sentence each why the other three fail.

J.39 Certification-style. A physician reports a global fracture care code for a closed distal radius fracture. Eighteen days later the patient returns for an unrelated evaluation of a rash. Which modifier, if any, belongs on the evaluation and management service, and what does it assert? (A) none; the visit is inside the global period · (B) modifier 24 · (C) modifier 58 · (D) modifier 79. Choose and defend in two sentences.

J.40 † The Encounter extension. Take this chapter's counterfactual — Account 10-4471's patient referred to an orthopedic practice on March 14 rather than seen at Northgate — and write the coder's summary for the orthopedic claim: the E/M category and why it differs, what the modifier 25 argument would have to be built from and why it is weaker, which procedure code applies and what single clause in the note decides it, which diagnosis code is supportable on that date and what makes the answer different from the real file's, and which line on the real claim disappears entirely. Then state, in two sentences, why this chapter deliberately prices none of it.