Chapter 40 — Quiz

25 questions: multiple choice and short answer. The answer key is in the collapsed block at the bottom.

A note on this quiz. Roughly a third of it is arithmetic, and every one of those items can be answered exactly — if you set the calculation up correctly. The distractors on those items are the answers you reach by making one specific, nameable mistake: multiplying where you should divide, using the charge instead of the allowed amount, or putting the overturn rate in the wrong place. The key names the mistake behind each wrong answer, because on this material knowing why a wrong answer was attractive is the whole skill.

⚠️ Every dollar figure here is constructed. \$36.00 per hour, 58 minutes, 68%, and everything derived from them belong to Northgate Family Medicine, a teaching example. No item asserts a salary, a job-growth figure, or a survey result, because this book publishes none.

1. Account 10-4471's denial was worked across three touches totaling 58 minutes. At a fully loaded labor cost of \$36.00 per hour, the cost of working that denial to an overturn was:

• A. \$20.88
• B. \$34.80
• C. \$58.00
• D. \$104.40

2. The amount at issue on the denied line — the figure the appeal could recover — was:

• A. \$185.00
• B. \$150.72
• C. \$128.40
• D. \$98.40

3. The reason the answer to question 2 is not \$185.00 is that:

• A. The practice discounted the charge
• B. The payer priced the line with CO-45 before removing the allowed amount with CO-97, so the charge was never recoverable
• C. The patient's copay reduced the recoverable amount
• D. Modifier 25 caps the recoverable amount at the allowed rate

4. Net recovery on Account 10-4471's appeal — the allowed amount restored, less the labor that restored it — was:

• A. \$93.60
• B. \$128.40
• C. \$63.60
• D. \$150.72

5. Northgate's measured appeal overturn rate is 68%, derived from:

• A. 68 of 100 appeals filed
• B. 57 of 84 appeals decided
• C. 185 of 267 denials preventable
• D. 267 of 4,180 lines adjudicated

6. The break-even allowed amount is computed as the labor cost divided by the overturn rate rather than multiplied by it, because:

• A. Division always produces a more conservative figure
• B. You pay the labor on every appeal you write and collect on only some of them, so the amount at issue must be large enough that its expected value covers the certain cost
• C. The overturn rate is a percentage and percentages are always denominators
• D. The payer pays 68% of the allowed amount on a successful appeal

7. Using \$34.80 and 68%, the break-even allowed amount is:

• A. \$23.66
• B. \$34.80
• C. \$51.18
• D. \$76.76

8. A practice's loaded rate is \$48.00 per hour, its median denial in a category takes 25 minutes, and its overturn rate in that category is 40%. Its break-even allowed amount in that category is:

• A. \$8.00
• B. \$20.00
• C. \$50.00
• D. \$120.00

9. Sorted by the allowed amount on the denied line, the share of Northgate's 267 denied lines falling below the break-even was 41% — and those lines carried about a tenth of the money. The correct reading of that pair of figures is:

• A. The practice should appeal all of them, because they are numerous
• B. The practice should appeal none of its denials, because most are small
• C. A large share of the denial count represents a small share of the denial dollars, so individually appealing them is expensive relative to what it returns
• D. The denial log was constructed incorrectly

10. The 41% figure should be treated by a reader as:

• A. An industry benchmark to compare their own practice against
• B. A property of one constructed denial log, from which the method generalizes and the number does not
• C. The threshold below which appeals are prohibited
• D. A figure published by the credentialing organizations

11. Short answer. State the chapter's conclusion in two clauses — what was true of Account 10-4471's appeal, and what is not the general rule — and then say in one sentence what must happen to the denials that fall below the break-even.

12. A denied line falls below a practice's written break-even. The line carried group code CO. The practice may:

• A. Bill the patient for the amount
• B. Decline to appeal, classify the denial, and adjust it with a code identifying it as preventable
• C. Adjust it as a contractual adjustment so the denial report stays clean
• D. Leave it open until timely filing expires and then write it off

13. Working a small denial reveals that the practice was paid for something it cannot support. The break-even threshold:

• A. Permits the practice to disregard it, as the amount is immaterial
• B. Governs the appeal decision only and has no authority over an identified overpayment or the sixty-day clock
• C. Extends the reporting deadline proportionally
• D. Applies once the amount exceeds the threshold

14. Q4 — could Account 10-4471's denial have been prevented? — is answered:

• A. No; the edit was the payer's and nothing in the practice could have stopped it
• B. Yes; a template prompt on procedure-day notes and a scrubber edit that stops the pairing and asks a question, built once for roughly \$102.00 of staff time and costing nothing per claim afterward
• C. Yes; the coder should have omitted modifier 25
• D. Only by declining to bill the office visit

15. The single most important limit on the prevention answer is that:

• A. Templates are prohibited in clinical records
• B. The edit belongs to the payer and fires on the claim, so the practice can reliably prevent the cost of the denial and only make the denial itself less likely
• C. Scrubber edits cannot evaluate modifiers
• D. Prevention always costs more than recovery

16. A scrubber rule that recognizes the 99214-25 + 20610 pairing and appends modifier 25 automatically would be:

• A. Efficient prevention, since the modifier is supported on this file
• B. An assertion nobody chose about a record nobody read — the same failure mechanism this book has documented roughly a dozen times
• C. Acceptable if a coder reviews it monthly
• D. Required by the National Correct Coding Initiative modifier indicator

17. Short answer. Chapter 37 §37.3 established that a quality standard of "95%" that does not say which measure it means is not a standard. Name the two measures whose difference matters most to an individual coder, and state which of the two is the harder number to hit on identical work.

18. A production standard of twelve charts per hour, applied to an eight-hour day, most often fails because:

• A. Twelve charts per hour is unattainable in any setting
• B. It is derived from chart time only, and silently deletes the scrubber flags, the biller's questions, the self-audit, and the update reading
• C. Charts vary in length
• D. It does not account for meal breaks

19. When a coder falls behind against a production standard, the work that gets compressed first is:

• A. The routine four-minute charts
• B. The lookups and the queries — which is precisely where accuracy is made
• C. The self-audit sample
• D. Payment posting

20. Chapter 39 §39.10 owns the apprentice designation. Chapter 40 §40.4 owns:

• A. The continuing education requirement
• B. The job search — the artifact to bring, the adjacent roles, and how to be seen
• C. The exam content outline
• D. The code book annotation rules

21. §40.4's central hiring argument is that a candidate without experience should bring:

• A. A longer résumé
• B. An artifact — a complete claim file they can walk somebody through — rather than a claim about themselves
• C. References from instructors
• D. A list of credentials in progress

22. In an outsourced or offshore coding arrangement, the obligation that never transfers to the vendor is:

• A. Meeting the turnaround standard
• B. The certification on the claim, and the duty to report and return an identified overpayment
• C. Maintaining the encoder license
• D. Continuing education for the vendor's coders

23. Short answer. §40.9 says to specialize in a body of knowledge and never in a configuration. Explain the distinction, and give one example of each from anywhere in this book.

24. The reading habit §40.10 prescribes — one primary source a month, read at the source — is argued to compound primarily because:

• A. You will memorize the annual changes
• B. It earns continuing education units
• C. You become one of very few people in any building who has read the primary document, in a field where most people work from a summary of a summary
• D. It is required to maintain a credential

25. Short answer. Name the update schedule for ICD-10-CM, CPT, HCPCS Level II, and the National Correct Coding Initiative edits, and then state the single instruction this book gives about coding from a textbook — including this one.