Course Directors
Laxmaiah Manchikanti, MD
Andrea M. Trescot, MD
Hans C. Hansen, MD
Questions & Answers
2
Coding, compliance and Practice Management
Contents
Page
Numbers
1.
Documentation
1-9
2.
Practice Management
9-26
3.
Coding & Billing
26-46
4.
Compliance
46-61
Answers
61- 125
NOTICE
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required. The American Society of
Interventional Pain Physicians (ASIPP), Course Directors and Faculty Members of the Review
Course of this work have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with current standards. However, in view
of the possibility of human error or changes in medical science, neither ASIPP nor the Course
Directors, nor Faculty Members, nor any other party who has been involved in the preparation
of this work warrants that the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or for the results obtained
from use of such information. Readers are encouraged to confirm the information contained
herein with other sources. Please let us know if there are any errors.
ASIPP
1
Coding, compliance and Practice Management
CODING, COMPLIANCE AND
PRACTICE MANAGEMENT
SECTION I: DOCUMENTATION
Directions: Choose the best answer
1.
E. Under the advance nurse practitioner act, nurses are
entitled to payment equal to that of physicians.
4.
Which of the following is a critical component of
evaluation and management services?
A. Time
B. Counseling
C. Medical decision making
D. Coordination of care
E. Nature of presenting problem
Multiple components of proper medical record
documentation DOES NOT include the following:
A. The reason for the patient visit
B. The indication of services provided
C. The location of the services
D. Itemized billing for services
5. Choose the correct statement for History of Present Illness:
E. Plan of action including return appointment
A. For level I service, 4 items are documented
B. For level II service, 4 items are documented
2. A physical therapist assistant (PTA) is working in a
C. For level III service, 4 items are documented
medical pain clinic as an employee of the group practice.
D. For level IV service only 3 items are documented
She is approached by one of the physicians who just
E. For level V service only 3 items are documented
evaluated a Medicare patient and did a peripheral nerve
block. The physician would like the patient to begin 6. What are the requirements for Past, Family, Social History
documentation?
physical therapy immediately to assist with the patient’s
A. Three items for level 1 & 2 office visits
pain management needs. The physician told the PTA
B. Three items for subsequent hospital care, follow-up,
that the patient just finished 12 sessions of rehab at
consultations, subsequent nursing home care
another clinic for a different condition. The PTA tells the
C. None for level 3 office visits
physician that she cannot see the patient today. What is
D. One (1) specific item from EACH of the three categothe reason that the patient cannot be seen today by the
ries for level 3 office visit
PTA?
E. One (1) specific item from EACH of the three categories
A. The patient has to exhaust all interventional medical
for complete comprehensive service
options for pain management first before being seen
by the PTA
B. The patient has not been an active patient of the medi- 7. Multiple functions of a medical record include all EXCEPT:
A. Support “medical necessity”
cal clinic for at least 30 days
B. Reduce medical errors & professional liability exposure
C. The patient has not been evaluated by a physical theraC. Reduce audit exposure
pist
D. Facilitate claims review
D. The patient cannot receive physical therapy on the
E. Facilitate upcoding
same day he sees the physician if both are employed by
the same group practice
8. A physical therapist assistant (PTA) performed a treatment
E. The patient has exceeded the payment cap
with a Medicare beneficiary from 1230 until 1315. The
PTA is an employee of the physician group practice which
3. What level(s) E&M service can a registered nurse (R.N)
also employees a physical therapist (PT). At 1215, the
Perform?
physical therapist left the building to attend a training
A. If the physician is in the office but does not see the
session at the hospital. The physical therapist returned
patient, and the nurse spends a long time with the
to the clinic at 1430. The physician overseeing the care
patient, he/she may report a level 3 service: 99213
of the Medicare beneficiary was in the clinic suite seeing
B. An R.N. may not report any E&M service codes
other patients during the time the Medicare beneficiary
C. The only appropriate level of service for an R.N. to
was being cared for by the physical therapist assistant.
report is 99211
How would the PTA bill for physical therapy services for
D. An R.N. may report whatever level of service he/she
this patient?
provides/documents
ASIPP
2
Coding, compliance and Practice Management
A. The charges would be billed incident to the physician
B. The charges would be billed under the physical therapists Medicare provider number
C. The charges would be billed under the physical therapist assistant’s Medicare provider number
D. The visit would not be billable
E. The charges would be billed under the NP’s provider
number – the NP who referred the patient to rehab
9. Today a PhD psychologist saw Mr. Bradshaw in a follow up
visit at the pain clinic. Mr. Bradshaw was injured at work
about eight months ago and continues to suffer as a result
of the injury. He is having trouble coping with the pain
and changes that have occurred in his life as a result of
his injury. When the focus of treatment for an individual
patient is a result of an underlying medical problem, as
opposed to a mental health problem, the psychologist
should use which one of the following CPT codes:
A. Diagnostic interview (90801).
B. Individual behavioral health intervention (96152).
C. Individual behavioral health assessment (96150).
D. Individual psychotherapy (90806)
E. Therapeutic procedures (97110)
10. What are the documentation requirements for Review of
Systems?
A. Review of one (1) system for problem focused visit
B. Review of two (2) systems for expanded focused visit
C. Review of one (1) system for detailed visit
D. Complete or 10+ systems for comprehensive visit
E. Complete or 10+ systems for detailed visit
11. Four patients are seen for physical therapy for one hour,
simultaneously, as part of a back stabilization group class.
The four patients are performing similar exercises, under
the instruction and direction of one physical therapist.
How would you most appropriately bill for this visit?
A. Each patient would be billed for four units of therapeutic exercise, CPT code 97150.
B. Each patient would be billed for one unit of therapeutic
exercise, CPT code 97110 and a group therapy code,
CPT code 97150
C. Each patient would be billed for one group therapy
code, CPT 97150
D. Each patient would be billed for four units of therapeutic exercise and one group therapy code
E. One patient is billed CPT code 97110 four units. The
other patients are not billed
12. Today the physical therapist saw a Medicare patient for
a 50 minute visit. During that 50 minutes, the PT spent
23 minutes doing exercise instruction (CPT code 97110)
and neuromuscular re-education (CPT code 97112) was
performed for 27 minutes. This visit should be billed as:
A. 97110 x 2 units, 97112 x 3 units
B. 97110 x 1 unit, 97112 x 1 unit
C. 97110 x 1 unit, 97112 x 2 units
D. 97112 x 3 units
E. 97112 x 2 units, 97110 x 2 units
ASIPP
13. What is the primary purpose of the National Correct
Coding Initiative? (NCC)
A. For every third party payer to use in claims processing
B. To control improper coding (unbundling of CPT codes)
that leads to inappropriate payment in Part B claims.
C. To ensure that medical providers adhere to appropriate
coding standards of specialty societies
D. For use by Local Medicare Carriers when paying claims
if they don’t have their own program to identify improper code submission by providers, i.e., bundled
codes
E. To facilitate up coding by physicians to third party
payers other than Medicare to make up for loss of
income.
14. Which of the following tax advantages does an “S”
Corporation provide to the medical practice as compared
to a C Corporation?
A. Investors are able to deduct losses against other income.
B. Provides for automatic tax filing extension.
C. Income is taxed at a lower rate than individual tax
rates.
D. Graduated tax rate.
E. Income is only taxed once.
15. In assigning critical Evaluation and Management (E/M)
codes, three critical components are used. These are
A. History, nature of the presenting problem, time
B. History, examination, counseling
C. History, examination, time
D. History, examination, medical-decision making
E. History, medical-decision making, counseling
16. Medical record functions include all of the following
EXCEPT:
A. Support insurance billing
B. Provide clinical data for education
C. Provide clinical data for research
D. Promote continuity of care among physicians
E. Reduce quality of care
17. In general, all three critical components (history, physical
examination, and medical decision making) for the
Evaluation and Management (E/M) codes in CPT should
be met or exceeded when
A. The patient is established
B. A new patient is seen in the office
C. The patient is given subsequent care in the hospital
D. The patient is seen for a follow-up inpatient consultation
E. The patient is undergoing an interventional procedure
18. How do Local Medicare Contractors that pay claims in
each state make coverage determinations?
A. All coverage determinations are updated and sent to
the Local Contractor by the Centers for Medicare and
Medicaid Services (CMS) once a year.
B. The Medical Director at each carrier reviews statistical
data to determine how much it has paid for each CPT
Coding, compliance and Practice Management
3
procedure code and reduces payments on the most 22. An MSDS is:
frequently paid codes by means of restrictive coverage
A. Mandatory manual of current OSHA affairs
policies
B. A medical waste discharge plan
C. A committee of physician specialists, (Carrier Advisory
C. The materials list of ingredients, and chemical comCommittee (CAC)), in the State participates in the deposition
velopment of Local Coverage Decisions (LCD).
D. Documentation procedures of blood borne pathogens
D. All claims that have a valid CPT code are paid, there are
E. A component of the hazardous waste spill kit.
no exceptions.
E. All interventions without a National coverage policy are 23. An electronic medical record vendor approaches you
considered for coverage
stating that the electronic medical record will increase
productivity, and allow the physician to capture an
19. Do non-Medicare payers allow physicians to report nonelevated evaluation and management code by enhanced
physician services as “incident to” if they meet the same
documentation. The vendor goes on to relate that the
requirements as Medicare?
electronic medical record efficiently documents a higher
A. Yes, all payers recognize the “incident to” billing concode and can increase the practice bottom line. Your
cept
correct response is:
B. The term “incident to” is unique to Medicare and “inciA. Ask the vendor to show you the vendor support for the
dent to” regulations are Medicare regulations.
electronic medical record.
C. Non-Medicare payers do not pay for services unless the
B. Demonstrate an amortization schedule to justify cost
physician is present in the room with the patient durof the unit.
ing the provision of the service
C. Ask for a demonstration of workflow and enhanced
D. None of the above
operational components to justify a higher E/M.
E. All of the above.
D. Ignore the vendor, but ask for a demonstration.
E. Consider the vendor as relating a common sales pitch,
20. A patient who comes to you on a regular basis for
and examine the input output efficiency of the eleccontrolled substance management has been found to be
tronic medical record independently.
doctor shopping. This information was relayed to you
by a reliable pharmacist, stating the patient is known in 24. “Incident To” billing for physician extenders under CMS
the community to divert medications. If you decide to
guidelines Statute S2050 is used to define services of midterminate the relationship, and the patient declares that
level practitioners such as physician assistants and nurse
he is going to sue you for abandonment, he has done it
practitioners. The supervising physician, immediately
before and he will win again. Your next step would be:
available by phone is consulted by the nurse practitioner
A. Negotiate a reasonable termination plan, with a medicaregarding a patient. The electronic medical record will
tion taper and assistance in finding another physician.
support:
B. Immediate termination, irrespective of the threat.
A. 100% of charged capture because the physician is imC. Developing an immediate referral so there is no intermediately available
ruption in treatment.
B. 85% charge capture of the physician’s fee
D. Consider the threat incredulous and avoid confrontaC. Defined by the electronic medical record, if CPT guidetion, informing the patient that 30-days of medication
lines are met, 100% capture defined by complexity,
will be prescribed and then you are done with him.
and medical decision-making.
E. Inform the patient of your policy to continue emerD. The practice is unable to bill for the nurse practitioner’s
gency care for 30-days, and offer detoxification, then
services.
assure continuity, both verbally and in writing.
E. The nurse practitioner may bill under his or her provider number 100% of the fee, irrespective of conver21. Drugs and supplies used “incident to” the physician’s
sation with the physician.
service paid separately or considered bundled into the
CPT code for an injection or nerve block because:
25. An office billing employee reports to the physician that
A. All “incident to” items and services should be individua template has been developed for each of the separate
ally reported and are separately paid by Medicare
providers to expedite billing processing and reporting.
B. All “incident to” items and services are considered paid
The template is compliant, and ensures a Level 3 new,
for in the payment for only one CPT code, nothing
consultative, and return patient, as determined by the
should be separately reported
American Medical Association 1997 CPT guidelines. The
C. “Incident to” only refers to non-physician practitioners
content will be placed in the electronic medical record
and “global” refers to supplies, radiology services and
and accessed by keystroke. The physician’s response is
drugs
to:
D. Drugs and supplies are considered “incident to” costs.
A. Accept the template as an important time conserving
E. If Medicare does not pay “Incident to” items and serelement in the practice.
vices must be collected from the patient.
B. Consider the templates as an important component of
efficiency and compliance.
C. Review the template to determine a true Level 3 report-
ASIPP
4
26.
27.
28.
29.
30.
Coding, compliance and Practice Management
ing, CPT guidelines.
standards, allowing physician’s offices to comply with
D. Discard the template.
federal, state and private reporting requirements.
E. Ask the other members of the tier team to provide input
and favored dialogue to the template.
31. In response to a call from the patient’s spouse informing
the physician that the patient is abusing narcotics
Informed consent
prescribed by the physician, the physician notes in the
A. Is a tool that physicians utilize to avoid litigation, ensurpatient’s medical record that the spouse called to report
ing best outcomes.
such information. The spouse is concerned that her
B. Requires the patient’s family or significant other to be
husband would be extremely upset if he knew she called
aware of physician comments.
with the information. The husband requests a complete
C. Is binding in circumstance such as surgery where other
copy of his records.
procedures must be performed.
A. The physician is permitted to withhold the informaD. A tool for the physician to explain risk complication
tion
options to procedure and review with the patient the
B. The physician must provide entire chart immediately.
risk and reward of procedure.
C. The physician must determine with 100% certainty
E. In any format (implied, oral, written, general) is equivathat, wife will be harmed, to withhold the informalent in meeting criteria required in any situation
tion.
D. The physician is required to provide oral information,
Written consent
but withhold written information.
A. Is considered the same as general consent.
E. The physician may provide this information only after
B. A written consent addresses individual treatment with
spouse’s death
inherent risk and reward.
C. A written consent is always binding, and may be signed 32. For a service to be reasonable and necessary it must be:
by immediate family members.
A. Safe
D. Is the least common type of consent obtained.
B. Experimental
E. A written consent is inferior to implied consent.
C. Investigational
D. Patient can afford to pay
Choose accurate statements about Evidence Based
E. Furnished only in an hospital
Medicine (EBM):
A. EBM emphasizes examination of evidence for clinical 33. When a physician is uncomfortable treating a patient due
research
to religious or sexual nature, it is best to:
B. EBM de-emphasizes systematic collection of clinical
A. Openly discuss with the patient as to why the relationstudies
ship will not continue.
C. EBM does not provide a role for synthesis of evidence
B. Allow for orderly transfer to another physician.
D. EBM emphasizes intuition
C. State to the patient that lifestyle preference will not
E. EBM depends on unsystematic experience
yield a solid patient-physician relationship.
D. Follow specific policy as to types of patients that the
Physicians may bill for ancillary services that are
physician will follow, and define them with the staff.
“incident to” services rendered by non-physician,
E. Avoid charges of discrimination by treating the patient
auxiliary personnel as long as:Choose the answer that
as any other, irrespective of lifestyle or religious activbest completes this sentence.
ity.
A. The service takes place in a physician’s office.
B. The non-physician, auxiliary personnel is an employee 34. Patients with chronic pain who meet criteria for substance
of a physician.
addiction should be:
C. The physician is physically on-site and immediately
A. A.dismissed from the practice
available when the auxiliary practitioner is providing
B. B.deferred from pain treatment until documented
service.
completion of an addiction medicine program
D. The physician is immediately available.
C. C.treated with interventional pain measures, but not
E. Physicians are never permitted to bill for “incident to”
adjuvant opioids
services under the Civil False Claims Act.
D. D.treated simultaneously for addiction and pain, including opioids, if needed to control the pain
The Institute of Medicine defined core features in the
E. E.treated regardless of whether or not the patient is
electronic medical record (EMR) .These include:
compliant with appropriate expectations of use for
A. Patient notification of abnormal laboratory data
opioid pain medications
B. Decision support
C. Alert reminders and practice tools
35. Identify the accurate statement relating to guideline
D. Allowing payer sources to have access to the medical redevelopment methodology.
cord, and payer sources’ attorneys and interested third
A. Expert-opinion methodology is the best as it is a strucparties’ access to the medical record
ture window, time consuming and expensive.
E. Reporting electronic data storage using uniform data
B. Consensus method is the best method as it is unstruc-
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Coding, compliance and Practice Management
5
tured, rapid and inexpensive.
40. Research informed consent may not be obtained?
C. Evidence-based method is structured, time consuming,
A. In person from a competent subject
provides different viewpoints and possibly biased.
B. By telephone only from a legally authorized representative
D. Evidence-based methodology is structured, time conC. In person from a competent subject, who cannot write
suming, expensive, utilizes explicit and reproducible
his full name
methodology.
D. In a language other than English with an approved
E. Expert opinion method, consensus method, and evitranslation.
dence-based method all are equally accepted by insurE. A member of the research team, other than the primary
ance companies.
investigator.
36. Documents specifying patient responsibilities when they 41. In obtaining clinical informed consent how much
are prescribed opioid pain medications should not be
information is considered “adequate”?
characterized as:
A. The currently available literature regarding the specific
A. Contracts
procedure.
B. Covenants
B. The same information that a fellow physician would
C. Informed consent
expect.
D. Patient compliance agreements
C. What this specific patient needs to know and underE. Controlled substance agreements
stand in order to make an informed decision.
D. The top five risks associated with this procedure.
37. Identify key attributes of guidelines:
E. What a reasonable physician would tell her patient.
A. The guidelines should include only clarity, clinical applicability, and clinical flexibility.
42. A pain physician receives a referral from an orthopedic
B. Guidelines only include documentation, reliability and
surgeon who has recently performed back surgery on
reproducibility.
a patient whom the pain physician has never seen. The
C. It is essential to include multiple attributes of guideorthopedic surgeon has done all he can do for this
lines including validity and scheduled review.
particular patient. The pain physician performs the
D. Practice guidelines should be developed only utilizing medirequirements for a level 4 patient encounter, but decides
cal language with a complicated algorithmic approach.
during the encounter that the patient would benefit
E. Clinical guidelines should use general populations
from a lumbar epidural steroid injection. The physician
without definition as scientific and clinical evidence
dictates a report to the referring surgeon and mails it to
does not permit any other approach.
him. This patient encounter should be coded as:
A. 62311 – Bill only the procedure code because the E&M
38. A patient undergoes an intrathecal pump implantation
service is bundled
procedure, and develops a deep tissue infection because
B. 62311 and 99244-25 – Bill the procedure and a level 4
the instrument pack was not sterilized. Negligence
consult. A consult is billable even when treatment is
occurred in the following circumstance?
administered
A. The operating room nurse failed to notify the surgeon
C. 62311 and 99204-25 – Bill both the procedure and a
that the instrument pack was not appropriately sterillevel 4 new patient code. You can’t bill a consult beized.
cause the referring physician has done all he can for
B. The operating surgeon did not verify that the instruthe patient, so he is referring the patient for treatment
ment pack was appropriately sterilized.
and hasn’t requested an opinion.
C. The pump manufacturer failed to obtain a consent for
D. 62311 or 99204-25 – Bill either the procedure or the
the implanted device.
new patient code because you can’t bill both on the
D. The patient’s alienated spouse was not contacted by the
same date of service
physician after the infection was discovered.
E. 62311 or 99244-25 – Bill either the procedure or the
E. The wrong antibiotic was prescribed by the operative
consult code because you can’t bill both on the same
physician.
date of service
39. While waiting to operate, a surgeon asks a physician 43. A physician receives a call to the emergency room at 11:
colleague what the best antibiotic to use for surgical
30 p.m. to see a Medicare patient whom he admits to
implants. The colleague states she always uses Antibiotic
the hospital at 12:30 a.m. The physician performs an
G. The patient is prescribed Antibiotic G by her surgeon
emergency H&P and then documents an inpatient H&P.
and is found to be allergic two days later, but suffers no
These services are coded as follows:
injury. Who is negligent?
A. An inpatient initial hospital care code only
A. The colleague
B. Both an inpatient initial hospital care code and an
B. The surgeon
emergency department visit code
C. The pharmacist
C. An inpatient consult only
D. No one.
D. An outpatient consult only
E. The patient
E. Both an emergency department visit and a subsequent
hospital care code
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6
44. A physician has an NP and a RN in his office. Patient
Smith is an established Medicare patient who is on a
regimen of pain medication every 30 days, and comes
in for medication management. The NP is busy, so the
physician asks the RN to see the patient and advise the
physician whether the meds should be reviewed. The
RN spends 10 minutes with the patient, takes a problem
focused history, writes the assessment and plan, and
performs straightforward medical decision making,
deciding to recommend that the meds be renewed. The
RN comes out of the room, discusses her recommendation
with the physician who steps into the room for a minute
to verify the necessity of the meds. The MD signs the
prescription renewing the meds, signs the chart, and
notes his approval of the plan on the chart. This visit
should be coded as follows:
A. 99211 – a level 1 established patient visit. Even though
the RN spent 10 minutes with the patient, and preformed a problem focused history and straightforward medical decision making - enough to qualify for
a 99212 - a RN visit can never be billed higher than
99211.
B. No visit can be billed because the RN isn’t credentialed
with Medicare, and Medicare limits billable E&M
codes to those mid-level practitioners who are credentialed with Medicare.
C. No visit can be billed because the physician wasn’t in
the room for the entire visit and didn’t take the history.
D. 99212 – a level 2 established patient visit. The documentation requirements for a level 2 established
patient visit were met, i.e., problem focused history
and straightforward medical decision making, and
the physician was in the office when the visit was
conducted; therefore, this visit can be billed incident
to the physician.
E. 99213 - a level 3 established patient visit. Once the physician and nurse became involved, a level 3 is always
warranted.
45. A general surgeon admits a patient to the hospital due to
pain during the advanced stages of cancer. The surgeon
consults with the pain physician as to whether the patient
is a candidate for implantation of a pump. The pain
physician begins the exam, but is interrupted by a call
from the surgeon to supply the pain physician with more
information and to request that pain physician review
the MRI films in the chart and discuss the past 24 hour
hospital course with the nursing staff. The pain physician
spends 30 minutes outside the patient’s room, on the
floor, talking to the surgeon, talking to the nursing staff,
and reviewing the chart. When the physician returns to
the room, he spends 60 minutes in the room providing
counseling regarding prognosis and treatment options,
all of which he appropriately documents in a consult note
placed in the medical chart. The physician also spends 20
minutes doing an H&P, for a total of 110 minutes on the
case, 30 of which are outside the room. The encounter is
appropriately coded as:
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Coding, compliance and Practice Management
A. 99255 – a level 5 inpatient consult because the physician
spent the required 110 minutes for a level 5 inpatient
consult either with the patient and/or on the unit/
floor, and documented that the majority of the visit
was spent counseling the patient regarding treatment
options and prognosis.
B. 99254 – a level 4 inpatient consult because 30 minutes
of the 110 total minutes were not spent face to face
with the patient, but were spent talking to the surgeon,
the nurses, and viewing films on the unit. Since only
80 minutes was spent face to face, one must code a
level 4.
C. 99245 – a level 5 outpatient consult because 30 minutes
were spent out of the room.
D. 99205 – a level 5 outpatient new visit because this was
the first patient encounter with this patient.
E. 99233 – a level 3 subsequent hospital care code, which is
the highest subsequent care code billable, because one
cannot bill a consult based primarily on time. Only
non-consults can be coded based on time.
_____________________________________
Directions: Each question below contains
four suggested responses of which one or
more is correct. Select
A if
1, 2 and 3 are correct
B if
1 and 3 are correct
C if
2 and 4 are correct
D if
4 is correct
E if
All (1, 2, 3 and 4) are correct
_____________________________________
46. What are the documentation guidelines for physical
examination?
1. Level 1 - Problem Focused visit requires a limited exam
of affected body area with documentation of 1-5 elements in one or more area(s)/systems(s)
2. Level 2 - Expanded Problem Focused - Limited visit
requirements include exam of affected body area and
other symptomatic or related organ systems with
documentation of 6 elements in one or more area(s)/
systems.
3. Level 3 - Detailed Extended - Detailed visit requirements include exam of affected body area and other
symptomatic or related organ systems with documentation of at least 2 elements from each of 6 area(s)/
system(s) or at least 12 elements in 2 or more are
4. Level 4 & 5 - Comprehensive visit requirements encompass documentation of at least 18 elements from
at least 9 area(s)/system(s).
7
Coding, compliance and Practice Management
47. What are components of bullet methodology in Evaluation
and Management(E/M) services?
1. History - 8 possible factors
2. ROS - 14 possible factors
3. Exam includes single organ system or multi-system
4. Medical decision making
52. The purpose of documentation is:
1. To record information
2. To communicate information
3. To obtain proper reimbursement
4. To document level of service
53. Choose the accurate statement(s) about physical
examination of a patient with low back and lower
extremity pain of 6 months duration.
1. Physical examination may be conducted either by
choosing general multi-system examination or a
single system examination.
2. A single system examination utilizing psychiatric, respiratory, or skin is sufficient.
3. To cover appropriate physical examination in the above
49. A Medicare beneficiary is seen by his physician on March
patient, the examination should consist of a general
1 and physical therapy is ordered at that time. The patient
multi-system examination or a single system examibegins physical therapy on March 3 and on May 2, at the
nation encompassing musculoskeletal or neurological
patient’s tenth visit, the decision is made by the PT that
systems.
three additional PT visits will be needed. The patient has
4. Single system examination of musculoskeletal system
not seen his physician since March 1 however the original
involves examination of all components in musculoPT plan of care included a treatment frequency and
skeletal system and no other examination is required.
duration of 1 x per week for 12 weeks and the physician
has recertified the therapy plan of care twice. What would 54. What are the components of Medical Decision Making?
prevent this patient from continuing physical 1. He
1. Review of records/investigations
would need a new signed order from his physician before
2. Chronological description of development of patient’s
returning to PT because the original order was more that
symptoms
60 days old.
3. Risk of significant complications, morbidity, mortal2. Medicare limits the number of physical therapy visits
ity
to 10 per episode of care.
4. Insurance coverage
3. The maximum duration for physical therapy services
is 60 days.
55. Components of Physical Examination if the planned
4. He has not seen his physician in the last 60 days.
anesthesia includes intravenous sedation, regional or
general anesthesia should include the following:
50. A clinical psychologist (CP) saw Mr. Johnson today at
1. An assessment of the patient’s mental status
the pain clinic. Mr. Johnson is a Medicare beneficiary.
2. An examination specific to the proposed procedure
The CP did a health assessment which took 45 minutes,
3. Documentation of the results of an auscultatory excalled the patient’s psychiatrist to discuss Mr. Johnson’s
amination of the heart and lungs
current status (15 minutes), interpreted the MMPI report
4.
An assessment and written statement about the
(20 minutes) and spent 45 minutes writing the report
patient’s general health
of the MMPI findings. The CP can be expected to get
reimbursed when billing for:
56. Certification documentation completed by the physical
1. Provision of direct services to patients.
therapist for Medicare beneficiaries receiving PT services
2. The time it takes to interpret the MMPI
must contain the following elements:
3. The time it takes to complete the writing of a report
1. Certification period dates which encompass a thirty
when psychometric testing is performed
day period
4. The length of time it takes to coordinate care with
2. Functional and measurable treatment goals
other healthcare providers
3. Signature of ordering physician, certifying the plan
of care
51. Accurate statements describing interventional procedure
4. Records of previous physical therapy episodes of care
documentation are:
1. Procedural documentation in an office includes only
the procedure and discharge
57. The following statements are some of the functions of a
2. Procedural documentation in an office includes medimedical record.
cal necessity and procedure.
1. A medical record indicates quality of care
3. Documentation for an office procedure requires H & P,
2. Promotes continuity of care among physicians
medical necessity and procedure.
3. Provides clinical data for research
4. Documentation of a procedure in a facility requires H
4. Increases audit exposure and malpractice liability
& P, medical necessity and procedure.
48. The following components of physical therapy visit or
treatment cannot be carried out by a physical therapist
assistant:
1. Ultrasound and electrical stimulation treatment
2. Initial evaluation, examination, diagnosis
3. Daily assessment of patient’s progression toward goals
4. Discharge summary documentation
ASIPP
8
Coding, compliance and Practice Management
58. Multiple types of documentation are as follows:
1. Procedural documentation
2. Discharge
3. Billing and coding
4. Patient payment sources
64. General consent
1. Allows the physician or surgeon to operate in the
patient’s best interest
2. Is utilized in emergency situations
3. Is utilized as family members or designated individuals
when necessary to proceed in the patient’s best inter59. Medical decision making involves multiple components.
est.
The following are involved in medical decision making.
4. Is the same as a written consent
1. Risk of significant complications, morbidity, mortality
65. Components of documentation of a procedure include:
2. Risks associated with presenting problems, diagnostic
1. Preoperative: informed consent, discussion and plan,
procedures, management options
preparation
3. Review of records and investigations
2. Intraoperative: monitoring, preparation, description
4. Comprehensive physical examination
3. Postoperative: monitoring, complications
4. Discharge/Disposition: Status, instructions, return
60. A psychological assessment generally consists of the
appointment
following:
1. Psychometric testing.
66. Principles of development quality clinical policies include
2. Review of the medical record
the following:
3. Diagnostic interview
1. Evidence-based approach
4. Physical exam
2. Standardized criteria for assessing literature
3. Defined process for development
61. Areas of development of the EMR include:
4. Levels of strength of recommendations
1. Data input and development of outcome management
67. An EMR performs the following roles:
2. Document transfer to federal health programs
1. Enhances quality of care
3. Information management of medication interactions,
2. Decreases cost of care
dosing areas, and document management
3. Improves quality of life for providers
4. Portable tools to eliminate redundant systems such as:
4. Increases potential risk of record breach to the pracpagers, cell phones, and telephone systems
tice
62. True statements regarding participation in a clinical or 68. Requirements for informed consent include statements
research study include:
of:
1. To determine whether your patients qualify for the
1. Material risks
study, you may review their medical records with
2. Expected outcome
the help of a drug company researcher, without any
3. Alternative treatments
restrictions under HIPAA.
4. Effects of no treatment
2. It is not necessary to enter into a business associate
agreement with the company performing the research 69. The medical record includes each of the following:
to sign on as an investigator.
1. To be secure and uniquely identify the patient
3. A physician participating in a research study using
2. To be immediately available for patient and physicians
his patients may not contact them to determine their
to review
interest in the project without a business associate
3. Contain completed operative note within 24 hours of
agreement.
the procedure
4. Under HIPAA regulations, a research participant pa4. To explain rationale of procedure for CPT assessment
tient is entitled to see the information before or after
the end of the study based on the research protocol.
70. A patient called to schedule an appointment at your clinic.
He told you that he has Federal Workers’ Compensation
63. When considering an electronic medical record in an
coverage for his area of pain. As a medical provider, you
Ambulatory Surgery Center, the risk-reward benefit
will have to be aware of the following:
favors an electronic environment. An electronic medical
1. You can know what the accepted conditions are for
record would be expected to:
a claim by asking the injured worker. If the worker
1. Increase quality and productivity
does not know, he can contact the Employing Agency
2. Enhance compliance
directly.
3. Improve physician compliance and decrease variability
2. With Federal Workers’ Compensation all services need
in documentation
to be prior authorized
4. Improve reimbursement
3. You need to be enrolled as a provider to treat an injured
federal employee.
4. Authorization may be obtained by any one of the following means: online, by phone, or by fax.
ASIPP
9
Coding, compliance and Practice Management
71. You are asked to consult on a patient who has end-stage
liver disease. The cirrhotic patient has severe pancreatitis,
and legitimate need of medication is met. The primary
care physician asks you to choose a medication for pain
control that will effectively treat pain, and have minimal
risk of toxicity to the patient. Furthermore, the patient
will be in a long-term care facility where the medications
are controlled by others. Choices for consideration
include:
1. Sustained release Morphine Sulfate, with immediate
release Morphine for breakthrough.
2. Timed release Oxycodone with immediate release Oxycodone for breakthrough.
3. Hydromorphone prn.
4. Hydrocodone.
and when this is refused he states that he will report
you to the Medical Board because he will “go through
withdrawal” if not given his medication.Your correct
response is:
1. Discharge the patient and document aggressive behavior.
2. To prescribe Percocet® as legitimate medical need may
be argued
3. Develop a multimodality treatment course emphasizing function and progressive analgesic, initiating with
the milder schedule for drug, such as CIV Darvocet®.
4. Treat the patient as any other with similar presenting
symptoms emphasizing function,and defining clear
legitimate medical need for controlled substances, irrespective of a patient’s demands.
72. Do non-Medicare payers allow separate payment for 75. Physicians may be accused of the following when
supplies such as needles, syringes and/or surgical trays
improperly discharging a patient:
used for nerve blocks and injections when they are
1. Abandonment
performed in the office, place of service (POS) 11?
2. Discrimination
1. Private payers do not allow additional payment for
3. Wrongful Termination
supplies
4. Unethical accommodation
2. Payment for supplies used for nerve blocks and injections is payer specific.
76. The EMR stores information as:
3. Private payers will pay an additional fee for all supplies
1. Text file
used in the office
2. Alphanumeric file
4. Payment for supplies is an issue that should be ad3. A structured database for data retrieval
dressed in the fee schedule section of the contractual
4. HEDON file
agreement.
77. What are the potential pitfalls of clinical guidelines?
73. A physician may choose to exclude a patient from the
1. Geographic bias.
practice, but must be very careful when a protected status
2. Resistance to change.
of patient may emerge. In the case of HIV, discrimination
3. Advocacy bias.
may be alleged unless the physician has made it clear
4. Oversimplification
that there is no discrimination of care, particularly to
a protected status, where the practice chooses not to
treat the individual based solely on preference and not
ECTION
RACTICE
ANAGEMENT
by discrimination. This may be difficult to prove, and
the costly legal pathways to defense are borne on the
physician should even an allegation be made. It may be Directions: Choose the best answer
seen that the patient is actually represented at no cost, on
the basis of discrimination. The physician pays his/her 78. Aged Accounts Receivable report should be run monthly.
The goal is to have 90 days and less balance be greater
own defense. Discrimination laws tend to vary state to
than:
state. The Americans Disability Act (ADA) is broad in its
A. 90%
scope and favors the patient.When confronting a patient
B. 60%
for non-payment of bill, you may consider discharging
C. 80%
the patient if:
D. 95%
1. A formal process in writing warns the patient of disE. 50%
charge
2. The patient has not made an effort to pay
3. The patient is not protected from financial crisis such 79. Which of the following are guidelines for good
evaluations?
as bankruptcy
A. Be familiar with company policies and procedures.
4. The patient has refused all attempts to pay
B. Avoid generalities, ambiguities, and sarcasm.
C. Make the time necessary to compose the evaluation.
74. The 28-year-old male is sent to your office for evaluation
Avoid poor English and typographical errors.
and management of pain. The MRI reveals modest
D. Ensure that there are no surprises, by providing the
facet disease in the cervical spine, and the exam
employee with effective feedback during the entire
is unremarkable. His complaints are intractable
evaluation period
paracervical and suprascapular pain interfering with his
E. All of the above
ability to work. He requests narcotics, Percocet® by name,
S
2: P
M
ASIPP
10
Coding, compliance and Practice Management
80. What authority does a Local Medicare Carrier have
D. The provider has 120 days to appeal a denial at each
regarding payment for an item or service that is nonlevel
covered because of a National Coverage Decision (NCD)?
E. The Provider appeal may file at any time after one year.
A. The coverage determination on whether specific medical items and services are reasonable and necessary 84. What are the accurate statements of the Medicaid review
under Medicare Law is published in the National
process compared to Medicare?
Coverage Manual and Local Carriers do not have the
A. Yes, the Medicaid review process is mandated by CMS
discretion to pay for the services
and it has the same steps
B. The Medical Director of a Local Carrier has the authorB. No, the Medicaid process has only four steps where
ity to review a comprehensive report and information
Medicare claims have five
on the item or service sent by the treating physician
C. It is similar with the exception of the amount of time a
and pay the claim if, in his/her opinion, medical necesprovider is allowed to file a claim
sity has been demonstrated.
D. Medicaid has no established federal review process, it
C. The CAC may overturn the NCD and publish a local
is State specific
coverage addendum that the specific item or service
E. Medicaid will lose Federal Grants if they do not follow
may be paid under special circumstances.
Medicare review process.
D. The CAC and/or the Carrier Medical Director may
write to the Medicare Coverage Advisory Commit- 85. What advantage does pre-approval or pre-authorization
tee (MCAC) for permission to pay for the item or
by “other” third party payers, meaning payers other than
service;
Federal programs, i.e., Medicare and Medicaid give a
E. Medical Director of a Local carrier has overriding auprovider?
thority on National coverage policies.
A. Pre approval means that when a provider is told that
a specific item or service is “authorized” payment is
81. How does a physician practice determine that a private
guaranteed
payer is bundling its claims?
B. Payers always give pre-approval in writing and this will
A. When the practice manager reports that the revenue is
guarantee payment
lower during the first quarter of the current year than
C. Obtaining pre-approval offers providers a “safety-net”,
it was last year during the first quarter
it does not guarantee payment
B. When the monthly charges increase and the income
D. Pre approval is not effective unless the physician perfrom insurance payers remains the same
sonally makes the request
C. When the staff that analyzes the explanation of benefits
E. Pre approval must be always obtained by the patient.
(EOB) by comparing the claims to the original claims
submission and reports that there are consistent deni- 86. One of your nurse practitioners just told you that the
als for a specific type of service
new physician you hired last month is already known
D. When a patient calls to advise that his/her insurance
as the office super-flirt and that he has declared he will
company denied a claim because the physician billed
conquer every nurse in the office by year’s end. The most
too many services in one day
appropriate course of action you can take is:
E. When patient complains that practice is over charging.
A. Don’t get involved. It’s not any of your business and it
would be an invasion of your staff ’s privacy to inquire
82. There are currently how many levels of appeal/review
further
available when a provider and/or Medicare beneficiary
B. You have an obligation to go to your nurse practitioner
disagrees with Medicare’s initial determination of claim
and warn her not to spread rumors, and to refrain
payment/denial?
from discussing issues relating to co-workers
A. There is no opportunity to ask for a review, the Carrier
C. You should institute an internal investigation to determine whether or not the allegations have merit
or Fiscal Intermediary determination is final
D. You should talk privately to your new physician and
B. Three levels of appeal all at the Carrier level
remind him of your office policies prohibiting inapC. Five levels of appeal; the final level is a judicial review in
propriate conduct in the office. You should then make
U.S. District Court
sure he has signed your anti-harassment policy, and
D. Four levels of appeal, the final level is the Administrayou should then keep a very close eye on his behavior
tive Law Judge (ALJ)
in the office
E. Six levels, the final level is the review by secretary of
E. Fire him he’s bad news and you are just buying trouble
HHS.
keeping him around
83. The timely filing limits for each level of appeal are?
A. The provider has 120 days to file an initial appeal and 87. Medicare can pay a “clean” claim no sooner than:
A. 10 days of receipt
60 days to file an appeal following each level where an
B. 5 days of receipt
unfavorable decision is rendered
C. 30 days of receipt
B. All appeals must be resolved within 120 days
D. 15 days of receipt
C. There are no timely filing limits relative to request for
E. 2 days of receipt
appeal of a Medicare claim denial
ASIPP
Coding, compliance and Practice Management
11
88. Your file clerk, a hispanic woman in her 50’s has been with
Compensation injury, re-injuring himself.The proper
you for a year, but during that year she has been a terrible
approach to dealing with the sister of the plaintiff is to:
employee. There have been several significant problems
A. Withdraw care and discharge from the clinic.
that have been caused by her misfiling of records, she is
B. State to the sister that your partner will continue to treat
chronically late, and several patients have complained
her, but you will not be treating her due to conflict of
about her abrupt manner of speaking to them. You have
interest.
never warned her about her behavior, and you have never
C. Continue to treat the sister as every other patient, benoted any performance defects in her employment file.
cause the lawsuit does not involve her or action against
Your new office manager has decided he wants to get
you personally.
rid of her. He devises a plan to make her employment
D. Consider it wise to discontinue treatment and provide
life unbearable by ignoring her, giving her weekend
orderly transfer to another physician of equal comassignments, and giving her the dreaded telephone duty.
petence informing the patient, both verbally and by
After several weeks of this treatment, your nurse quits.
registered letter.
Which of the following statements are correct:
E. Transfer care to a university based system that is imA. Your office manager’s plan worked like a charm so you
mune from liability concerns.
give him a raise and vow to use the technique in the
future
92. Torts are civil wrongs recognized by law as grounds for
B. You breathe a sigh of relief because you know the clerk
a lawsuit. These wrongs result in an injury or harm
can’t sue you because she quit and was not fired
constituting the basis for a claim by the injured party.
C. The clerk can sue for constructive discharge based on
The primary aim of tort law is to provide relief for the
race and/or age if she can establish that the employer
damages incurred and to deter others from committing
made conditions so intolerable that any reasonable
the same harm. Which of the following may the injured
person would have been forced to quit
person not sue for?
D. The clerk can sue for constructive discharge based
A. Loss of earning capacity
on race or age only if she can demonstrate that her
B. Three times medical expenses
replacement was less qualified to perform the job duC. Injunction to prevent release of protected information
ties.
D. Pain and suffering
E. You are immune from suit because she was a bad emE. Actual and potential reasonable medical expenses
ployee
93. Which of the following may report a physician to the
89. Which of the following promotes effective evaluation
National Practitioner Data Bank?
meetings?
A. A plaintiff ’s attorney after filing a successful claim.
A. Have an agenda, encourage feedback, and listen.
B. A professional society.
B. Include a third-party witness in your meeting.
C. A judge imposing sanctions.
C. Be hospitable: offer coffee and doughnuts before the
D. A state licensing board, that receives an allegation.
meeting to break the ice.
E. A professional society that conducts formal peer reD. A and B.
view.
E. All of the above.
94. Data to evaluate for each doctor monthly includes:
90. What is the most important element of an employee
A. new patients and no charge patients
evaluation?
B. established patients
A. A statement from the employee expressing his or her
C. procedures
opinions
D. A and C only
B. A description of available resources at the disposal of
E. A, B and C
the employee in attempting to meet the performance
requirements
95. Under the RBRVS for physician payments, three (3)
C. A narrative summary of the employee’s work history,
components are assigned relative value units. These are:
clearly setting forth past performance deficiencies
A. Physician work, experience, and malpractice insurance
D. A clear and unambiguous description of the disciplinexpense
ary or corrective action to be taken if performance
B. Geographic index, wage index, and cost of living index
requirements are not met within the mandated time
C. Conversion factor, CMS weight, and hospital specific
period
rate
E. Specification of exact tasks to be performed and reasonD. Physician work, practice expense, and malpractice inable time frames, in clear, unambiguous language
surance expense
E. Fee-for-service, per diem payment, and capitation
91. A 47-year-old patient complaining of low back pain is an
established patient with the clinic. It becomes apparent, 96. Steps that a practice can take to minimize theft and fraud
however, that her brother who was recently treated by
include:
you is filing a lawsuit against you because he allegedly
A. Internal audits
returned to work prematurely from a Workman’s
B. External audits
ASIPP
12
Coding, compliance and Practice Management
C. Segregation of duties
D. Competitive bidding for purchases
E. All of the above
her injury. How many days does the HR staff have to
complete the Injury and Illness Form 301 in order to be
compliant?
A. Two
B. Seven
C. Ten
D. Fourteen
E. Thirty
97. Currently, payment to the physician for outpatient surgery
performed on a Medicare patient is based upon which
prospective payment system?
A. DRGs
B. APGs
C. RBRVS
104. Budgets are very useful for an organization for all of the
D. ASCs
following reasons EXCEPT:
E. APCs
A. Provides a benchmark to compare actual results to
B. Forces management to plan
98. Three keys of success have been identified.These are:
C. Requires all areas of the company to communicate
A. Staffing, financial and profitability
D. Provides information on patient flow
B. Staffing, measuring and patient satisfaction
E. Provides goals for the company to work toward
C. Physician, financial and practice growth
D. Number of procedures, profitability and staffing
105. Which one of the following statements regarding an
E. Marketing, physician and profitability
impact analysis performed by a medical provider is
correct?
99. Practice patterns and medical protocol should be the
A. An impact analysis should be done after changes are
responsibility of:
implemented to a providers fee schedule
A. The CEO/Administrator.
B. For an impact analysis to accurately calculate the affect
B. Committee of employees.
of new fees, the historical data should be weighted for
C. The Medical Director.
the types of services performed by the provider
D. The clinical staff.
C. An impact analysis is an excellent method of predicting
E. Each physician.
the coming year’s revenue based on a new or revised
fee schedule
100. The correct definition of CPT-4 is:
D. The main purpose of an impact analysis is to calculate
A. Inpatient and outpatient diagnosis classification system
how much future revenue will be generated by increasand an inpatient procedure classification system
ing the providers charges
B. Systematic listing of procedures and services performed
E. An impact analysis is basically a study of the affect a deby physicians
crease in a provider’s fee schedule will have on future
C. Uniform method for healthcare providers and medical
revenues
suppliers to code professional services and procedures
D. Inpatient coding system for tracking time and supplies 106. Which of the following statements pertaining to pricing
consumed per procedure
philosophies is not true?
E. Classification system developed by CMS for providers
A. The relative value approach takes into account the cost
to code services and procedures for billing purposes
of professional liability insurance
B. The standard measure used by providers for the relative
value approach is Medicare’s Relative Value Units
101. The Quick Ratio is a measurement of:
C. The market-drive approach ties the providers fees to
A. Current Assets to Current Liabilities
those of similar providers in the area
B. Current Liabilities to Current Assets
D. The market-driven approach assumes that the patients
C. Profitability
are price sensitive but unaware of cost differences
D. Assets
among providers
E. Owners Equity
E. The Geographic Practice Cost Index is used to convert
Medicare’s national RVU values to regional values
102. When recapping needles it is best to:
A. Use personal protective equipment
B. Have a policy in place to define the appropriate recap
and disposal of sharps.
107. It is June 30, 2005. You are analyzing your A/P invoices
C. Bend the needle, then replace the cap
and determining which items you need to pay. Look at the
D. Use the 2-hand technique to guide the needle sheath
following accounts payable listing and determine what
E. Self blunt needle, recap
dollar amount is due to be paid today:
103. Employers are responsible for completing an Injury
and Illness Incident Form 301. Sally Jones was injured
at the clinic on May 10, 2005. Sally reported the injury
to the Human Resources Department the same day of
ASIPP
Vendor Name
Company A
Company B
Company C
Company D
Company E
Invoice # Invoice Date Invoice Amount
456
6/15/05
200.00
325825
5/25/05
300.00
125485
6/15/05
500.00
6523
5/30/05
600.00
925586
6/20/05
100.00
Terms
Net 90
Net 30
Net 15
Net 30
Net 30
Coding, compliance and Practice Management
A. $1,400
B. $1,700
C. $900
D. $1,000
E. $1,600
108. A practice has the following: Cash of $40,000; Accounts
Receivable of $60,000; Equipment of $10,000; Accounts
Payable of $20,000; Long term debt of $70,000 and
Capital of $20,000. Assuming the practice uses the accrual
method of accounting, what would the total assets be?
A. $40,000
B. $50,000
C. $90,000
D. $110,000
E. $120,000
13
113. A surgery center is surveyed for accreditation by:
A. Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
B. American Cancer Society
C. Commission on Accreditation of Rehabilitation Facilities (CARF)
D. Office of Inspector General (OIG)
E. American Hospital Association
114. Which of the following would be LEAST likely to
influence the collection ratio
A. An increase in the practices billing rate
B. Discounts on payments not being applied properly
C. An increase in the practices billed amount for procedures
D. Unaddressed incorrect payments
E. Uncollected secondary billings.
109. The senior physician notices that a new physician
routinely fails to code all required diagnoses and 115. One of managed care organizations policies to decrease
procedures for a patient encounter. This indicates that
criticism of their one-sided contracts is:
there is a problem with:
A. Allowing the provider Medical Directors to determine
A. Accuracy
medical necessity.
B. Validity
B. Moving some of the objectionable provisions from the
C. Billing and coding
contract to the policy and procedure manuals.
D. Timeliness
C. Allowing a vague description of the managed care
E. Reliability
organization’s coding standards.
D. Adding a “least cost” standard to the contract.
110. The degree to which the CPT and ICD-9 codes selected
E. Allowing a very general definition of the services to be
accurately reflect the diagnoses and procedures are
covered.
described as:
A. Reliability
116. Prevalence of errors in outpatient settings are common
B. Validity
in patient encounters. The most common error in the
C. Completeness
outpatient setting is:
D. Timeliness
A. Communication error
E. Accuracy
B. Prescribing error
C. Improper diagnosis
111. With regards to risk in a pain management practice, the
D. Loss of patient data
physician should understand that controlled substances
E. Improper follow up with abnormal lab result
are a significant point of concern. The definition of risk
is:
117. Functions performed by the Practice Management
A. Unacceptable behavior relating to drug use.
Software include the following:
B. The concept of loss.
A. Appointment and procedures scheduling and reschedC. Misuse or diversion of a controlled substance.
uling
D. Psychiatric influences to concerns of misuse and diverB. Management of accounts receivable and collections
sion.
C. Creation of electronic billing
E. Potential for financial gain as a result of selling medicaD. Provider input terminal
tions.
E. Integration
112. During a given month, the practice has $30,000 in gross 118. The EMR incorporates different sectional components to
charges of which about$15,000 will be written off via
best manage the practice. The specific part of the EMR
contract adjustments, collects $40,000 in receipts and
that relates to clinical services, requiring provider input
writes $10,000 in checks to vendors. Under the cash
is:
method of accounting, what would this practice show as
A. The front office
net income before taxes?
B. The back office
A. $5,000
C. The integrated pad, or workstation
B. $15,000
D. The server pod
C. $30,000
E. The office input at the front desk
D. $20,000
E. $25,000
ASIPP
14
119. Ways to build revenue include:
A. Recall and no show contact
B. Mine charts, screenings, seminars
C. Pay for referrals
D. A and B only
E. A, B and C only
Coding, compliance and Practice Management
C. Self-insured employers that do not subscribe to state
laws are foolproof from litigation
D. Self-insured employers that subscribe to state laws and
administer their own benefits are very rigid and do not
accommodate injured workers at light duty positions.
E. Inherent problems with worker’s compensation system
include poor understanding of the cause of pain, particularly in the absence of definitive diagnostic tests
resulting in unsuccessful return to work and ineffective case management, etc.
120. A 16-year old patient has terminal cancer and has failed
all treatment. Pain is worsening and he requires higher
doses of opioid analgesics for pain relief. He inquires as
to whether a research program may or may not help. One
of the side effects with the new treatment is worsening of 124. In looking at the financial statements for the period, you
peripheral neuropathy. At this point, he refuses further
find that your net collections have been decreasing over
treatment. His parents want you to talk to him and enroll
the last few months. All of the following could be possible
him in the experimental protocol. Which of the following
causes EXCEPT:
is your next course of action?
A. Provider productivity
A. Inform the patient that he can not refuse treatment
B. Payer mix
B. Begin treatment if the parents provide written consent
C. Number of patient visits
C. Respect the patient’s wishes and cancel plans for treatD. Inventory level of supplies
ment
E. Billing/Collecting process
D. Avoid further escalation in opioid doses.
E. Discuss the issues with the patient
125. What are the accurate statements about federal
regulations?
121. A code of medical ethics that includes fundamental
A. They are promulgated by Congress, CMS, and OIG.
elements of the patient-physician relationship and
B. They are promulgated by the Department of Justice
principles of medical ethics involving professional
(DOJ), Federal Bureau of Investigations (FBI) and Ofresponsibility and obligation of physicians is published
fice of Inspector General (OIG).
by
C. Courts may not promulgate any regulations, as it is the
A. American Board of Medical Specialties
duty of Congress and Administration.
B. American Medical Association
D. They are enforced by Congress.
C. International Association for the Study of Pain
E. They are enforced by local Medicare Carriers
D. Office of Health and Human Services
E. Government Accountability Office
126. Which of the following is NOT an appropriate strategy for
helping patients make healthcare decisions?
122. The electronic medical record assists the practice
A. If the patient’s situation is not emergent, emphasize
with billing guidelines, CMS guidelines and following
they do not have to decide immediately on a treatstandards of “Incident to” billing. “Incident to” billing
ment option.
for physician extenders is a CMS guideline detailed in
B. Have paper & pens available for the patient to take
Statute S2050, which states that:
notes.
A. Accountability of supervising physician. The nurse
C. Provide intellectually appropriate articles explaining
practitioner, or PA’s can bill at 100% if the physician is
the patient’s condition and treatment options.
immediately available on-site and involved in medical
D. Provide your patients with a list of websites you think
decision making
are reliable and contain helpful information.
B. The practice may bill the physician extender, nurse
E. Describe the treatment options in esoteric terms.
practitioner, or PA at 100% if available by telephone
C. Requires that an 85% allowance of the physician fee is 127. The reasonable person standard requires patients to be
necessary if the physician only sees the patient every
provided with the following information, EXCEPT:
other visit
A. The (suspected) diagnosis
D. 100% may be billed by the nurse practitioner or physiB. All reasonable treatment alternatives, including doing
cian extender if they use their own provider codes
nothing
E. The electronic medical record ensures improved data
C. A description of reasonably foreseeable burdens for
assessment and decision making, supporting 100%
each treatment alternatives, including doing nothing
physician fee by the extender.
D. A description of reasonably foreseeable benefits treatment alternatives, including doing nothing
123. True statements with worker’s compensation coverage are
E. An explanation of all theoretical risks.
as follows:
A. State-mandated worker’s compensation programs also 128. A patient can appoint all of the following as their
cover all types of federal employees.
surrogate decision-maker EXCEPT:
B. Difficult cases are automatically settled after 12
A. Spouse
months.
B. Friend
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Coding, compliance and Practice Management
C. Their physician
D. Non-traditional significant other
E. Relative
129. Medical ethics can best be described as
A. Proper conduct in patient relations
B. Proper care of the patient
C. Proper appearance of the physician when first encountering the patient
D. Proper documentation of the examination of the patient
E. Proper billing practices
15
not use formal quality assessment and often provides
a qualitative summary.
C. Health technology assessment reviews include only
topics of interest to public and utilize criterion-based
selection with uniform application utilizing rigorous
critical appraisal and usually evidence-based.
D. A systematic review is usually evidence-based, often
addresses a focused clinical question, utilizes comprehensive search of many databases, and appraises the
literature rigorously with a formal quality assessment.
E. Health technology assessments are often broad in scope
representing the interest of health policy makers, without bias, and always evidence based.
130. The new JCAHO standards require which of the
following:
135. You just hired a new female office manager. On her first
A. The use of intravenous morphine
day, she told your female nurse practitioner a joke with
B. Frequent assessment of a patient’s pain
sexual overtones. Your nurse does not complain. Ten
C. Successful treatment of a patient’s pain
months later, she files suit against your practice, alleging
D. Recording of the physician’s satisfaction
sexual harassment, based on the sexual joke. Which of
E. Demonstrated use of the analgesic ladder algorithm
the following is true:
A. Your nurse has a strong case, because telling even one
sexual joke at work is considered unlawful harass131. Which of the following would be most likely to precipitate
ment.
may be considered unlawful harassment.
an inaccurate decrease in accounts receivable aging
B. Your nurse has a weak case because it is not considered
numbers?
unlawful sexual harassment when a female tells anA. Contractual discounts on payments not being made in
other female a joke.
a timely manner
C. Your nurse has a weak case unless she can demonstrate
B. Uncollectible debts not being written off
that the harassment was pervasive.
C. Delays in claim submissions
D. Your nurse’s failure to report her manager’s conduct
D. Delays in refunding overpayments
is irrelevant because an employer cannot require an
E. Delayed patient collections
employee to report alleged harassment.
E. Your nurse has a strong case because the person who
132. Which of the following is a properly designed control
told the joke was a manager.
procedure for internal control of accounts receivables?
A. Lag time on billing charges should be closely watched
136. Meta-analysis of studies on chronic non-cancer pain
B. Protocol for authorizing write-offs and discounts
(CNCP) conclude:
should be established
A. evidence in long term studies show that the benefits of
C. Prior authorizations should be obtained before services
opioid use outweigh the risks
rendered if you think they won’t be paid
B. evidence from short term studies show that strong opiD. Patient statements are mailed on a monthly basis
oids are superior to non-steroidal anti-inflammatory
E. Insurance requests for medical records should be logged
drugs for pain relief, but not patient functionality
and dated
C. evidence from short term studies show that strong opioids are superior to non-steroidal anti-inflammatory
133. Which of the following is NOT required as part of a postdrugs for pain relief and patient functionality
exposure evaluation and follow-up?
D. evidence from short term studies show weak and strong
A. A confidential medical evaluation
opioids are superior to non-steroidal anti-inflammaB. Documentation of the route of exposure and circumtory drugs for pain relief
stances under which exposure occurred
E. evidence from short term studies show that weak and
C. Identifying and testing source individual’s blood restrong opioids are effective for nociceptive, but not for
gardless of consent
neuropathic pain
D. Providing the employee post-exposure protective treatment
137. Staffing a pain practice can be your greatest incurred
E. Providing the employee counseling
expense. How many staff members, including ancillary
care providers and administrative personnel, can you
134. Chose the correct statement describing core features of
expect to hire for a single doctor interventional pain A.
a review.
Three to four
A. A narrative review is often broad in scope and performs
B. Five to six
rigorous critical appraisal of evidence typically using
C. Six to seven
evidence-based methodology.
D. Seven to eight
B. A systematic review is often broad in scope and may
E. More than eight
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16
138. Which of these is not considered to be a key community
demographic for choosing a location for an interventional
pain practice?
A. Industry “heavy”
B. Active waterfront port
C. Access to an international airport
D. Expanding population, growing work force
E. Popular tourist destination
139. Which of these is not a standard NCQA outcome criteria
measurement?
A. Return to Work
B. Physician Reimbursement
C. Patient Satisfaction
D. Cost of Care
E. Quality of Life
Coding, compliance and Practice Management
policies pursuant to:
A. The Health Insurance Portability and Accountability
Act (HIPAA).
B. The Freedom of Information Act.
C. The Medicare Act.
D. The Medicare Information and Policy Response Act.
E. The Medicare Release of Information Act.
144. Which of the following must appear in an accounting of
disclosures to the patient?
A. All disclosures for treatment purposes.
B. All inadvertent disclosures that have been made to a
person who is not the patient.
C. All disclosures made pursuant to an authorization
signed by the patient.
D. All incidental disclosures.
E. All disclosures made for purposes of claims processing.
140. Low morale due to poor management and leadership,
among other things, can affect productivity and
profitability adversely. According to a recent research 145. Which of the following is an advantage of group decision
study, what impact can low morale have on overhead
making?
costs?
A. One person dominates to push for a particular deciA. Decrease by up to 50%
sion.
B. Increase 5%
B. Time is needed for discussion.
C. Increase 15-30%
C. Group pressure encourages group think.
D. Increase 40-60%
D. No single person strongly influences the decision makE. Increase by up to 100%
ing process.
E. Decisions are made swiftly and accurately
141. Your front desk staff is the first and last point of contact
with your patients. They also manage the physician 146. An interventional pain program predominantly
schedules and are responsible for starting the billing
managing cancer patients may be accredited by all of the
process. Which of these is the least effective strategy for
following EXCEPT:
optimizing this position?
A. American Cancer Society (ACS)
A. Maintain a high turnover rate. Fresh faces are more
B. Joint Commission on Accreditation of Healthcare Orlikely to be friendly and energized.
ganizations (JCAHO)
B. Pay out bonuses based on productivity.
C. Accreditation Association for Ambulatory Health Care
C. Pay out bonuses based on efficiency.
(AAAHC)
D. Provide continuous medical education.
D. Commission on Accreditation of Rehabilitation FaciliE. Provide continuous customer service education trainties (CARF)
ing.
E. State Department of Health for Physical, Occupational,
and Behavioral Components
142. Which of the following statements is correct?
A. A patient may request that a provider amend a diagno- 147. Which of these statements is true:
sis that was submitted on a billing claim form.
A. A person accused of harassment must have intended to
B. A provider must act on a patient’s request for amendharass the coworker. If he or she was merely joking,
ment within 30 days, either deny or amend.
or was just being friendly, his or her actions will not be
C. A provider does not agree with a patient’s request for
considered “harassment.”
an amendment. However, the provider must make the
B. Even one tasteless joke of a sexual nature can form the
amendment but can note disagreement in the amendbasis of a successful suit for sexual harassment.
ment and inform insurer.
C. A clinic is immune from a sexual harassment suit if the
D. Provider has to amend diagnosis in 30 days as provider
individual responsible for the wrongful conduct is emmay not deny the patient request.
ployed by a drug company and not by the clinic itself
E. Provider has no obligation even if the information on
D. If your office manager refuses to give your receptionist
the claim was inaccurate.
a raise because the receptionist will not go out on a
date with him, your clinic can be held liable even if
143. Dr. Jones receives a response to his Medicare audit.
you have a policy prohibiting managers from dating
Medicare requests a repayment of $299,000.00. Dr.
staff members.
Jones wants to get copies of all Medicare policies used
E. Berating someone for being late to work can be considby Medicare to support the audit denials. Dr. Jones sends
ered unlawful harassment.
a letter to the Medicare Carrier asking for all relevant
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Coding, compliance and Practice Management
17
148. If an implementation specification in the HIPAA
policies in medical management.
security rule is labeled “addressable,” that means that
C. It is easy to understand what works best and why medithe specification . . . ?Choose the word or phrase that best
cal care is expanding rapidly.
completes the sentence.
D. The gap between the science and practice averages
A. Is required.
more than 10 years.
B. Is optional.
E. More than 50% of patients are inclined to be compliant
C. Does not need to be implemented now, but will need to
with a designated guideline based on evidence-based
be implemented by April 20, 2010.
medicine.
D. Is one whose appropriateness and reasonableness must
be assessed.
153. The first level of appeal of a negative Medicare audit
E. Does not need to be implemented now, but will need to
decision is to:
be implemented by April 20, 2006.
A. Federal District Court.
B. Administrative Law Judge.
149. Steve and Mary are employed in your office. Mary has
C. The Qualified Independent Contractor.
brought a complaint to your administrator, claiming
D. Medicare Arbitration.
Steve has been sexually harassing her by repeatedly
E. The Medicare Carrier which issued the negative audit
making comments about her physical appearance, and
decision.
about what she wears to work. If your clinic is sued
because of Steve’s conduct, which of the following is NOT 154. Your accountant submitted the following information in
a viable part of the defense to the suit:
the month end financial report: Cash $34,000; Accounts
A. Mary’s office wardrobe consists of short skirts, black
Receivable $90,000; Equipment $15,000; Accounts
fishnet stockings, see-through blouses, and sweaters
Payable $28,000; Long term debt $75,000 and Capital
with plunging necklines.
$30,000. Assuming your practice uses the accrual method
B. When Steve comments on Mary’s appearance, Mary
of accounting, what are your total assets at month end?
giggles and thanks him.
A. $34,000
C. Mary and Steve have been dating for two year, and they
B. $49,000
frequently discuss their workouts at the office.
C. $139,000
D. Mary did not complain directly to human resources
D. $124,000
director, as required in the employee handbook
E. $169,000
E. Mary frequently asks Steve to comment on her wardrobe choices.
155. An internal control weakness would best defined as
a condition in which errors or irregularities are not
150. You are reviewing the practice’s month end financial
detected within a timely period by:
reports. The practice posted $80,000 in gross charges
A. An independent audit of reports on control proceof which $25,000 will be written off via payer contract
dures
adjustments. You posted $47,000 in receipts and mailed
B. Employees in the normal course of performing their
$16,000 in payments to vendors. Using the cash method
functions
of accounting, what is the practice’s net income before
C. Manager when reviewing financial statements and key
taxes?
performance indicators
A. $55,000
D. Outside consulting firms
B. $39,000
E. The financial manager during year end audits
C. $64,000
D. $31,000
156.You have determined, based on recent growth, your
E. $86,000
practice will need to recruit one additional nurse to
assist the physician(s) and one additional clerical staff to
151. Modern organization structure requires input and output
assist the switchboard with scheduling and appointment
between:
reminders.What are the first critical steps to be taken?
A. CEO/Administrator, physicians, patients, clinic and
A. Write a job description for each position.
finance
B. Ensure the practice employee handbook is current.
B. CEO/Administrator, Board, and physicians.
C. Establish a compensation package for each position.
C. Physicians to the CEO/Administrator.
D. Prepare interview questions regarding the candidate’s
D. Physician to CEO/Administrator, clinic and finance.
family and social interests.
E. Finance to the Physician and CEO/Administrator.
E. Hire a recruiting firm
152. Which of the following is the correct statement explaining 157. Mary Smith, Office Manager, has been authorized to
the reality of today’s evidence-based medicine?
recruit a new clerical employee. She feels newspaper
A. Approximately 80% of the medical care provided
classified ads are non-productive and decides to try
in today’s environment is based on evidence-based
a different approach before resorting to printed ads.
medicine.
Which choice is the best to begin?
B. All conditions get similar attention due to government
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18
Coding, compliance and Practice Management
A. Mary can call the local hospital(s) HR Departments and 162. Your receptionist is an avid Republican, and imposes her
views on fellow employees. She is also an incompetent
colleagues from other offices to identify candidates.
receptionist. You terminate her after she put a banner
B. Hire a recruiting firm.
behind her desk that said “Bush 2008 and Forever,”
C. Ask her employees for suggestions.
and stamped “Vote Republican” on several patient files.
D. Speak with the doctors and see if they have any friends
Which of the following is true:
looking for work.
A. Your ex-receptionist has a good claim against your
E. Ask company attorney
clinic because your reason for terminating her was
clearly based on her political beliefs, and such clear
158. Dr. Jones realizes that his medical records are illegible.
discrimination can form the basis of a successful disDr. Jones should:
crimination suit.
A. Dictate her medical records word for word and submit
B. Your treatment of her could be considered hostile work
them with the medical records before May 15, 2007.
environment harassment under federal discriminaB. Send the records in figuring that the reviewer will be
tion law
a physician with equally poor penmanship who will
C. You have a right to terminate an employee for poor
probably be able to read the records.
performance and for damaging patient files.
C. Dictate her medical records word for word and submit
D. If you failed to issue warnings to your receptionist bethem as soon as they are ready.
fore you terminated her, you may be liable for wrongD. Send in the records as is because Medicare requires that
ful termination
all handwritten records be legible and will not accept
E. You should not have terminated your receptionist berecords dictated after the fact.
cause she has an absolute right to express her personal
E. Modify the original medical record to make it easier
opinions in the workplace.
to understand before making copies to send to Medicare.
163. All of the following are major principles of medical
ethics, except?
159. Marketing is a way to educate the community about
A. The principle of respect for autonomy
your practice and its’ services, without “advertising” in
B. The principle of nonmaleficence
the weekend paper. Which of the following is the least
C. The principle of beneficence
important audience to market to?
D. The principle of justice
A. Local Construction Company
E. The principle of egalitarianism
B. Third Party Payers
C. Local Retail Establishments
164. Which of the following is a physician/employer’s best
D. Workers Compensation Carriers
defense to a sexual harassment claim?
E. Attorneys
A. The conduct did not cause emotional or psychological
injury to the complaining employee.
160. How many days of your average charges should be in your
B. The conduct did not occur very often and wasn’t very
total accounts receivable?
offensive
A. 30-45 days
C. The conduct between co employees did not occur durB. 45-60 days
ing business hours
C. 60-80 days
D. The conduct did not occur at the clinic or in the mediD. 80-100 days
cal offices.
E. Anything under 200 is sufficient
E. Adoption of comprehensive written policies prohibiting harassment, conduct of periodic training sessions,
161.It is March 30, 2007. You are analyzing the clinic’s
well publicized procedure and prompt thorough inoutstanding A/P invoices to determine which items you
vestigations .
need to pay in today’s check run. You do your company
A/P check runs twice per month. Review the following
accounts payable outstanding list to determine what 165. Which of the following is not an example of hostile
environment sexual harassment?
dollar amount is due to be paid in today’s check run:
Vendor
Invoice # Invoice
Invoice
Terms
A. A physician asks a nurse out on a date and she refuses.
Date
Amount
B. A female coworker repeatedly touches a male coworker
Company A
456
3/15/07
200.00
Net 90
on his shoulders, hugs him goodnight, and makes
Company B
325825
2/25/07
550.00
Net 30
numerous comments about his “tight little butt.” He
Company C
125485
3/15/07
600.00
Net 15
Company D
6523
2/28/07
430.00
Net 30
tearfully asks her to stop.
Company E
925586
3/20/07
100.00
Net 30
C. The staff posts sexually explicit jokes and cartoons on
A. $1,780
the office kitchen bulletin board.
B. $1,580
D. A male coworker repeatedly touches another male
C. $980
coworker on his shoulders, hugs him goodnight, and
D. $1,000
makes numerous comments about his “tight little
E. $1,680
butt.”
E. All of the above are examples of hostile environment
sexual harassment.
ASIPP
Coding, compliance and Practice Management
19
166. Which of the following behavior is not considered
hours your pregnant nurse will not work.
unlawful harassment?
E. Terminate her immediately. You warned her not to get
A. Constantly yelling at your staff over small, inconsepregnant.
quential mistakes.
B. Use of epithets, slurs, and insults directed at an indi- 170. Your receptionist has just received an e-mail from a
vidual because of his national origin.
coworker. It is the fifth time the coworker has asked
C. Putting up a screen saver on your office computer that
your receptionist out on a date. Is his conduct sexually
has a sexually explicit picture of two nurses. (It’s in
harassing?
your office and no one has the authority to use it but
A. No. And it’s none of your business. Stop reading your
you.)
employees’ e-mails.
D. Repeatedly calling yourself and others names such as
B. Yes. You may become liable to the receptionist for the
“old geezer” and “senile” in meetings and during an
harassment because you knew about it and did nothinformal discussion with your staff.
ing to stop it.
E. All of the above are examples of unlawful discrimination.
C. It depends.
D. It is sexually harassing behavior, but because it is a private e-mail, you may do nothing unless and until she
167. A study involving a new pain medication is being
complains to you. You should act only after she makes
proposed. Which of the following is not required in the
a specific complaint to you.
informed consent?
E. You may act only if you have a written policy against
A. The names of the Insitutional Review Board board
dating coworkers.
members who approved the study
B. The aims of the study
171. Your nurse practitioner has complained to you on several
C. The anticipated benefits of the study
occasions that the drug rep that comes every Friday has
D. The potential hazards of the study
repeatedly asked her out, often attempted to kiss her, has
E. The discomforts of participating in the study
groped her and has made suggestive remarks to her. She
has told the drug rep to leave her alone, but the conduct
168. Employers are required to provide training to all
continues. What is the appropriate response?
employees with occupational exposure that . . . Which
A. Explain to your nurse that you have no right to control
one of the following DOES NOT accurately complete this
an individual who is not your employee.
sentence?
B. Suggest to her that she simply make light of the situaA. Is provided at no cost to the employees.
tion and not be overly sensitive.
B. Is provided at the time of initial employment and as
C. Talk to the drug rep and insist he immediately cease the
requested by the employee thereafter.
unwanted behavior.
C. Is appropriate in terms of content and vocabulary
D. Immediately call the drug company, tell the rep’s boss
given the employees education level, vocabulary and
the drug rep is a “sex maniac”, and demand they send
language.
another rep from now on.
D. Is provided during working hours.
E. The next time the drug rep comes to your office, you
E. Discusses the employer’s Exposure Control Plan, blooddeck him.
borne diseases and modes of transmission and the use
of personal protective equipment.
172. Presumed or implied consent for a chest tube after
pneumothorax is valid in which of the following
169. One of your nurse practitioners is pregnant. She has
circumstances?
informed you she will only be working four days a week
A. The patient is transported to the Emergency Room in
and will cut her hours to four hours a day. She also told
shock and obtunded.
you she would only work in one of your clinic locations
B. The patient is transported to the Emergency Room, is
because she doesn’t want to make a long commute while
short of breath but competent and does not want a
she is pregnant. This new plan puts additional burden
procedure.
on your other nurse practitioner, and creates problems
C. The patient is in the ICU, is short of breath but compescheduling patients. What can you do?
tent and does not want a procedure.
A. If she is pregnant, you must accommodate her or you
D. The patient is in the ICU and has made his decision
risk a pregnancy discrimination suit.
against interventional treatment abundantly clear preB. You are not required to give her preferential treatment.
viously, signing a DNR, but is now obtunded.
You are only prohibited from discriminating against
E. The patient’s legal guardian is in the ICU, with the
her. If your other employees are not allowed to reduce
obtunded patient, indicating that the patient would
their hours or refuse to work at your other clinic, then
never consent to a chest tube and has signed a DNR,
you do not need to grant your pregnant employee
which is not taped to the front of the chart.
those benefits.
C. You may insist she take a leave of absence until after she 173. Which one of the following procedures is the most correct
has the baby.
statement of the requirements of the HIPAA privacy rule,
D. Rearrange other employees’ schedules to cover the
assuming that the physician is a covered entity under
HIPAA?
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20
Coding, compliance and Practice Management
A. The HIPAA privacy notice must be posted in a physician’s office and a copy need only be given to a patient
when s/he requests it.
B. A HIPAA privacy notice must be posted in a physician’s
office and must be given to every patient on the date
s/he is first rendered services.
C. A HIPAA privacy notice need not be posted in a physician’s office and a copy need only be given to a patient
when s/he requests it.
D. A HIPAA privacy notice need not be posted in a physician’s office, but must be given to every patient on the
date s/he is first rendered services.
E. If the physician maintains a website, the patients may be
told to go to the website to obtain a copy of the privacy
notice.
employment change had anything to do with his hurt
feelings
C. The actions involve a supervisor taking adverse action
against a subordinate – it only takes one incident to
create liability.
D. Since you, as managing physician of the clinic, did not
know about the situation, the clinic has no responsibility to prohibit the conduct and therefore has no
liability for the conduct.
E. There is no evidence that the physician acted improperly by fondling her, making sexually explicit comments,
or otherwise conducting himself in an inappropriate
way.
178. Diagnostic interventional pain procedures include which
174. In human subject research, who is required to obtain
of the following:
consent?
A. Facet joint injections
A. The nurse checking the patient in.
B. Sacroiliac joint injections
B. The primary investigator.
C. Vertebroplasty
C. A designated properly trained person who is knowlD. Selective nerve root injections
edgeable about the study and able to answer quesE. Discography
tions.
D. The patient should read the consent independent of
any third party and have a witness sign the consent 179. Modalities of treatment commonly used in chronic pain
before discussing the research procedure.
include all of the following except:
E. The competent patient’s family members should obtain
A. Psychological therapies
the consent and sign as witnesses.
B. Physical therapies
C. Interventional pain procedures
D. Functional capacity evaluations
175. What is informed consent?
E. Behavioral therapies
A. Telling the patient he needs to have done.
B. Letting the patient ask what needs to be done.
C. Telling the patient about the options of treatment, 180. Physical therapy treatments include which of the
which may include no treatment.
following:
D. An ongoing interactive process by which a patient unA. Heat and cold therapies
derstands his choices regarding healthcare, not necesB. Therapeutic exercises
sarily written.
C. Hydrotherapy
E. A comprehensive list of written risks associated with
D. All of the above
a specific procedure, provided to the patient prior to
E. None of the above
initiating the procedure.
181. The prevalence of sacroiliac joint pain in patients with
176. What are the elements of full informed consent?
prior lumbar fusion has been estimated to be:
A. The name of the procedure, written in lay language
A. 10%
B. Written list of alternative treatments
B. 35%
C. Signature of patient documenting consent
C. 50%
D. A witness signature
D. 68%
E. The patient have an opportunity to be an informed
E. 5%
participant in his health care.
177. Your physician partner tells your nurse practitioner that
he will take her to your next medical meeting in Tahiti
if “she makes it worth his while.” She refuses and finds
herself being transferred to the night shift in your clinic
located in Omaha. Your nurse practitioner is not happy.
Do you have reason to worry?
A. It was just one incident and just one request for a date
so it isn’t sufficient to be considered “harassment.”
B. She turned him down and there is no evidence her
ASIPP
182. The use of herbs, metals, massage, and other products
and techniques with the intent of cleansing the body and
restoring balance is used in which of the following:
A. Homeopathy
B. Acupuncture
C. Chiropractic
D. Ayurveda
E. Massage Therapy
Coding, compliance and Practice Management
_____________________________________
Directions: Each question below contains
four suggested responses of which one or
more is correct. Select
A if
1, 2 and 3 are correct
B if
1 and 3 are correct
C if
2 and 4 are correct
D if
4 is correct
E if
All (1, 2, 3 and 4) are correct
_____________________________________
21
185. In order to properly bill for behavioral health services,
1. The clinical psychologist should follow all appropriate
state and federal guidelines.
2. The clinical psychologist should bill incident to the
interventional pain physician.
3. The clinical psychologist should bill under his or her
own provider number.
4. The clinical psychologist should bill incident to the
certified nurse practitioner who did the original medical evaluation
186. Doctoral level clinical psychologists are licensed to
practice independently within a scope of practice that
includes:
1. The assessment, diagnosis, and treatment of mental
health disorders
2. Billing for services when working within the hospital
setting
3. Assessment and treatment, but not diagnosis, of physical health disorders
4. Conducting research in the university hospital setting
183. A physical therapist assistant(PTA) is working within a
medical clinic as an employee of the group practice. She
is approached by the physician who has just evaluated
a patient and would like the patient to begin physical
therapy immediately to assist with pain management.
The PTA points out that she cannot see the patient. What
187. Which of the following is true about the cash accounting
is the reason that the patient cannot be seen?
method?
1. The patient has not exhausted all medical options for
1. Must use this method if business carries inventory to
pain management first
sell to public
2. The patient has not been an active patient of the medi2.
Revenue
is recorded when earned
cal clinic for at least 30 days
3. Evens out revenue and expenses over time
3. The patient cannot receive physical therapy on the
4. Expenses are recorded when a check is written
same day they see the physician if both are employed
by the same group practice.
4. The patient has not been evaluated by a physical 188. Your office manager filed an EEOC charge against your
clinic, claiming he was terminated because of his age. He
therapist
has evidence that he was called “senile,” an “old fart,” and
was accused of having “Old-Timer’s Disease.” Which of
184. A physical therapist is employed by a physician group
the following are potential defenses to his Charge?
practice. The therapist does not have an individual
1. He is under the age of 40
provider number with the designation of physical
2. You have several good examples of his poor work
therapist in private practice but instead bills for physical
product and you have documented the warnings he
therapy services incident to the physician present in the
received before his termination.
office, which is the case today. A Medicare patient arrives
3.
He was hired 6 months ago by the same person that
at the clinic with an order for physical therapy. The order
terminated him.
was written by a physician who is not a member of the
4. He has always been a “whiner” and you can present
group practice that employs the physical therapist. Which
evidence that he complains about everything.
statements are true about this situation?
1. The patient cannot be seen by the PT because the service cannot be billed incident to a physician who has 189. Some of the communication issues faced by health care
providers in terminal patients include?
not participated in the patient’s care.
1. Diagnosis and prognosis
2. The patient can be seen by the PT but would first need
2. Advanced directives and do-not-resuscitate(DNR)
to be seen by one of the physician members of the
orders
group practice that employs the physical therapist, to
3.
Spiritual
needs
allow billing incident to.
4. Symptom Management
3. The physical therapist can bill under her own Medicare provider number with payment reassigned to
the group practice, in order to receive referrals for 190. Roles of a clinical psychologist within a pain clinic are
the following:
physical therapy from physicians outside of the group
1. Direct services to patients
practice.
2. Direct services to patients, consultation, supervision
4. The patient can be seen with the visit billed incident
3. Direct services to patients, consultation, management
to the physician because the physician is present in the
4. Direct services to physicians
office suite at the time of the visit.
ASIPP
22
191. When preparing to hire a psychologist, it is essential to
determine:
1. How to add the psychologist to the clinic’s liability
insurance.
2. How much psychologist can guarantee in income
3. The employment screening needs that are required by
the psychology state and provincial licensing boards.
4. How much profit the clinic would make
192. Due to the Needlestick Safety and Prevention Act,
employers of an ASC should understand the following
items to be true:
1. The new regulation has language that requires an employer to evaluate innovations in technology development that reduce sharps exposure.
2. Employers need to seek input regarding sharps safety
devices from non managerial employees who are responsible for direct patient care and may be exposed
to injuries themselves.
3. Requires employers to maintain a “sharps incident”
tracking log
4. Requires exposure control plans be reviewed and
updated at least annually to reflect changes in sharps
safety technology.
193. Which of the following are appropriate strategies for
helping patients make healthcare decisions?
1. Provide patients with a list of support groups so they
can hear what treatment options other patients have
chosen and what benefits & burdens they have experienced.
2. Ask the patient about their “decision-making model.”
3. Try to have the patient’s surrogate present at all significant conversations.
4. Ask the patient to develop a list of those activities that
gives their life meaning so you can discuss their illness
and the benefits & burdens of the various treatment
options within the context of their everyday life.
194. Dr.Jones and Dr.Smith are interviewing a new candidate
for office manager of their busy practice. The candidate
is a very attractive woman with outstanding experience
and academic credentials. The doctors and the candidate
bond immediately and the discussion becomes very
relaxed. Dr. Smith asks the candidate is she is married
or single and begins to delve into her personal life. The
candidate picks up her belongings and 3 days later the
doctors receive a letter from her attorney. What went
wrong with the interview?
1. The doctors did not know the “right” and/or legal
questions to ask.
2. The interview became too informal.
3. No one paid attention to the candidate’s body language
or changes in tone.
4. The interview process was not well planned.
195. How do Program Safeguard Contractors work?
1. They show up unannounced
2. You have to talk
3. They generally want to talk to MD
ASIPP
Coding, compliance and Practice Management
4. Call attorney only after you talk
196. A physical therapist is providing physical therapy
treatment to Patient A in a closed treatment room. A
physical therapist assistant is providing treatment to
Patient B in a different room, within the same clinical
space. There is a physician (who is also the employer
of the PT and the PTA) is also working on site. The
physical therapist is employed by the medical clinic but
has an individual Medicare provider number, making it
a physical therapy private practice setting. The physical
therapist assistant services are billed by the supervising
PT. The level of PTA supervision by the physical therapist
required for this setting is:
1. General supervision
2. Direct supervision by the physician only
3. Direct personal supervision
4. Direct supervision
197. Employee retention is a very important factor in
managing a practice, because turnover is very costly both
in productivity and expense. Which of the following is
the best way to retain employees?
1. Create an environment (culture) where employees feel
appreciated, comfortable and look forward to coming
to work every day.
2. Motivate employees to do their best through various
methods.
3. Never do anything in the office which might be considered biased, off-color or considered harassment.
4. Pay the highest salaries in the area and the practice will
be assured of getting the best employees.
198. What expenses listed below does a physician practice have
to incur to report Place of Service 11, (POS 11)?
1. All fixed expenses such as rent and utilities
2. Administrative, billing, nursing and technical staff
costs
3. Supplies and equipment
4. Laboratory Expenses
199. Intervals for OSHA training are required at:
1. Hiring
2. With changes in regulatory statutes
3. Annual thereafter
4. When a violation occurs
200. OSHA training is considered:
1. Voluntary
2. Mandatory for full-time employees only
3. Congruent to the individual practice
4. Necessary employment requirement for full time and
part time employees
201. The Hepatitis B vaccination (HBV) is:
1. Offered to all employees
2. Non required for employees with no positive serology
3. Refused by an employee, if the employee desire.
4. Required only in employees that are in immediate
contact with patients
23
Coding, compliance and Practice Management
202. Hazardous chemicals require:
1. Container labels
2. Training as to appropriate response to spill and storage
3. Material Safety Data Sheets, MSDS, referencing these
chemicals
4. Reinforced glass container
203. What method does CMS use to pay for drugs?
1. Every Medicare Carrier prices drugs based on the cost
in its geographic region
2. Medicare pays the Average Wholesale Price for drugs
3. Payment for drugs is published in the Medicare Physician’s Fee Schedule (MPFS) in November of each year
4. Medicare pays on the basis of Average Sales Price
(ASP).
204. Choose correct statements in reference to exclusion:
1. A health care provider may knowingly employ an excluded person when the excluded person’s job does not
involve providing or billing for services reimbursed by
a federal health care program
2. A provider with a felony conviction relating to a controlled substance is subject to mandatory exclusion
3. The minimum length of time for mandatory exclusion
is 10-15 years
4. The Balance Budget Act enacted a three strikes – you
are out provision
205. When an employee is involved in a minor contact with
blood or body fluids the employee may:
1. Administer their own first aid
2. Dispose of the material in a plastic lined container or
toilet
3. Allowed cleansing and covering of the injury
4. Required to seek immediate medical care.
206. Engineering controls in Universal/Standard Precautions
in exposure prevention requires that:
1. Staff consultants engineer recommended protocols for
waste disposal
2. Develop mechanical biosafety protocols
3. Develop and build a waste station
4. Assist in device management such as disposable needle
precaution systems, and waste containment devices
207. Patients who are non-compliant, may be manifesting:
1. Unrecognized psychiatric disease
2. Malingering, or factitious disease
3. Secondary gain
4. Operant conditioning
208. An upset patient presenting with depression, anxiety, and
possible substance abuse has been labeled by Workman’s
Comp as a “malinger”. The differential diagnosis should
include:
1. Somatoform disorder
2. Undiagnosed or untreated psychopathology such as
bi-polar disease.
3. Untreated depression
4. Early signs of suicidal ideation
209. When terminating a patient it is suggested that:
The physician confronts the patient regarding noncompliance, and document in the chart.
2. In cases of non-payment, it should be elaborated to
the patient that services rendered require service payment.
3. Recommended that the patient not be provoked, withholding specifics, that might lead to misunderstanding, and discharge from the practice.
4. Define in patient friendly terminology of policies
and procedures to avoid patient confusion when
confronted.
1.
210. The physician may refuse to see a patient who is:
1. Non-compliant
2. A non-payer of services
3. Potential threat to the office personnel
4. Difficult to accommodate due to specific disease type
such as HIV
211. OSHA training includes familiarity with procedures
to handle on Blood Borne pathogens, a citation will be
issued if:
1. The employer fails to keep the workplace free of hazard
2. Hazard was recognized and not responded to in an appropriate or timely manner
3. Hazard, was, or could cause harm, and no corrective
response was made by the employer
4. Antiseptics and spill kits weren’t at the site of exposure.
212. A 27-year-old nurse who works for you has come in
contact with blood from a spill. The patient is unknown,
as is the HIV and HBV status. The owner/physician
should perform the following:
1. Document routes of exposure
2. Identify if a vector source is known, and identify.
3. Provide the employee the opportunity for serological
testing
4. Avoid repeat exposure by allowing the employee to
convalesce for one month.
213. Designated Health Services providers that furnish 20 or
more Part A and Part B services during the year must
maintain certain information in the form, manner and
at the times that the Centers for Medicare and Medicaid
Services or the Office of Inspector General specifies. The
information required to be kept does NOT include the
following:
1. The name and unique identification number (“UPIN”)
of each physician who has a reportable financial relationship with the entity.
2. The name and unique identification number of each
physician who has a family member who has a reportable financial relationship with the entity.
3. The covered services furnished by the entity.
4. The name and social security number of each physician’s immediate family members.
ASIPP
24
214. The income statement is done monthly and captures:
1. Revenue
2. Expenses
3. Net Income
4. Assets
215. The Balance Sheet is a financial statement that includes:
1. Assets
2. Liabilities
3. Owners Equity
4. Expenses
216. Landmarks in regulations in healthcare in the United
States include:
1. 1965 - Health Care Law
2. 1992 - Addition of Medicaid
3. 1993 - Health Security Act of Clinton
4. 1976 - Health Insurance Portability and Accountability
Act
217. Types of methods to measure patient satisfaction
include:
1. Mystery Shopper
2. Survey
3. Testimonials
4. Physician’s”feeling”
218. Which of the following are true regarding informed
consent?
1. Consent must be given freely
2. The consent must be witnessed
3. The person must be capable of giving consent
4. The majority of states require consent forms
219. As you are walking by an exam room, you hear your nurse
practitioners making fun of the new physician (a Muslim)
you have hired. Although the physician was not in the
room, you heard the nurses mock his accent and call him
“towel head.” What should you do?
1. Deal with the situation immediately. Explain to the
nurses that they are violating the clinic’s policy against
harassment, and warn them that any future inappropriate conduct will result in discipline, up to and
including termination. Then note the warning in their
personnel files.
2. Ignore it – the physician didn’t hear it and you simply
overheard the remarks. Injecting yourself into the situation will simply cause morale problems.
3. Run to the personnel manual and make sure you have
an anti-harassment policy.
4. Have a private conversation with the new Muslim doctor. Explain that his accent and his turban is causing
distractions to the office staff. Ask him to dress like
other doctors in the office, and to work on speaking
without an accent.
220. In a malpractice action, the final determination of
culpability and liability are determined by:
ASIPP
Coding, compliance and Practice Management
1.
2.
3.
4.
Deviation of the standards of practice
Causation of incident
Damage and suffering due to the incident
History of previous lawsuits
221. Which of the following is not a legal defense to a negative
audit result.
1. Waiver of Payment.
2. Treating physician rule.
3. Innocent error rule.
4. Provider Without Fault.
222.True statements regarding confidentiality of medical
records include which of the following?
1. The payer of worker’s compensation claims has rights
to all records upon request.
2. Any agent acting on behalf of the Centers for Medicare
and Medicaid Services may have access at any time to
medical records of patients reimbursed by Medicare.
3. Private indemnity insurance companies must obtain
express written consent from the patient prior to reviewing the medical record.
4. Release of mental health records may require special
consent even though they are integrated into the general medical record.
223. True statements about QUI TAM (Whistleblower Act) are
as follows:
1. Suits are usually brought by employees
2. If the government proceeds with the suit, the whistleblower receives 50 to 60% of settlement.
3. Individuals can bring suit against violators of Federal
laws on their own behalf as well as the government’s
4. If the government does not proceed and the individual
continues, the individual receives 100% of the settlement
224. The following may be considered reasons for alterations
and stress in the patient-physician relationship:
1. Managed care constraints.
2. Physician time of encounter less than 5 minutes.
3. Poor response to patient concerns and follow-up.
4. Magnification of the disease.
225. Tasks performed by the EMR include:
1. Transcription
2. Clinical decision making and support
3. Chart documentation
4. Patient data retrieval for personal use
226. What are the principles and objectives of pay for
performance for physicians?
1. Encourage coordination of Part A and Part B services
2. Discourage efficiency through investment in administrative structure and process
3. Reward physicians for improving health outcomes
4. Encourage upcoding
Coding, compliance and Practice Management
25
3. There are probable multiple indirect positive benefits
227. There are some items and services for which Medicare
of this effort with improved patient care and decreased
will not pay because they are not Medicare benefits and
practice variation
for which a provider will furnish a form known as a
4.
They
provide an inordinate amount of restrictions
Notice of Excluded Medicare Benefits, (NEMB) instead of
an ABN. Which one of the following services, although
never covered, requires an ABN?
233. Which of the following statements are true?
1. Vaccinations
1. An employee must complain to the appropriate super2. Routine eye care, eyeglasses and examinations
visor in order to have claim of harassment
3. Services under a physician’s private contract
2. If most people laugh at your colorful language and
4. Acupuncture
jokes, it’s not harassment.
3. Harassment doesn’t cover joking with people who are
my same sex or race.
228. Select the most import item(s), (in the following list), that
4.
Only
the person who is targeted with offensive behava practice specializing in the treatment of interventional
ior can complain.
pain management needs to know before it signs a
managed care contract
1. How important this contract is to its practice
2. Whether or not all of the pain management specialists 234. Which of the following incorporation types does not
give an owner the ability to deduct business losses on
in the city or region are members of the plan
individual tax returns?
3. What the reimbursement is for the services the practice
1. Sole Proprietorship
currently provide or anticipate adding to its practice in
2. C-Corp
the future, by CPT procedure code
3. S-Corp
4. How much the insurer pays for the list of CPT codes
4. General Partnership
that it provides as an Exhibit or an Attachment
229. Which of the following is the least crucial element of
235. Which of the following best describe approaches for
maximizing income?
generating employee improvement that can be used as
1. Patient volume
part of the evaluation process?
2. Reimbursement rates
1. Develop goals and objectives for employees whose
3. Minimizing overhead
performance is satisfactory, and those whose perfor4. Quality of care provided
mance is inconsistent or marginal.
2. Develop a bar graph comparing productivity of all
230. Medicare beneficiaries now have Medicare HMO options
employees in the department/division, and attach it to
known as Medicare+Choice (M+C). With regard to a
each employee’s performance evaluation.
provider and/or beneficiary’s appeal rights, choose all
3. Develop performance requirements for employees
that apply.
whose performance is unsatisfactory
1. The right to request an expedited reconsideration of a
4. Develop photos from the office holiday party and
denied service
promise not to post at the front desk if performance
2. The right to request and receive appeal data from M+C
improves
organizations
3. The right to receive notice when an appeal is forwarded
to an Independent Review Entity (IRE)
4. The right to request Administrative Law Judge (ALJ) 236. On April 20, 2007 Dr. Jones receives a letter from Medicare
dated April 15, 2007 requesting 60 records on specific
hearing if the IRE entity upholds the original adverse
patients for dates of service January 1, 2005 through June
determination and the remaining amount in contro30, 2006. The letter requires that Dr. Jones provide copies
versy is $100 or more.
of the records within thirty (30) days of the date of the
letter. Which of the following would be an appropriate
231. Identify the desired outcomes measures for clinical
response by Dr. Jones:
guidelines.
1. Send the requested records in so that Medicare receives
1. Improve quality of care.
them before May 15, 2007.
2. Improve individualization without consistency.
2. Call immediately and request an extension of time
3. Lower healthcare expenditures.
from Medicare in order to ensure a full response to the
4. Increased liability.
record request.
3. Send the records by certified mail, return receipt requested.
232. Identify accurate statements about clinical policies
4.
Review the records carefully and then provide Medi1. They are expensive and labor intensive to develop and
care with only those records supporting the services
maintain
provided.
2. The actual impact on the quality of care is nearly impossible to determine
ASIPP
26
237. When a physician practice receives an adverse
determination for all or part of a claim for services
from a payer with whom h/she is contracted, it should
immediately
1. Write to the State Insurance Commission to complain
and ask for intervention
2. Call the payer provider information line to ask why the
claim was not paid
3. Resubmit the claim with a different CPT procedure
code and/or a different ICD-9 diagnosis code
4. Review the reason for denial, documentation, payers
Medicare policy, and any pre authorization.
Coding, compliance and Practice Management
241. How do you report the unlisted drug code J3490 so payer
knows how much to reimburse for the drug?
A. List the code J3490 in the “procedure code “ field (24D)
and the amount of the drug given in the number of
services field, (24G) attach a letter that describes the
drug
B. List code J3490 in 24D and number “1” in the units/
services field (24G) and list the name of the drug, the
amount given and the strength in the information
field (Box 19 on the 1500).
C. CMS doesn’t pay for unlisted drugs; they should not be
reported to Medicare
D. List J3490 in 24D, and the amount used in 24G and
always send an invoice with the claim for the unlisted
drug
E. Collect from the patient.
238. Choose the accurate statement regarding interventional
pain management treatment modalities.
1. Implantable therapies including intrathecal pumps
and spinal cord stimulators have been shown to be 242. A potential False Claims Act issue is billing patients for
medically unnecessary services. In this context, medically
cost effective when treating patients with back and leg
unnecessary services are . . .Choose the answer that best
pain diagnosed post-laminectomy syndrome.
completes this sentence.
2. The evidence supporting percutaneous adhesiolysis for
A. Those services not warranted by a patient’s documenttreatment of back and leg pain in patients with posted medical condition.
laminectomy syndrome is strong for short term (<3
B.
Those
services that are not approved by the Health and
months) pain relief and moderate for long term relief.
Human Services Department (HHS).
3. The evidence supporting medial branch neurotomy
C. Those services not required for a patient’s survival.
treatment for the relief of facet joint pain is strong for
D. Those services that do not yet have a CPT code.
short term (<6 months) pain relief and moderate for
E. Services that have not actually been performed on a
long term pain relief.
patient.
4. Sacroiliac joint injections have been proven to be cost
effective in post lumbar surgery patients with sacro243. Which of the following is coded as an adverse effect in
iliac pain.
ICD-9-CM?
A. Paralysis secondary to multiple sclerosis
239. Chronic pain is described as:
B. Rejection of transplanted heart
1. Pain that persists beyond the usual course of an acute
C. Dizziness due to side effect following administration
disease or a reasonable time for any injury to heal.
of Gabapentin
2. Persistent pain that is not amenable to routine pain
D.
Non-functioning
spinal cord stimulator due to defeccontrol methods.
tive design.
3. Pain in which healing may never occur.
E. Reaction to antibiotic administered prophylactically
4. Pain that exists longer than 1 month.
SECTION 3: CODING AND BILLING
Directions: Choose the best answer
244. Select true statements about upcoding:
A. It is the largest risk area outside of unbundling
B. Compliance with documentation guidelines may not be
the most important aspect
C. It is not necessary to meet level of care if computerized
records are used.
D. Medicare will investigate only down coding.
E. Medicare will reward you for upcoding
240. How do you determine the “number of services/units” to
list on the CMS 1500 form (or electronic field) for the “J”
245. Choose the accurate statements describing legitimate
codes?
professional courtesy:
A. All “J” codes are reported as “1” unit
A. When a physician practice waives coinsurance obligaB. List the number of mgs, mls, mcgs, or units that are
tions or other out-of-pocket expenses for other phyadministered to the patient in the “number of services
sicians or family members, but only based on their
field”.
referrals.
C. Each “J” code lists a specific dosage, such as, “per 10
B. When a hospital or other institution waives fees for
mg”.
services provided to their medical staff, but not emD. Convert the amount listed in the “J” code to ml’s and
ployees.
calculate the number of ccs were used
C. When an organization waives fees based on proportion
E. All “J” Codes are reported as “10” units.
of referrals.
ASIPP
Coding, compliance and Practice Management
D. When a physician practice is able to collect full fee, by
increasing charges proportionately.
E. When a physician practice waives all or part of a fee
for services for office staff, other physicians or family
members.
27
physician’s opinion as to what course of treatment is
preferable for an inpatient. Upon entering the room, the
pain physician realizes that he has seen the patient in his
own practice during the past year. The pain physician
documents a consult and puts it in the medical chart.
This service should be coded as follows:
A. An initial hospital care code because this is the first
time the physician has seen the patient during this
hospital stay
B. A subsequent hospital care code because this is an established patient, thereby precluding either an initial
hospital care code or a consult
C. An inpatient consult
D. An outpatient consult
E. A confirmatory consult
246. An established patient last seen in January 2002, presents
for a visit in June 2005. Based on the length of time
between visits, the physician performs a complete H&P,
including a detailed history, a comprehensive exam,
accompanied by moderate medical decision making. On
the same visit, the physician decides to perform a lumbar
epidural steroid injection since a prior set of injections
had worked in 2002. These services are coded as follows:
A. 99204 – level 4 comprehensive new patient visit
B. 99214 – level 4 established patient visit
C. 62311 – epidural only; the visit is not billable since the 249. A pain physician receives a consult request from a
referring surgeon for an inpatient. After the initial
visit is related to the procedure
consult, the pain physician continues to make additional
D. 62311 and 99204 -25 – due to the length of time bevisits to the patient to monitor the course of treatment.
tween visits, the visit qualifies as a new patient visit,
These additional visits should be coded as:
which is billable with a procedure because a new paA. Subsequent hospital care visits
tient visit is typically above and beyond the usual preB. Inpatient consults
procedure visit bundled into the procedure
C. Follow-up inpatient consults
E. 62311 and 99214-25 – Once an established patient,
D. Confirmatory consults
always an established patient, but since the visit was a
E. Outpatient consults
complete H&P, it is billable in addition to the procedure.
250. What are the accurate statements about billing and
compliance?
247. An established Medicare patient arrives to have the
A. A physician may mark up durable medical equipment
second lumbar epidural performed. Prior to the
items under the Stark Physician Self-referral in-office
epidural, the physician performs a visit in which he
ancillary services exception.
takes an interval history to determine the effect of the
B. If a practice which does not have a compliance plan
first epidural, and makes an assessment that the second
discovers a billing error, it is not necessary for this
epidural is warranted. The physician dictates the patient
practice to make a voluntary disclosure and a refund
encounter, the interval history, his assessment and the
of the overpayment.
plan to proceed with the second epidural. This patient
C. When a provider receives a payment from Medicare
encounter should be coded as:
that should have gone to the patient, the provider
A. 62311 and 99213 – Both the epidural and the visit were
should keep the payment.
medically necessary, and both can be billed.
D. Direct supervision is defined as “The physician is reB. 62311 and 99213-25 – The 25 modifier must be apsponsible overall, but is not necessarily present at the
pended to the E&M code in order for the visit to be
time of procedure.”
payable. The 25 modifier indicates that the visit was
E. If an employee files a qui tam (whistleblower) suit
separate and distinct or above and beyond the usual
against his or her employer, the employer may ask
pre-procedure visit, which is supported by the facts in
the employee to stay out of the work place and refrain
this scenario.
from speaking to his or her co-workers until a full inC. 62311 – The visit is not billable because the visit was
vestigation has taken plan.
part of the usual pre-procedure visit that is bundled
into reimbursement by Medicare of the procedure
D. 62311-22 – Whenever one performs a visit and a proce- 251. Identify accurate statements: When a health care provider
fails to honor a patient’s written request for an itemized
dure, but does not bill the visit, one adds the 22 modistatement of items or services within 30 days, what
fier to show that the procedure was more complex
penalties may the provider face from the HHS Office of
than usual, which allows the provider to obtain extra
Inspector General (OIG)?
reimbursement.
A. Exclusion from Medicare program
E. 99215 – The provider can bill either the procedure or
B. Civil monetary penalty of $5,000
the E&M visit. Since the procedure is not billed, the
C. Civil monetary penalty and exclusion
provider can elect to raise the visit level to level 5 to
D. Civil monetary penalty of $100 for each unfilled recompensate for not billing the procedure.
quest
E. Criminal penalty with 6 month prison time.
248. A pain physician receives a consult request from a
referring orthopedic surgeon requesting the pain
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28
Coding, compliance and Practice Management
252. Dr. Bob is on vacation and his patient Mrs. Smith, a 257. A physician sees a new patient in the office who has been
Medicare beneficiary, will be seen in the office today by
recently diagnosed with cancer. The physician performs
the NP. Dr. Bob evaluated Mrs. Smith and initiated Mrs.
the history, exam and medical decision making. The
Smith’s treatment plan 3 weeks ago. Dr. Jim, another
physician documents that he spends 60 minutes with the
member of the group is seeing patients in the office
patient in the exam room. However, during the exam,
during Mrs. Smith’s visit. Mrs. Smith does not have any
the patient becomes tearful and upset with the prospect
new complaints; the NP evaluates her and advises Mrs.
of dying, requiring the physician to spend a majority of
Smith to continue treatment plan that Dr. Bob initiated.
the visit educating the patient about his particular type
How is the service reported to Medicare?
of cancer and counseling the patient about his diagnosis
A. Report the service using the NP’s own name and PIN
and prognosis, all of which the physician documents. As
number
a result of the patient’s condition, the physician forgets
B. Report the service as an “incident to” service, using Dr.
to document the review of systems as well as the past,
Bob’s name and PIN number
family, and social history. The encounter is appropriately
C. Report the service as an “incident to” service, using Dr.
coded as:
Jim’s name and number
A. 99201 – a level 1 new patient visit because without a
D. Report as an “incident to” service with Dr. Jim’s PIN
review of systems or past, family, social history, the
and name. List Dr. Bob’s name and UPIN number as
highest code that can be billed is a level 1.
the “referring doctor (Boxes 17 & 17a & 17b) on a paB. 99202 – a level 2 new patient visit because without a
per form or in the corresponding field when the claim
review of systems or past, family, social history, the
is filed electronically.
highest code that can be billed is a level 2.
E. Report as an “Incident to” service using Dr. Bob’s PIN
C. 99203 – a level 3 new patient visit because the physician
and name.
is not required to fill out the review of systems or the
past, family, or social history, since a the patient can fill
253. When a pain specialist performs a 3 level lumbar
out the review of systems and a nurse can fill out the
discogram in an outpatient hospital place of service
past, family and social history.
(POS) 22, films are taken, and a report is issued what
D. 99204 – a level 4 new patient visit because under exradiology code(s) should be reported:
treme patient circumstances such as fear of dying due
A. 72295-26 x 3
to cancer, the CPT Code allows the coding of a level 4
B. 72295-26 x 1
even without the otherwise required documentation.
C. 77002-26, 72295-26
E. 99205 – a level 5 new patient visit because the physiD. 77003, 72295 x 3
cian documented that he spent enough time with the
E. 77002X3, 72295X1
patient to warrant a level 5, i.e., 60 minutes, and the
physician documented that the majority of the time
254. When a physician loans a C-Arm to an ambulatory
was spent counseling about the patient’s diagnosis and
surgical center, place of service (POS), 24 where h/she
prognosis.
performs procedures, the correct code to report for
fluoroscopic guidance for a facet injection is:
A. 77003-26
258. A pain physician sees a Medicare pain patient in the
B. 77002-26
office for the pre-procedure visit relating to a scheduled
C. 77003
epidural that day. The patient has been complaining of
D. 76000-26
radicular back pain. On the date of the procedure, the
E. 77003TC
patient also complains of headaches that have become
unmanageable by over-the-counter medications. The
255. When an epidurogram is performed in the office, place of
physician performs a level 3 E&M service for the headache.
service (POS) 11, images are taken and a formal radiologic
The physician also performs a brief E&M service for the
report is issued, the physician should report code(s):
back to insure that the clinical indications still warrant
A. 77003 and 72275
the epidural. The physician prepares one dictation, in
B. 77002 and 72275-26
which he includes the patient’s headaches, the low back
C. 72275
pain, and the lumbar epidural injection for that day. The
D. 77003-26 and 72275-TC
physician prescribes narcotics for the headaches. This
E. 72275 and 77002 TC
patient encounter should be coded as:
A. 62311 – Bill only the procedure code because the E&M
256. When a physician performs a facet joint nerve injection
services are bundled
using fluoroscopic guidance in an office setting, place of
B. 99215 – Combine the two E&M services into the highservice (POS) 11, he/she should report what code(s):
est E&M code because 99215 pays more than a lumbar
A. 76000-26
epidural in the office
B. 77003
C. 62311 and 99213-25 – Bill both the procedure and the
C. 77003-26-TC
E&M code for the headaches, provided that the level
D. 77002
of the E&M code relates solely to the headaches and
E. 77002-26
not the back
ASIPP
Coding, compliance and Practice Management
D. 62311 and 99215-25 – There are two separate E&M services, one for the headaches and one for the low back;
combine the two E&M services (levels 3 and 2) to bill
one level 5 E&M code.
E. 62311 and 99211-25 – The failure of the physician to
dictate a separate note on a separate piece of paper for
the headaches reduces the work value of the level 3
E&M code to level 1.
259. A 38-year old white female who underwent multiple
lumbar surgeries with low back and lower extremity
pain underwent one-day adhesiolysis with CPT 62264.
She underwent adhesiolysis in the past with average
relief of 3 months on 3 occasions in the past. This has
improved her physical and functional status. Following
the last adhesiolysis, which was performed bilaterally,
however, the catheter was positioned at the end of the
procedure on the left side laterally and ventrally. The
medications included 5 mL of Xylocaine 2% preservative
free, 6 mL of 10% sodium chloride solution, and 6 mg of
non-particulate Celestone. She complained of significant
pain with the last dose of hypertonic sodium chloride
injection in the recovery room on the right side. This
was managed by giving her 1 mL of Fentanyl and 30 mg
of Toradol. She presented 3 days after the injection with
severe intractable pain on the right side of the lower
extremity and low back with inability to move, however,
the examination showed only mild subject weakness
with no neurological deficit. She was unable to tolerate
Neurontin. She received only 20% to 30% relief with
hydrocodone 4 times a day. A week after the procedure,
MRI showed no evidence of abscess, discitis, etc. since she
continued to be in pain, the physician performed a caudal
epidural steroid injection under fluoroscopy in an ASC.
Choose the correct statement for coding this visit:
A. Code 62311 – epidural steroid injection and caudal
or lumbar epidural steroid injection and 99214
– established outpatient visit due to a detailed history,
detailed examination and medical decision making of
moderate complexity
B. Code 62311 – caudal epidural steroid injection only
C. Code 99214-25 – office visit only without a procedure
D. Neither Code 62311 nor an evaluation code 99214 or
any other code may be charged as the patient is in the
10-day global period for the procedure
E. Code 62311-78 return to the operating room for a
related procedure in post-operative period and 9921425 – may be charged
29
B. CPT 62273- epidural blood patch
C. CPT 62273 – lumbar epidural blood patch, CPT 9921325 - office or other outpatient visit with medical decision making of low complexity
D. CPT 62311-78 – lumbar epidural injection, return to
the operating room for a related procedure during the
postoperative period
E. CPT 62311-79 – lumbar epidural, unrelated procedure
or service by the same physician during the postoperative period
261. An interventional pain physician billed for blocking of
left T5/6 and T9/10 facet joints. What are the nerves to be
blocked for proper blockage of both joints?
A. T3 and T4 medial branches on the left side
B. T4 and T5 medial branches on the right side
C. T3, T4 and T6, T7 medial branches on the left side
D. T4, T5 and T7, T8 medial branches on the left side
E. T5, T6 and T8, T9 medial branches on the left side
262. You are asked to perform diagnostic facet joint nerve
blocks to block L3/4 and L4/5 facet joints on the right
side. What are the correct medial branches needed to
block these two joints?
A. Right L2, L3, and L4 medial branches
B. Right L3 and L4 medial branches and L5 dorsal ramus
C. Right L1, L2 and L3 medial branches
D. Right L3 and L4 medial branches
E. Right L1, L2, and L4 medial branches and L5 dorsal
ramus
263. A patient is admitted to the hospital by a general surgeon.
The pain physician is requested to see the patient for
the purpose of providing whatever pain treatment was
necessary during the hospital stay. Regarding the pain
physician’s initial visit, made for the purpose of assessing
a course of treatment, that visit should be coded as
follows:
A. An inpatient initial hospital care code
B. A subsequent hospital care code
C. An inpatient consult
D. An outpatient consult
E. A confirmatory consult
264.True statements about IDET coding include all of the
following, EXCEPT:
A. A new code was established effective January 1, 2007
B. IDET codes are 22626 (22527 is add’l level)
C. Moderate sedation by the surgeon performing IDET
is bundled
260. A 58-year old white male underwent a trial subarachnoid
D.
Fluoro
is not bundled
infusion with morphine for neuropathic pain of lower
E. 22526 and 22527 may not be reported as bilateral proextremity. A day after the catheter was removed, the
cedures
patient complained of postural headache and was
diagnosed with postlumbar puncture headache. The
patient failed to respond to caffeine and bedrest , hence, 265. What are the correct statements about standards and
guidelines?
it was decided to proceed with an epidural blood patch.
A. Standard is a degree of quality, level of achievement,
Choose the correct statement with regards to coding of
etc., regarded as desirable and necessary for some
this A. CPT 62310 – caudal or lumbar epidural injection
purpose.
and CPT 99213-25 – office or other outpatient visit of low
complexity
ASIPP
30
Coding, compliance and Practice Management
B. Standards are systematically developed statements to
help practitioners and patients make decisions about
appropriate health care for specific clinical circumstances.
C. Guidelines are documents demonstrating a degree of
quality, level of achievement, etc., regarded as desirable and necessary for some purpose.
D. Guidelines are superior to standards
E. Guidelines are the same as standards
266. A pain physician performs a procedure on a nonMedicare inpatient for the implantation of a femoral
nerve catheter for continuous infusion. As is typical of
indwelling catheters, the pain physician rounds on the
patient for 3 days and then discontinues the catheter. The
daily pain rounds should be coded as:
A. 99231 – A level 1 subsequent hospital care code
B. 01996 – Catheter management is coded with 01996
C. No code – This service is bundled into payment for the
placement of the catheter
D. 99231-58 – The 58 modifier is for staged procedures or
services, and it is contemplated that catheter management constitutes a different stage of the service from
the procedure.
E. 01996-59 – The 59 modifier indicates that the post-op
rounds were a distinct and separate service from the
insertion of the catheter. Since this is not a Medicare
patient, the usual bundling rules do not apply.
267. A pain physician performs surgery on a Medicare patient
for the percutaneous implantation of neurostimulator
electrodes. Thirty days later, the patient is complaining
of pain in the area of the electrode implantation. The
physician sees the patient to rule out infection or other
complications. The physician takes an expanded problem
focused history, performs an expanded problem focused
exam, and engages in low medical decision making. This
patient encounter should be coded as:
A. 99213 – An expanded problem focused history and
exam, together with low medical decision making are
exactly the requirements for 99213.
B. 99212 – Inspection of a surgical site which does not
result in any surgical revision is coded as a level 2.
C. No code – The physician cannot bill this code because
it relates to a complication for which a return to the
operating room is not necessary, and occurs within the
90-day Medicare global for electrode implants.
D. 99213-25 – Use the 25 modifier to indicate the visit is
separately billable.
E. 63660-52 – Bill the code for the revision of the electrodes with the 52 modifier for reduced services since
the E&M is not billable.
268. A pain physician sees an established patient who speaks
very poor English. The patient brings his wife, but her
English isn’t much better. The patient’s neck pain has
recently gotten worse, but there hasn’t been any new
incident to cause it. The physician takes a expanded
problem focused interval history, and performs an
expanded problem focused exam. Medical decision
ASIPP
making is low. There was no time spent counseling.
Nevertheless, the physician spends 45 minutes face to face
with the patient due to communication problems with
the patient and his wife. This patient encounter should
be coded as:
A. 99213 – An expanded problem focused history and
exam, together with low medical decision making are
exactly the requirements for 99213. The physician
cannot bill for the extra interpretation time.
B. 99214 – The physician increases the normal level of
99213 by 1 level to accommodate for the increased
interpretation time.
C. 99215 – The physician spent 45 minutes with the patient, and a level 5 typically involves 40 minutes, so the
physician can code a level 5.
D. 99213 and 99354 – The physician bills the correct E&M
code for the services performed, and then captures
the additional 30 minutes with the prolonged services
code, 99354.
E. 99215 and 99211-25 – The physician spent 45 minutes
with the patient; 5 minutes is equivalent to 99211, and
40 minutes is equivalent to 99215.
269. A pain physician sees a new patient who was referred
by an orthopedist for 3 epidural steroid injections. The
pain physician has purchased an E&M electronic medical
record (EMR) which operates on a palm pilot device. The
pain physician’s routine for each new patient is to spend
about 15 minutes with the new patient. The use of the
EMR allows the physician to fill out enough information
to document a comprehensive history, comprehensive
exam, and moderate medical decision making. There
was no time spent counseling. This patient encounter
should be coded as:
A. 62311 and 99201-25 – any time a script comes from a
referring physician with an order to perform 3 epidural
steroid injections, the visit should be coded as level 1
B. 62311 and 99202-25 – The CPT Code provides that a
physician typically spends 20 minutes in a 99202; here
the physician is spending 15 minutes on average with
new patients; a physician cannot use an EMR to artificially inflate the documentation so as to code a higher
visit than would be medically necessary; otherwise, the
physician could consistently bill level 5 visits, which
typically take 60 minutes per the CPT Code, in just
15 minutes.
C. 62311 and 99203-25 – The use of the EMR causes the
code to be inflated, so since the documentation warrants a level 4, and the time equates to a level 2, average
them out to bill a level 3.
D. 62311 and 99204-25 – Time is not the issue; the EMR
is designed to capture documentation levels for Medicare billing; so one looks solely to the comprehensive
history, comprehensive exam, and moderate medical
decision making, which equates to a level 4.
E. 62311 and 99205-25 – A new patient visit only needs
two of the three elements of an evaluation and management code, so the comprehensive history and
comprehensive exam are enough to warrant a level 5,
regardless of the moderate medical decision making.
Coding, compliance and Practice Management
31
270. A pain physician sees an established elderly patient who 272. A pain physician receives a request from a referring
had back surgery 3 years ago. The patient’s complaints
surgeon to perform a series of 3 epidural steroid
are new based on a slip and fall that recently occurred.
injections on a patient the pain physician has not seen
The physician takes a comprehensive history based on
before. In order to ascertain whether the referring
the new event. The physician performs a comprehensive
surgeon’s ordered treatment is the correct treatment, the
musculoskeletal exam based on the new event. The
pain physician performs a level 4 H&P. After performing
comprehensive history and exam are both medically
the H&P, the physician performs a lumbar epidural
necessary. The physician spends 40 minutes with the
injection. This patient encounter should be coded as:
patient which is typical for a level 5 established patient
A. 62311 – the visit is not billable because it is bundled
visit. However, the diagnosis is readily apparent to the
into the procedure
physician once the history and exam are done, such
B. 62311and 99244 – the procedure and a level 4 consult
that the medical decision making is low. This patient
are both billable
encounter should be coded as:
C. 62311 and 99204 – the procedure and a level 4 new
A. 99211 – low medical decision making automatically
patient visit are both billable
reduces the coding to level 1
D. 99204 – a level 4 new patient visit only because the
B. 99212 – low medical decision making automatically
procedure is bundled into the visit
reduces the coding to level 2
E. 99244 – a level 4 outpatient consult only because the
C. 99213 – Ordinarily, this would be level 5, except for
procedure is bundled into the visit
the low medical decision making, which reduces this
to level 3
D. 99214 – Ordinarily, this would be level 5, except for 273. In a patient with bilateral chest wall pain, a physician
the low medical decision making, which reduces this
performed bilateral intercostal nerve blocks at 7th, 8th,
to level 4
and 9th intercostal nerves under fluoroscopy. What is the
E. 99215 – An established patient visit only needs two
correct coding for these procedures?
of the three elements of an evaluation and manageA. CPT 64420 – single intercostal nerve block and CPT
ment code. The exam and history constitute 2 of the
64421 – multiple intercostal nerve blocks
3 E&M elements; they both are comprehensive which
B. CPT 64421-50 multiple intercostal nerve blocks and
warrants a level 5, and they are both stipulated to be
CPT 77002 – fluoroscopic visualization
medically necessary. Therefore, the low medical deciC. CPT 64420 x 6 – single intercostal nerve blocks and
sion making does not reduce the level 5 code.
CPT 77002 x 6- fluoroscopic visualization
D. CPT 64421-50 – multiple intercostal nerve blocks, CPT
271. A pain physician sees an established patient. The patient’s
77003-50 - fluoroscopic visualization
complaint is the same as in prior visits, i.e., moderate back
E. CPT 64421 – multiple intercostal nerve blocks, CPT
pain, which is controlled by prescription medication,
77002 fluoroscopic visualization
which the physician refills in the same dosage and drug
type as he had in the past. Nevertheless, the physician
performs a comprehensive history, a comprehensive 274. A patient comes into the office to pick up a prescription
exam, and low medical decision making. There was no
for medication refill. The new receptionist takes the
time spent counseling. This patient encounter should be
patient’s chart into the doctor and the doctor looks at
coded as:
the medication record, writes a prescription and gives it
A. 99211 – a nurse could have performed this visit, so
to the receptionist to give to the patient. The receptionist
99211 is the correct code
hands the patient the prescription and tells the patient to
B. 99212 – this is a typical medication management visit,
have a nice day. This encounter should be reported to the
with no change in medication, and there was no mediinsurance company as:
cal necessity for a comprehensive exam, and as such,
A. 99211 - An incident to service because the receptionist
one should code only what was medically necessary,
is employed by the physician and the doctor looked at
which is a level 2
the chart and wrote the prescription;
C. 99213 – A detailed history warrants a level 3 under any
B. 99212 - The physician should report a level two office
circumstances
visit because the physician looked at the patient’s
D. 99214 – The combination of a comprehensive history
medication record and made a medical decision to
and comprehensive exam, even with low medical deciwrite the prescription;
sion making warrants a level 4
C. No charge should be submitted because the receptionist
E. 99215 – An established patient visit only needs two of
is not qualified to perform, and did not perform an ofthe three elements of an evaluation and management
fice visit and the doctor did not see the patient;
code, so the comprehensive history and comprehenD. 99213 - Anytime a physician writes a prescription, it is
sive exam are enough to warrant a level 5, regardless of
considered a management decision that justifies a level
the low medical decision making
3 office visit.
E. The level of code to charge depends on the patient’s
insurance company
ASIPP
32
Coding, compliance and Practice Management
however it has not been assigned a HCPCS “J” code. Dr.
275. A 44-year-old male, established patient, with chronic
Andrews should bill Medicare and all other payers for the
myofascial pain syndrome, effectively managed by
drug using the unlisted code, J3490 x 1 unit of services.
desipramine, gabapentin, and oxycodone 10/325 three
A. Dr. Andrews should bill all payers using unlisted drug
times daily presents with new onset of urinary hesitancy.
code J3490
Physician performs a problem focused history with low
B. Dr. Andrews should only collect a $5 handling charge
complexity of medical decision making. Physician refers
for the drug from the patients
the patient to an urologist. What is the appropriate EM
C. If any of the patients have Part D prescription coverage
code for this visit?
Dr. Andrews can bill Part D using the unlisted drug
A. 99211, established patient, office or other outpatient visit
code J3490 for Medicare patients, and non-Medicare
(time 5 minutes), no physician presence is required
payers as usual
B. 99212, established patient, office or other outpatient
D. Dr. Andrews can only bill non-Medicare payers using
visit, problem focused
J3490
C. 99213, established patient, office or other outpatient
E. Dr. Andrews may not send a bill to any payer for the
visit, expanded problem focused
drug
D. 99214, established patient, office or other outpatient
visit, detailed visit
E. 99215, established patient, office or other outpatient 278. A 46-year-old female, established patient, who is
experiencing increased symptoms while in a pain
visit, comprehensive
management treatment program involving interventional
techniques and medication management with exercise
276. Mrs. Kennedy, a Medicare beneficiary, arrived at Dr.
program, presents for reassessment and counseling.
Watson’s office for her third epidural steroid injection for
Interventional pain physician takes a detailed history,
low back pain with radiculopathy. She tells Dr. Watson
conducts an examination and provides the patient with
that she had a recurrence of her headaches in the past
counseling, instructing in an exercise program and
week. Dr. Watson takes a problem focused interim history
refers the patient to physical therapy and psychology.
and performs a problem focused examination before
Identify the appropriate coding for this evaluation and
writing a prescription. He then proceeds with the pre
management visit.
procedure history and a brief exam to ensure the patient
A. 99211, established patient, office or other outpatient
still requires the epidural injection. He performs the
visit (time 5 minutes), no physician presence is reinjection and the patient spends 20 minutes recovering to
quired
be sure she is stable.. The visit is appropriately reported:
B. 99212, established patient, office or other outpatient
A. 99212, 62311 - A level 2 exam (problem focused history,
visit, problem focused
exam and straightforward decision and the epidural
C. 99213, established patient, office or other outpatient
injection;
visit, expanded problem focused
B. 99213-25, 62311 - Since the physician performed a pre
D. 99214, established patient, office or other outpatient
procedure history and exam relative to the patients
visit, detailed visit
back pain and a history & exam for the headache, he
E. 99215, established patient, office or other outpatient
added the two together and reported a level 3 E&M;
visit, comprehensive
which requires an expanded problem focused history
and exam;
C. 62311- No exam should be reported, an exam is bun- 279. An established, 43-year-old female patient, with frequent
intermittent, moderate to severe episodes of low
dled into the procedure code;
back pain, requiring transforaminal epidural steroid
D. 99212-25, 62311 The physician should report both the
injections, hydrocodone therapy, presents with continued
exam and the injection. Since the exam was above
low back and lower extremity pain requiring her to miss
and beyond the work that the doctor would usuwork, presents for a follow-up visit,. Physician takes
ally perform before performing a scheduled epidural
history, performs a detailed examination, and changes
injection, a modifier -25 is appended to bypass the
medical therapy. At this time it was also decided that
bundling edit. A diagnosis code to indicate that the
patient will be referred for a neurosurgical consultation.
E&M code was for a headache should be linked to the
How would you code this visit?
E&M code.
A. 99211, established patient, office or other outpatient
E. 99213, 62311 no modifier is required because the exam
visit (time 5 minutes), no physician presence is reis not bundled when it is for a different condition
quired
B. 99212, established patient, office or other outpatient
visit, problem focused
277. Dr. Andrews works in a section of the city that is very
C. 99213, established patient, office or other outpatient
economically depressed and a significant number
visit, expanded problem focused
of his patients suffer from severe headache pain. A
D. 99214, established patient, office or other outpatient
pharmaceutical company asked Dr. Andrews to participate
visit, detailed visit
in continued clinical studies for a new headache drug that
E. 99215, established patient, office or other outpatient
it recently introduced. The vendor will supply the drug
visit, comprehensive
at no cost to Dr. Andrews. The drug is FDA approved;
ASIPP
Coding, compliance and Practice Management
280. An established patient for neck pain and headaches
returns with a new onset low back pain which started
following motor vehicle injury. Pain also radiates
into lower extremity associated with numbness and
tingling. Patient is evaluated with a detailed history,
and physical examination. Appropriate management
included evaluation with an MRI, physical therapy and
nonsteroidal anti-inflammatory drug therapy. How
would you code this visit?
A. 99211, established patient, office or other outpatient
visit (time 5 minutes), no physician presence is required
B. 99212, established patient, office or other outpatient
visit, problem focused
C. 99213, established patient, office or other outpatient
visit, expanded problem focused
D. 99214, established patient, office or other outpatient
visit, detailed visit
E. 99215, established patient, office or other outpatient
visit, comprehensive
281. Mary Ann, a Physician’s Assistant (PA) started working
for Dr. Bartlett on November 1, 2006. Prior to starting
work she filled out the necessary 855 Medicare enrollment
form. By December 8, 2006, Mary Ann was a credentialed
provider with Medicare and had been issued her provider
number. Select the accurate answer below:
A. Mary Ann may bill Medicare for her services under her
own name/number. Mary Ann is not required to accept assignment when she sees a new patientand bills
using her name and billing number;
B. Mary Ann may not bill ‘incident to’ services for Medicare beneficiaries when Dr. Bartlett is in seeing a patient in another office examining room;
C. Mary Ann may bill services she provides to Medicare
beneficiaries using her name and number; she must
accept assignment for the services;
D. Mary Ann may not provide any services to a Medicare
beneficiary when Dr. Bartlett is playing golf at the
club across town;
E. Mary Ann may see a new Medicare patient and bill using Dr. Bartlett’s name and number.
282. A Pain Management specialist provides all of her services
in St. Mary’s hospital outpatient pain clinic. Her practice
has grown considerably in the year since the clinic was
established. She is planning to hire a Nurse Practitioner
(NP) to assist her. Select the accurate answer:
A. The physician may only report services provided by
the NP employee as ‘incident to’ since the NP is the
doctor’s employee;
B. ‘Incident to’ services’ may not be reported to Medicare
when they are provided in a hospital outpatient clinic.
The provider should review non-Medicare payer
policies or write to the payers to inquire about their
policies;
C. When the NP and the physician share the visit, i.e., each
provider provides a portion of the service to a Medicare beneficiary during the encounter, Medicare does
not allow the doctor to report a service since the NP
33
participated in the beneficiary’s care;
D. The physician has a choice whether to report the NP’s
services to Medicare beneficiaries as ‘incident to’
(physician’s name and number) or report the NP’s
name and number.
E. All payers follow the same billing criteria as Medicare,
the doctor will follow Medicare guidelines for every
payer.
283. The AMA revised a number of radiology codes in the
2007 CPT Manual. Two codes have an impact on spinal
injections. Code 76005 was deleted and replaced by
77003. On January 2, 2007, Dr. Merriman performed
an interlaminar lumbar epidural injection under
fluoroscopic guidance for needle placement in his office,
place of service ‘11’ on Mr. Simpson who is covered by
an Aetna Insurance PPO plan. Dr. Merriman signed a
2 year lease for the C-arm in his office because he wants
to upgrade the equipment after 2 years. Select the
appropriate CPT codes and/or modifier(s):
A. 62311, 77003:
B. 62311, 76005-26
C. 62311, 76005
D. 62311, 77003-26
E. 62311 No fluoro may be reported
284. Effective January 1, 2007, CPT codes 76012 fluoroscopic
guidance for vertebroplasty per vertebral body and 76013,
CT guidance for vertebroplasty, per vertebral body, were
deleted. Two new CPT codes, 72291 (fluoroscopy) and
72292 (CT) with the same description, were established.
The CPT Manuals with code changes are released
in November of the proceeding year. If a provider
performed a vertebroplasty on 2 lumbar vertebrae using
CT guidance on December 30, 2006, what CPT codes
should he report?
A. 22521, 22522, 72292 x 2 units of service
B. 22521, 22522, 76013 x 2 units of service
C. 22521, 22522, 76013 x 1 unit of service
D. 22521, 22522, 76012 x 2 units of service
E. 22521, 22522, 72292 x 1 unit of service
285. Which of the following is the best predictor for a patient
with pain becoming violent?
A. Progressive psychomotor retardation
B. Prior diagnosis of a Dependent Personality Disorder
C. Past history of violence or destruction of property
D. Shouting at the office staff to be seen immediately
E. Shouting at the physician to change the medical record
286. Effective January 1, 2007, the AMA established CPT codes
22526, and 22527 to report intradiscal electrothermal
therapy (IDET). The manual shows a bulls eye symbol
next to codes 22526 and 22527, which indicates that
moderate sedation 99144, moderate sedation up to 30
minutes, 99145, each additional 15 minutes, is bundled
into the procedure. The anesthesia code for 22526 and
22527 is ASA 01905. Modifier -47 is described in the CPT
Manual as “anesthesia by surgeon”. The National Correct
ASIPP
34
Coding, compliance and Practice Management
Coding Initiative edits, to which Medicare Contractors
code for the service provided.
must adhere, bundles 01905, 99144-99150 and does not
A. -24 unrelated evaluation and management service by
allow a bypass modifier. Dr. Smith performed IDET on
the same physician during a postoperative period
the L3-4 and L4-5 intervertebral discs for Mr. Monroe, a
B. -79 unrelated procedure or service by the same physi40 year old patient covered by a Cigna Indemnity policy.
cian during the postoperative period
He also provided moderate sedation for Mr. Monroe
C. -59 distinct procedural service
because the patient was extremely apprehensive and
D. -25 significant, separately identifiable evaluation and
demonstrated a very low tolerance for pain. Sedation
management service by the same physician on the
time with Dr. Smith present was 50 minutes. Select the
same day of the procedure or other service
correct CPT codes to report for Dr. Smith’s services:
E. -58 staged or related procedure or service by the same
A. 22526, 22527, 99144, 99145
physician during the postoperative period
B. 22526, 22527, 01905
C. 22526-47, 22527-47
291. In evaluating quality and compliance with coding,
D. 22526, 22527
the degree to which the same results (same codes) are
E. 22526, 22527, 99144
obtained by different coders or on multiple attempts by
the same coder generally refers to:
287. As part of interventional pain management, you are
A. Validity
providing a patient with quarterly testosterone injections.
B. Completeness
Patient returns for a testosterone injection and was seen
C. Timeliness
by an RN and the injection was provided. How would you
D. Reliability
code this evaluation and management visit?
E. Accuracy
A. 99211, established patient, office or other outpatient
visit (time 5 minutes), no physician presence is re- 292. The Correct Coding Initiative (CCI) edits contain a listing
quired
of codes under two columns titled “comprehensive codes”
B. 99212, established patient, office or other outpatient
and “component codes.” According to the CCI edits, a
visit, problem focused
provider must bill Medicare for a procedure with the
C. 99213, established patient, office or other outpatient
following:
visit, expanded problem focused
A. Only the component code
D. 99214, established patient, office or other outpatient
B. Only the comprehensive code
visit, detailed visit
C. Both the comprehensive code and the component
E. 99215, established patient, office or other outpatient
code
visit, comprehensive
D. Comprehensive code and component code with modifier -59
288. An anesthesiologist performs a caudal epidural and
E. Comprehensive code and component code with moditwo lumbar interlaminar epidural steroid injections at
fier -51
different levels in a patient with chronic non-specific low
back pain. The accurate coding for these procedures is
293. Tachycardia after taking a correct dosage of prescribed
A. CPT 62311 – lumbar /caudal epidural steroid injection
oxycodone would be reported as (an):
B. CPT 62310 – cervical/thoracic epidural steroid injecA. Drug interaction
tion
B. Adverse reaction to a drug
C. CPT 62311 x 3 – lumbar/caudal epidural steroid injecC. Poisoning
tions
D. Late effect of an adverse reaction
D. CPT 62311 and 62311 x 2 – lumbar or caudal epidural
E. Late effect of a poisoning
steroid injections
E. CPT 62311 and 64483 & 64484 – caudal or lumbar 294. Dizziness and blurred vision following ingestion of
epidural and lumbar transforaminal epidural steroid
prescribed hydrocodone and three glasses of wine at
injections
dinner would be reported as a:
A. Poisoning
289. A direction to “Code first underlying disease” should be
B. Adverse reaction to a drug
considered
C. Late effect of a poisoning
A. Mandatory dependent upon the code selection
D. Late effect of an adverse reaction
B. A mandatory instruction
E. Drug interaction
C. Only when coding inpatient records
D. A suggestion only
295. Level III Healthcare Common Procedure Coding System
E. Applies only for worker’s compensation patients
(HCPCS) codes are updated by
A. CMS
290. A patient had lumbar disc decompression with 90-day
B. The fiscal intermediary
global period and presents one month later for an
C. AMA
unrelated Evaluation and Management (E/M) service.
D. AHA
Indicate the modifier that should be attached to the E/M
E. OIG
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Coding, compliance and Practice Management
296. What are the consequences of down coding?
A. Compliance with guidelines may not the most important aspect.
B. It is not necessary to assure proper coding of the level of
service during downcoding
C. Medicare will eventually reimburse all your down coding after 5 years.
D. Down coding is largest area of loss of revenue for the
practice
E. Medicare may not investigate down coding.
297. The “cooperating party” responsible for maintaining the
ICD-9-CM Disease classification is the
A. Centers for Medicare and Medicaid Services (CMS)
B. National Center for Health Statistics (NCHS)
C. American Hospital Association (AHA)
D. American Health Information Management Association (AHIMA)
E. National Institutes of Health (NIH)
298. Select the accurate statement about proper billing ?
A. Bill for items or services not rendered or not provided
as claimed
B. Submit claims for equipment, medical supplies and
services that are not reasonable and necessary
C. Double bill resulting in duplicate payment
D. Bill for non-covered services as if covered
E. Knowingly do not misuse provider identification numbers, which results in improper billing
299. Select the most accurate reason that the Place of Service
(POS) should be used on professional claims to tell the
payer where service(s) were rendered.
A. All payers allow payment for supplies when services are
provided in an office
B. When a hospital or ambulatory surgical center submits
a facility charge, third party payers hold the payment
until the physician submits the charge for his/her professional services for comparison of service codes’
C. Medicare and a number of non-Medicare payers allow
a higher payment when services are performed in a
physician’s office/clinic;
D. Third party payers use the place of service to determine
adjustments in the physician’s fee schedule for future
years.
E. All third party payers except Worker’s Compensation
allow a higher payment when services are provided in
an office.
300. Ms. Hilton, a Medicare patient, is in the hospital and has
been suffering from severe pain in both legs. Her pain
specialist diagnosed her condition as post laminectomy
syndrome and has tried several different therapies, none
of which has provided more than a few days of pain relief.
As a last resort, Ms. Hilton’s physician recommends a trial
for spinal cord stimulation. Ms. Hilton and her husband
and children are somewhat skeptical and told the doctor
that before they agree, they would like to have a second
opinion. The doctor arranges for a pain specialist, in a
different group practice, to see Ms. Hilton , the attending
35
physician asks for an opinion on other possible treatment
options for Ms. Hilton. The consultant performed a
detailed history & exam and made a medical decision
of moderate complexity. He dictated a report and his
opinion for the hospital record. He should report the
A. A subsequent care hospital visit from category 9923199233
B. An in-patient consultation code (99251-99255)
C. The specialist should have gotten an Advanced Beneficiary Notice, he may not bill Medicare
D. The specialist should report an outpatient consultation
code
E. The specialist should send a bill to the patient
301. According to the Center for Medicare and Medicaid
Services (CMS), the initial request for an inpatient
consultation may be verbal. However, both the requesting
and consulting providers must document the request in
the medical record.
A. The initial request for an inpatient consultation may be
verbal. However, both the requesting and consulting
providers must document the request in the medical
record.
B. CMS considers a Nurse Practitioner an appropriate
source to request a consultation from a physician
specialist.
C. In a transfer of care the receiving physician would report
the appropriate new patient visit code according to the
place of service and the level of visit performed.
D. A Nurse Practitioner may perform a consultation
service
E. A physician may not request a consultation from another physician member of the same group even if
that physician has expertise in a specific medical area
beyond the requesting physician’s knowledge
302. Do all of the National Correct Coding Initiative (CCI)
bundling edits correspond with CPT coding conventions
and the instructions in the CPT Manual?
A. Yes, Administar Federal, the contractor that develops
the edits coordinates with the CPT Editorial staff before quarterly updates are published
B. There is not always an NCCI edit t that corresponds
precisely to CPT coding conventions and instructions;
however AMA/CPT coding conventions do have a prevailing influence on coding edits
C. No, CMS local carrier decisions are the only policies
that Administar Federal considers when revising the
edits
D. Administar Federal relies solely on specialty society
manuals and communication from physicians to update the edits
E. A provision of HIPAA mandates that in 2009 the AMA
coding conventions be the same as CCI
303. A provider should make the same effort to collect the
amount owed by a non-Medicare patient as s/he does
from a Medicare patient because
A. All non-Medicare payers have a stipulation in the
Agreement that the provider signs that stipulates as
ASIPP
36
Coding, compliance and Practice Management
stated above
B. The doctor’s name is likely to wind up in a newspaper
article or “Letter to the Editor” if he doesn’t make
equal collection efforts for all patients
C. Medicare wants parity in the treatment of Medicare
and non-Medicare patients
D. The AMA published a mandate that collection efforts
are to be the same for all patients, regardless of insurance coverage
E. Patients not yet on Medicare generally can afford to pay
the co-pays & co-insurance
to obtain the precise muscle and injection location (CPT
95874). The procedure included injections into the right
sternocleidomastoid, splenius capitis, posterior scalene,
and oblique capitis inferioris muscle. An injection was
also made in the left semispinalis capitis. In addition to
CPT code 64613 for the injection procedure, what codes
should Dr. submit?
A. 95874 x 5, J0587 x 1
B. 95874 x 1, J0587 x 25
C. 95874 x 1, J0587 x 1
D. 95874-50, J0587 x 2500
E. 95874 x 1, J0587 x 1
304. Two of the most frequently and improperly used
modifiers that providers use to bypass National Correct 308. Dr. Sampson performed an L4 lumbar transforaminal
injection using fluoroscopic guidance for needle
Coding (NCCI) code edits are:
placement (CPT 76003). Since it was the patient’s first
A. Modifier 57 (Decision to do surgery) and modifier 24
injection he also performed a diagnostic epidurogram,
(Unrelated E&M by the same physician during a post(CPT 72275), hard copies of the images were put in
operative period
the patient’s record and Dr. dictated formal radiologic
B. Modifier 58 (Staged or related procedure/service by the
report. The work was performed in his office, POS 11.
same physician during the postoperative period and
In addition to the injection code what CPT procedure
modifier 24
code(s) should Dr. Sampson report?
C. Modifier 25 (Significant, separately identifiable E&M
A. 77003and 72275 ,77003 Fluoroscopic guidance and
by the same physician on the same day of the prolocalization of needle or catheter tip for spine or
cedure or other service) and modifier 59 (Distinct
paraspinous diagnostic or therapeutic injection proprocedural service such as different anatomic sites or
cedures (epidural, transforaminal epidural, subarachdifferent patient encounter)
noid, paravertebral facet joint, paravertebral facet joint
D. Modifier 76 (Repeat procedure by the same physician)
nerve or sacroiliac joint), including neurolytic agent
and modifier 25
destruction,72275 - Epidurography, supervision and
E. Modifier 24 and modifier 76
interpretation
B.
77002-26
and 72275-26:77003 Fluoroscopic guidance
305. Once CMS issues a National Coverage Decision, it will not
for needle placement (eg, biopsy, aspiration, injection,
reconsider until at least 7 years have passed.
localization device)
A. CMS does not reconsider an NCD under any circumC. 72275
stances
D. 77003-26 and 72275-TC
B. CMS may initiate a reconsideration process when it
E. 72275
receives an external formal request
C. CMS only initiates a reconsideration of its decision
309.Dr. Lincoln is an Interventional Pain Management
when a local Part B Carrier sends a request
specialist, primary specialty 09, with a sub-specialty
D. CMS will initiate a reconsideration of its decision only
designation of Anesthesiology, 05. A Medicare beneficiary
on request by the AMA
who
had anesthesia services from Dr. Washington, an
E. An official of the Department of Health & Human Seranesthesiologist (Spec. 05) in Dr. Lincoln’s group in
vices must request a reconsideration of a previously
June 2005, makes an appointment with Dr. Lincoln in
considered medical item or service
december 2005 for her low back pain which has been
increasingly worse in the last 3 months. Dr. Lincoln
306. What item(s) listed below does Medicare consider
performs and documents a comprehensive history, a
“incident to” a physician’s service and may be reported
detailed exam and makes a medical decision of moderate
and paid separately when services are provided in an
complexity. The visit should be reported as:
office setting, POS 11?
A. 99214 - A level 4 established patient visit which requires
A. Needles and syringes used to perform an injection/
a detailed history, detailed exam and medical decision
nerve block
of moderate complexity since Dr. Lincoln and Dr.
B. A substance such as Depo Medrol that is injected when
Washington are members of the same group;
a lumbar epidural steroid injection is performed
B. 99204 - A level 4 new patient visit, which requires a
C. Lidocaine that is used to anesthetize the area
comprehensive history and exam, medical decision
D. Pulse oximetry
making of moderate complexity, since the physicians
E. The time for the recovery period following the injecare not the same specialty and two of three requiretion
ments for a level 4 visit are performed and documented
307. Working in his office, Dr. Ledger is going to inject 2500
C. 99203 - A level 3 visit, which requires a detailed history,
units of Myobloc (J0587, per 100 units) in a patient’s
cervical spinal muscles. He used needle EMG guidance
ASIPP
Coding, compliance and Practice Management
a detailed examination and medical decision making
of low complexity. Dr. Lincoln and Dr. Washington
are not the same specialty, since Dr. Lincoln’s primary
specialty is 09, Interventional Pain;
D. 99203-22 - A level 3 visit with modifier -22, unusual
services, because the service was greater than usually
required for the code. Dr. Lincoln performed two of 3
elements that were higher than those that are required
to report a level 3 visit and he should be paid an additional amount.
E. 99213 A level 3 established patient visit which requires
an expanded problem focused history, an expanded
focused exam, and medical decision making of low
complexity
37
A. 99211 - A level one visit because the office nurse could
have asked the patient the questions and filled out the
questionnaire;
B. 99212 - No change in the patient’s status does not
warrant a comprehensive history, this is a problem
focused history and straightforward medical decision
making;
C. 99213 - A detailed history is reported since the visit
was not 25 minutes which is the threshold time for
a level 4;
D. 99214 - Management of a patient taking opioids is high
risk and regardless of the time spent, always warrants
a level 4;
E. 99212-22 - The visit should be modified to show the
payer that the physician is entitled to more than level 2
reimbursement for opioid management
310. A pain management specialist sees a Medicare patient
referred to her practice by Dr. Bush, a family practitioner.
Dr. Bush faxes a copy of his progress notes for the 312. A patient with established diagnosis of reflex sympathetic
dystrophy, with significant improvement after
patient’s last visit during which she complained of neck
sympathetic blocks, presently maintained on medical
pain, radiating down her right arm. In his note, Dr. Bush
therapy with gabapentin and desipramine, presents for
writes: “Ms. Chaney is also complaining of neck pain
an office visit. Physician spends approximately 5 minutes
radiating down her right arm. She said that she doesn’t
with the patient with focused history and straight forward
remember any specific incident that caused the pain;
medical decision making. What is the appropriate coding
however she and her husband took their grandchildren to
for this evaluation and management visit?
Worlds of Fun and she went on several rides. I explained
A. 99211, established patient, office or other outpatient
to the patient that I do not treat musculoskeletal
visit (time 5 minutes), no physician presence is reconditions and will send her to Dr. McCain for possible
quired
injections or whatever treatment he deems necessary.”
B. 99212, established patient, office or other outpatient
Dr. McCain should report his care as a consultation since
visit, problem focused
Dr. Bush referred the patient to him.
C. 99213, established patient, office or other outpatient
A. 99203 New patient visit requiring a detailed history and
visit, expanded problem focused
exam, medical decision of low complexity (Typical
D. 99214, established patient, office or other outpatient
time 30 minutes)
visit, detailed visit
B. 99204: New patient visit requiring a comprehensive
E. 99215, established patient, office or other outpatient
history and exam, medical decision of moderate comvisit, comprehensive
plexity (Typical time 45 minutes)
C. 99243: Consult requires a detailed history & exam,
medical decision making of low complexity (Typical 313. A non-Medicare inpatient underwent extensive knee
surgery. The anesthesiologist placed a femoral catheter
time 40 minutes)
for continuous infusion to control her pain. Another
D. 99203 and 99354: Prolonged service is reported to get
anesthesiologist, who is the pain specialist in the group
credit for additional time spent
rounds on the patient for 3 days. The first day the
E. 99244: Consult requires comprehensive history and expatient had increased pain and the doctor performed an
aml, medical decision of moderate complexity (Typiexpanded problem focused interval history and exam and
cal time 60 minutes)
made some adjustments in the medication. The patient’s
pain improved and visits on the 2nd and 3rd days were
311. An established Medicare patient who is on opioids
problem focused. The daily visits are reported using what
comes in for a prescription refill. The physician has
codes:
an interactive patient questionnaire that takes about
A. 99232x1 and 99231 x 2 - Subsequent care codes;
10 minutes to complete which he reviews with patients
B. 01996-52 x 3 - Daily hospital management of an epiduon narcotic management to comply with his strict
ral or subarachnoid continuous drug administration
controlled substance policy. The patient is stable and
with a modifier -52 since the catheter is not in the
is taking the medication as prescribed. No change in
epidural or subarachnoid space;
dosage is necessary. The doctor also uses electronic
C. 99232-25 x 1 and 99231-25 x 2 - The daily visits require
records complete with E&M templates. The doctor
a modifier -25 to indicate that the care is over and
uses the E&M template to perform and document the
above placement of the catheter after surgery;
necessary elements to complete a comprehensive history
D. No follow up days are billed because the code 64448
which took him another 10 minutes, for a total time of 20
specifically “includes daily management”
minutes with the patient. The visit is reported as:
E. 64447-52 x 3 days since the catheter was already in
place
ASIPP
38
314. A 44-year-old white female, an established patient
experienced reoccurrence of knee pain after she
discontinued Naprosyn for gastric irritation. She presents
for alternate therapy. Physician provides a 6 minute
visit with problem focused history and examination
and prescribes Mobic® 7.5 mg twice daily. What is the
appropriate coding for this visit?
A. 99211, established patient, office or other outpatient
visit (time 5 minutes), no physician presence is required
B. 99212, established patient, office or other outpatient
visit, problem focused
C. 99213, established patient, office or other outpatient
visit, expanded problem focused
D. 99214, established patient, office or other outpatient
visit, detailed visit
E. 99215, established patient, office or other outpatient
visit, comprehensive
315. A 32-year-old female was seen in interventional pain
management for persistent phantom sensations after
traumatic amputation. The physician evaluates the
patient with a detailed history, an expanded problem
focused examination and made a straightforward
medical decision. The physician advises with regards
to appropriate treatment and communicates with the
referring physician. What is the proper coding for this
evaluation and management service?
A. 99241, new or established patient initial office consultation, with a problem focused history and focused
examination with straightforward medical decision
making
B. 99242, new or established patient office consultation,
with expanded problem focused history and examination with straightforward medical decision making
C. 99243, new or established patient office consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient office consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient office consultation,
with comprehensive history and examination with
high complexity medical decision making
316. The medical decision-making is measured by all of the
following except:
A. Number of diagnoses/management options
B. Amount and complexity of data reviewed
C. Risk of complications
D. Specialty of the treating physician
E. Risk associated with diagnostic procedures
317. You were requested to provide a consultation on a 38year-old male with low back pain with radiation into
lower extremity. MRI findings were unequivocal. Physical
examination was normal. Nerve conduction studies were
negative. You advise the patient with regards to future
treatment and communicate with the referring physician.
In this evaluation a detailed history and examination was
ASIPP
Coding, compliance and Practice Management
carried out. Medical decision making included advice
to refer the patient to physical therapy. What is the
appropriate coding for this evaluation and management
service?
A. 99241, new or established patient initial office consultation, with a problem focused history and focused
examination with straightforward medical decision
making
B. 99242, new or established patient office consultation,
with expanded problem focused history and examination with straightforward medical decision making
C. 99243, new or established patient office consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient office consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient office consultation,
with comprehensive history and examination with
high complexity medical decision making
318. This following term describes translating codes from one
system to another (i.e., DSM-IV to ICD-9-CM)
A. Encoder
B. Prospective payment system
C. Crosswalk
D. Chargemaster
E. CPT
319. A 42-year-old female patient presents with intractable
chest wall pain following a radical mastectomy
performed 8 months ago for carcinoma of the breast. A
comprehensive history and examination was performed.
Physician communicates with referring physician and
provides medical decision making which was of moderate
complexity. How would you code this visit?
A. 99241, new or established patient initial office consultation, with a problem focused history and focused
examination with straightforward medical decision
making
B. 99242, new or established patient office consultation,
with expanded problem focused history and examination with straightforward medical decision making
C. 99243, new or established patient office consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient office consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient office consultation,
with comprehensive history and examination with
high complexity medical decision making
320. A 34-year-old patient, with post-cervical laminectomy
syndrome, presents with severe neck pain associated with
depression and drug dependency for your consultation.
Physician spends approximately 1½ hours with
comprehensive history and examination. What is the
appropriate coding for this visit?
Coding, compliance and Practice Management
A. 99241, new or established patient initial office consultation, with a problem focused history and focused
examination with straightforward medical decision
making
B. 99242, new or established patient office consultation,
with expanded problem focused history and examination with straightforward medical decision making
C. 99243, new or established patient office consultation,
with detailed history and examination with medical
decision making of low complexity
D. 99244, new or established patient office consultation,
with comprehensive history and examination with
moderate complexity medical decision making
E. 99245, new or established patient office consultation,
with comprehensive history and examination with
high complexity medical decision making
321. A 42-year-old male patient presents with localized low
back pain which started a week ago following strain.
There was no history of any medical problems. There
were no radicular symptoms. Patient had only local
tenderness without alteration of reflexes or sensation,
etc. What is the appropriate coding for this evaluation
and management service visit?
A. 99201, new patient office or other outpatient visit,
problem focused history and examination with
straightforward medical decision making
B. 99202, new patient office or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient office or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient office or other outpatient visit, with
comprehensive history and examination with moderate complexity medical decision making
E. 99205, new patient office or other outpatient visit, with
comprehensive history, examination and high complexity medical decision making
322. A long-term patient of yours brings her 12-year-old
daughter with progressive scoliosis. You take a detailed
history and conduct a detailed examination, advise
the patient with regards to further management
with a straightforward medical decision. What is the
appropriate coding for this visit?
A. 99201, new patient office or other outpatient visit,
problem focused history and examination with
straightforward medical decision making
B. 99202, new patient office or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient office or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient office or other outpatient visit, with
comprehensive history and examination with moderate complexity medical decision making
39
E. 99205, new patient office or other outpatient visit, with
comprehensive history, examination and high complexity medical decision making
323. A 21-year-old football player presents with five day old
injury complaining of severe low back pain and right
knee pain. The right knee is associated with swelling and
discoloration. What is the appropriate code for this initial
office visit?
A. 99201, new patient office or other outpatient visit,
problem focused history and examination with
straightforward medical decision making
B. 99202, new patient office or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient office or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient office or other outpatient visit, with
comprehensive history and examination with moderate complexity medical decision making
E. 99205, new patient office or other outpatient visit, with
comprehensive history, examination and high complexity medical decision making
324. A 68-year-old male presents with severe neck and
bilateral shoulder pain. His complaints included stress
incontinence. His physical examination was with brisk
deep tendon reflexes. The physician evaluation included
comprehensive history, comprehensive examination and
medical decision making of moderate complexity. Select
the appropriate coding for this initial office visit?
A. 99201, new patient office or other outpatient visit,
problem focused history and examination with
straightforward medical decision making
B. 99202, new patient office or other outpatient visit,
requiring an expanded problem focused history and
examination with straightforward medical decision
making
C. 99203, new patient office or other outpatient visit,
requiring detailed history and examination with low
complexity medical decision making
D. 99204, new patient office or other outpatient visit, with
comprehensive history and examination with moderate complexity medical decision making
E. 99205, new patient office or other outpatient visit, with
comprehensive history, examination and high complexity medical decision making
325. A review of the 13.0 CCI Edits show that CPT code 72275,
an epidurogram, is a component code (column 2) of
the more comprehensive CPT code 64483, (column 1)
lumbar transforaminal epidural injection. Code 77003,
fluoroscopic guidance for needle placement, is not listed
in column 2, i.e., bundled into code 64483. Dr. Johnson
wrote the following in his report: “Under fluoroscopic
guidance, after injection of 2mL of Isovue 300, an
epidurogram was performed.” The remainder of the
report describes the anatomical location of the needle,
ASIPP
40
Coding, compliance and Practice Management
the substances injected and the patient’s response. What
codes/modifiers should be reported?
A. CPT 64483, 72275
B. CPT 64483, 77003
C. CPT 64483-59, 72275
D. CPT 64483, 72275-59
E. CPT 64483, 77003-59, 72275
326. A new Medicare patient comes in to an interventional
pain specialist’s office for the first time complaining of
low back pain which started when she bent over to lift a
box 2 days ago. The physician proceeds to examine the
patient to rule out serious injury and to determine a
course of treatment. Based on the history & exam which
takes about 15 minutes, the doctor decides to perform an
ESI. The physician recently converted to an electronic
medical record (EMR) that operates on a palm pilot. He
has found that with the use of this palm and the EMR’s
E&M templates he can perform a comprehensive visit
and exam in 15 minutes. After completing the exam, he
performs the lumbar ESI. The encounter is coded:
A. 99202 and 62311-25 - It was medically necessary to
perform a history and exam to determine the course
of treatment and a modifier -25 should be appended
to the ESI code to bypass Medicare’s bundling edit;
B. 99202 and 62311 - The new patient history and exam
was performed to determine whether the patient had
a condition where an epidural injection would be contraindicated or the injury might
require additional studies perform the injection. It
is appropriate to report both codes, modifier – 25 is
usually not required for a new patient and a minor
procedure
C. 99204 and 62311 - Since the EMR provided the physician with the information that he needed to document
a higher level of service, the level documented should
be reported regardless of the time he spent;
D. 99203-25 and 62311 -The use of the EMR resulted
in a comprehensive visit and exam, the decision was
straightforward.Based on the time and medical decision making, the doctor compromised between a level
3 and level 4 and added modifier -25
E. 62311 No evaluation an management procedure should
be reported
327. A provider has how many days after receipt of Medicare’s
initial claim determination to file an appeal?
A. 60 days
B. 90 days
C. 365 days
D. 120 days
E. 45 days
328. Legible and complete medical records are not a factor
when:
A. A patient moves to another city and seeks care from a
new physician
B. A patient applies for a loan to buy a home with a 30
year mortgage
C. A third party payer conducts a billing review
ASIPP
D. A patient files a malpractice suit
E. A patient is admitted to the hospital
329. Select the item that is not required in the medical record
for a patient having a procedure performed in an
ambulatory surgical center (ASC):
A. A current history and physical
B. A signed consent for procedure form
C. The amount the ASC will bill the patient’s insurance
company
D. Discharge instructions
E. A list of the patient’s allergies
330. Dr. Jones total fee for a cervical epidural steroid injection
(CESI) under fluoroscopic guidance is $500.00. Mrs.
Simpson has had intermittent episodes of radicular pain
over the past 2 years and has gotten significant relief from
a CESI. She has not had pain since her last injection 8
months ago; however, she is going on a cruise and Dr.
Jones agreed to perform a prophylactic injection. The
correct billing procedure is:
A. Report the service to Medicare with a diagnosis of cervical radiculopathy;
B. Ask Mrs. Simpson to sign an Advanced Beneficiary
Notice. Dr. may charge Mrs. Simpson his usual fee
of $500;
C. Ask Mrs. Simpson to sign an Advanced Beneficiary Notice. Since Dr. Jones is a Medicare participating physician, he may only charge Mrs. Simpson The amount
Medicare will pay for the procedure;
D. There is no need to obtain an ABN, just explain that if
Medicare doesn’t cover the injection he will send her
a bill .
E. Obtain an ABN for the injection and keep in on file in
the event that the patient needs another prophylactic
service.
331. The 2007 CPT Manual added language in its instructions
for consultations that lists who qualifies as other
appropriate source. Which of the following is not
recognized by Medicare as an ‘appropriate source’?
A. Nurse Practitioner
B. Physician Assistant
C. Lawyer
D. Psychiatrist
E. Clinical Nurse Specialist
332. A patient develops difficulty during an interventional
procedure and the physician discontinues the
procedure. Identify the modifier that may be reported
by the physician to indicate that the procedure was A. -52
reduced services
B. -53 discontinued procedure
C. -73 discontinued outpatient procedure prior to anesthesia administration
D. -74 discontinued outpatient procedure after anesthesia
administration
E. -59 distinct procedural service
Coding, compliance and Practice Management
333. The Medical Director of a Local Part B Contractor was
suffering from persistent and severe pain in his right hip.
He had been seen by a number of different specialists,
and had undergone prescription treatment, physical
therapy, and injections into the hip joint with minimal
success. He finally received significant pain relief after
undergoing Prolotherapy. Since the Medical Director
of this Medicare Contractor found Prolotherapy to be a
reasonable treatment, he should:
A. Instruct the Carrier Advisory Committee to issue a
draft local coverage decision (LCD) allowing payment
for Prolotherapy for specific conditions
B. Publish an article in next month’s Part B Newsletter,
stating that Prolotherapy is covered for severe hip
pain Instruct providers to use CPT code 20610, injection large joint to report Prolotherapy injections - hip
joint
C. Since there is currently a National Coverage Decision
(NCD) that Prolotherapy is not a covered service, the
Part B Carrier may not cover Prolotherapy services;
D. Survey a representative selection of medical providers
in his region about the efficacy of Prolotherapy; if a
majority are in favor of allowing benefits, the Carrier
may cover the service.
E. Provide the service and appeal the denied claims with
an Administrative Law Judge.
334. There is an increased demand for health care provider
performance in an environment of consumer driven
health care. Hospitals’ performance is highly regulated.
The organization that is best known and widely
recognized for its hospital accreditation process is:
A. Centers for Medicare and Medicaid Services (CMS)
B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
C. State Medical Licensing Board
D. Medicare Quality Improvement Organization (QIO)
E. American Hospital Association (AHA)
335. What are the CPT codes describing new patient office
visits?
A. 99201, 99203, 99204, 99215
B. 99201, 99202, 99203, 99204
C. 99201, 99202, 99214, 99233
D. 99204, 99203, 99221, 99233
E. 99261, 99262, 99252, 99255
336. The time limit for a pre procedure assessment, intra
procedure note and discharge notes by a physician
performing a procedure in an ambulatory surgery center
should not exceed:
A. 30 days
B. 90 days
C. 60 days
D. 10 days
E. No time limit
337. Identify the accurate statement showing the differences
between consultation and a referral visit:
41
A. A problem is well known in both
B. A patient is referred for evaluation and treatment for a
consultation
C. Course of treatment is well known and predetermined
for a consultation
D. A patient is treated and followed in a referral visit
E. No correspondence is required as care is transferred in
consultation
338. According to ICD-9-CM, which one of the following is a
mechanical complication of an internal implant?
A. Erosion of skin by spinal cord stimulator electrodes
B. Epidural abscess following catheterization
C. Post lumbar puncture headache after spinal
D. Side effects of morphine in an intrathecal pump
E. Accidental injection of phenol into epidural space
339. A physician performed an outpatient surgical procedure
on the disc of a Medicare patient. Upon searching the
CPT codes and consulting with the physician, the coder is
unable to find a code for the procedure. The coder should
assign:
A. An unlisted Evaluation and Management code from the
E & M section
B. A HCPCS Level Two (alphanumeric) code
C. An anesthesia treatment service code
D. A code which is closest to the description
E. An unlisted procedure code located in the nervous system section
340. The Level II (national) codes of the Healthcare Common
Procedure Coding System (HCPCS) coding system are
maintained by the
A. American Medical Association
B. CPT Editorial Panel
C. Local fiscal intermediary
D. Centers for Medicare and Medicaid Services
E. International Classification of Diseases, Ninth Revision
(ICD-9 CM)
341. A nomenclature of codes and medical terms which
provides standard terminology for reporting physicians’
services for third party reimbursement is:
A. Current Medical Information and Terminology
(CMIT)
B. Current Procedural Terminology (CPT)
C. Systematized Nomenclature of Pathology (SNOP)
D. Diagnostic and Statistical Manual of Mental Disorders
(DSM)
E. International Classification of Diseases, Ninth Revision
(ICD-9)
342. A system of preferred terminology for naming disease
processes is known as a :
A. Set of categories
B. Diagnostic listing
C. Classification system
D. Medical nomenclature
E. International Classification of Diseases
ASIPP
42
343. A typical borderline patient will:
A. Develop a symptom of crisis to obtain attention.
B. Continue discussions of a rambling discoordinated
nature; Frequent flight of ideas.
C. Have many questions about their diagnosis.
D. Understand the potential for excessive risk.
E. Follow a compliant healthcare plan.
344. Which of the following is classified as a poisoning in ICD9-CM?
A. Reaction to contrast administered for epidurogram
B. Idiosyncratic reaction between various drugs
C. Carbazeran intoxication
D. Syncope due to cold medicine and a three martini
lunch
E. Motor paralysis for 2 hours following adhesiolysis
345. Dr. Smith requests a consultation from an interventional
pain physician on a patient in the hospital. The physician
takes a detailed history, performs a detailed examination,
and utilizes moderate medical decision-making.
The physician orders diagnostic tests and prescribes
medication. He documents his findings in the patient’s
medical record and communicates in writing with the
attending physician. The following day the physician
visits the patient to evaluate the patient’s response to the
medication, to review results from the diagnostic tests,
and discuss treatment options. What codes should the
physician report for the two visits?
A. An initial hospital visit and follow-up hospital care
B. An initial inpatient consult and initial hospital care
C. An initial inpatient consult and follow-up hospital care
D. An initial inpatient consult and a follow-up consult
E. An initial inpatient consult for both visits
346. DSM-IV-TR is used most frequently in what type of
health care setting?
A. Work hardening programs
B. Ambulatory surgery centers
C. Home health agencies
D. Behavioral health centers
E. Nursing homes
_____________________________________
Directions: Each question below contains
four suggested responses of which one or
more is correct. Select
A if
1, 2 and 3 are correct
B if
1 and 3 are correct
C if
2 and 4 are correct
D if
4 is correct
E if
All (1, 2, 3 and 4) are correct
_____________________________________
ASIPP
Coding, compliance and Practice Management
347. What are the examples of “unbundling?”
1. Fragmenting one service into component parts and
coding each component part as if it were a separate
service.
2. Reporting separate codes for related services when one
comprehensive code includes all relates services.
3. Breaking out bilateral procedures when one code is
appropriate.
4. Downcoding a service in order to use an additional
code when one high-level, more comprehensive code
is appropriate.
348. When the practice is making a decision whether to bill a
drug and/or how to bill for the drug, it should consider
which of the following?
1. Is the drug an expense to the practice?
2. Does the “J” code descriptor accurately describe the
drug administered?
3. What is the specific dosage described by the drug and
how much was given?
4. Does the local Medicare carrier have an LCD regarding
coding/billing requirements for this particular drug
(or compound)?
349. Under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) which third party payers are
required to use the National Correct Coding Initiative
(NCCI) bundling edits to determine claim payment?
1. All of the private payers that have insured lives in all regions of the United States such as United Health Care,
(UHC), Cigna, Aetna and Blue Cross Blue Shield.
2. All State Worker’s Compensation payers.
3. All Federal and third party payers regardless of size of
plan or location of insured lives
4. Medicare Part B Contractors are the only payers that
are mandated by CMS
350. What constitutes an electronic “clean claim”?
1. A claim that doesn’t have any modifiers appended to
the procedure codes
2. A claim that has includes the physician’s telephone
number
3. A claim that links only one diagnosis per procedure
line item
4. A Claim that is compliant with the HIPAA Transactions and Code Sets Rule and has accurate information about the patient and insured party
351. A consultation consists of some of the following
elements:
1. An opinion is requested
2. Request for opinion is received
3. The service/opinion is rendered and reported back
4. Patient is referred
43
Coding, compliance and Practice Management
352. What are the true statements about CPT history?
1. In 1956 the first edition of CPT was published
2. In 1960 the first edition of CPT was published
3. In 1965 Health Care Financing Administration adopted (HCFA) CPT
4. In 1988 AMA released minibooks
353. Choose the answers that apply? Do non-Medicare payers
allow separate payment for supplies such as needles,
syringes and/or surgical trays used for nerve blocks and
injections when they are performed in the office, POS 11?
1. No, private payers do not allow additional payment
for supplies
2. Payment for supplies used for nerve blocks and injections is payer specific. There is no “every carrier”
policy. Payers that have a fee differential modeled after
Medicare’s higher “office” rate are less likely to pay for
supplies
3. Yes, private payers will pay an additional fee for all supplies used in the office
4. Payment for supplies is an issue that should be addressed in the fee schedule section of the contractual
agreement, especially when the carrier doesn’t have a
higher payment for services performed in an office
354. What sections are utilized in Interventional Pain
Management Coding?
1. Evaluation and Management Section
2. Nervous System of Surgery Section
3. Radiology Section
4. Chiropractic Section
355. CPT provides Level I modifiers to explain all of the
following situations:
1. When face-to-face services provided by a provider are
greater than usually required for the highest level of
E&M service for a given category
2. When one surgeon provides only postoperative services
3. When the same laboratory test is repeated multiple
times on the same day
4. When a patient sees a surgeon for follow-up care after
surgery
356. Select the statements that are true.
1. A Pain Management Specialist, Specialty 72, may
report any code in the Osteopathic Manipulation Section of the CPT Manual
2. A Pain Specialist, regardless of specialty designation,
may report any CPT code for which services h/she is
trained and licensed to perform
3. When a Pain Specialist reports a CPT code to a third
party payer, h/she represents that h/she is trained and
licensed to perform the service.The provider is legally
responsible from a patient care perspective and for
truthful billing of his/her services.
4. An Interventional Pain Specialist, Specialty 9 may not
report any of the CPT codes listed in the Chiropractic
Section of the CPT Manual
357. What is sequential coding?
1. Line 1, surgery with greatest relative value – 100%
2. Line 1, describes the procedure you had complications
with
3. Lines 2-5, surgery with 50% reduction
4. Lines 2-5, describe easiest procedures
358. What are some of the common reasons for denials?
1. Arbitrary denial
2. Wrong coding
3. Misinterpretation of the coding
4. Incorrect coding
359. Identify true statements differentiating consultation and
referral visit:
1. Written request for opinion or advice received from
attending physician, including the specific reason the
consultation is requested.
2. Patient appointment made for the purpose of providing treatment or management or other diagnostic or
therapeutic services.
3. Only opinion or advice is sought. Subsequent to the
opinion, treatment may be initiated in the same encounter if criteria are fulfilled.
4. Transfer of total patient care for management of the
specified condition.
360. What are the true statements about Correct Coding
Policies?
1. A new patient is the one who has not received any
professional services from the physician or another
physician of the same specialty who belongs to the
same group practice, within the past 3 years.
2. If a patient received anesthesia 3 months prior by
the same group, the patient becomes an established
patient.
3. An established patient is the one who has received
professional services from the physician or another
physician of the same specialty who belongs to the
same group practice, within the past 3 years.
4. If a patient develops a different problem, the patient
automatically becomes a new patient.
361. What are the principles of reimbursement governing the
Medicare fee schedule?
1. Controlled by Congress and Centers for Medicare &
Medicaid Services (CMS)
2. Based on sustainable growth rate formula
3. May be based on performance
4. Becoming basis for payment by private payors
ASIPP
44
362. The patient’s exhibiting borderline characteristics are:
1. Exhibits signs of dependent disorder
2. Paranoid disorder
3. Dependent and obsessive disorder
4. Timid compliance
Coding, compliance and Practice Management
97110) is performed for 25 minutes; and neuromuscular
re-education (CPT code 97112) is performed for 8
minutes.This visit would be billed as:
1. 97035 x 1 unit, 97110 x 2 units, 97112 x 1 unit
2. 97110 X 1 unit, 97035 X 1 unit
3. 97035x 1 unit, 97110 x 1 units, 97112 x 1 unit
4. 97110 x 1 unit, 97112 x 1 unit
363. Borderline personality symptoms include:
1. Depression
2. Anxiety
3. Hostility to providers
4. Euphoria
369. The following statements about the eight minute rule are
true:
1. The number of units billed cannot exceed the total
time spent with the patient.
2. One unit of a timed code reflects treatment that encompasses at least 8 minutes and up to 22 minutes.
364. Possible causes of noncompliance to medication
3.
Interventions
that require less than 8 minutes of work
treatment includes:
should not be billed.
1. Financial consideration
4. Total treatment time can include the time spent to set
2. Patients unwillingness to be treated
up equipment for the visit
3. Misunderstanding treatment goals
4. Manipulative behavior
370. A physical therapist assistant performs treatment with a
Medicare beneficiary. The physical therapist assistant is
365. Identify true statements to assist in your practice
an employee of the physician group practice which also
by specialty designation of interventional pain
employees a physical therapist. The physical therapist
management:
has gone home for the day at the time of the Medicare
1. Physician profiling or comparative utilization assessbeneficiary’s visit with the PTA. The physician is still
ment
present in the clinic. How would the PTA bill for physical
2. 500% increase of practice expense calculation imtherapy services for this patient?
mediately
1. The charges would be billed incident to the physician.
3. Carrrier Advisory Committee (CAC) membership
2. The charges would be billed under the physical thera4. 100% increase in physician reimbursement
pists Medicare provider number.
3. The charges would be billed under the physical therapist assistant’s Medicare provider number.
366. Local Medical Review Policy (LMRP) or Local Coverage
4. The visit would not be billable.
Determination (LCD) are utilized in all states. What are
true statements?
1. LMRP or LCD is developed to assure beneficiary ac371. A clinical psychologist saw Mrs. Smith today. The Clinical
cess to care
Psychologist (CP) did a health assessment which took
2. Frequent denials indicate a need for development of
45 minutes, called the patient’s psychiatrist to discuss
LMRP or LCD
Mrs. Smith’s current status (15 minutes), interpreted the
3. A need for development of LMRP or LCD includes a
MMPI report (20 minutes) and spent 45 minutes writing
validated widespread problem
the report of the MMPI findings. The CP can be expected
4. LMRPs or LCDs are those policies used to make
to get reimbursed when billing for:
coverage and coding decisions in the absence of:
1. Provision of direct services to patients.
Specific statute, Regulations, National coverage policy,
2. The length of time it takes to coordinate care with
National coding policy or as an adjunct to a national
other healthcare providers.
coverage policy.
3. The time it takes to interpret the MMPI
4. The time it takes to complete the writing of a report
when psychometric testing is performed.
367. A physician performed stellate ganglion block under
fluoroscopy – What is the correct coding?
1. CPT 64510 - cervical sympathetic block
372. When the focus of treatment for an individual patient is a
2. CPT 64505 – sphenopalatine ganglion block
medical problem, as opposed to a mental health problem,
3. CPT 77002 – fluoroscopic guidance
the psychologist should use the following CPT code:
4. CPT 77003 - fluoroscopic guidance
1. Diagnostic interview (90801).
2. Individual psychotherapy (90806).
3. Individual behavioral health assessment (96150).
368. A physical therapy visit is 37 minutes in length. During
4. Individual behavioral health intervention (96152).
that 37 minutes, ultrasound (CPT code 97035) is
performed for 4 minutes; exercise instruction (CPT code
ASIPP
45
Coding, compliance and Practice Management
373. Select the reason(s) that it is important for a practice
to report services within the context of CPT coding
instructions, guidelines and conventions, even if the
medical provider disagrees with the AMA instructions?
1. Deliberately reporting codes that are contrary to CPT
coding instructions may be considered by CMS and/
or third party payers as knowingly submitting a false
claim to obtain payment for a service that was not
provided - a criminal offense
2. The most important step toward solving the problem of
health insurer’s use of “black box edits” and downcoding claims is to gain the confidence of the insurer(s) by
submitting claims that follow CPT instructions
3. When the government brings a criminal indictment
for submission of false claims against a provider, the
provider may be sentenced to prison
4. Loss of payer confidence in the physician community.
374. To ensure compliant “incident to” physician service
billing in a clinical setting, it is important to keep in mind
which of the following?
1. No other procedures may be performed on the patient
in the same day as an E&M service billed incident to
the physician performing the procedure.
2. The supervising MD must be present in the same exam
room during subsequent visits
3. A modifier must be attached to the billed code to
designate the service is being billed as incident to the
physician.
4. There must be a direct personal service furnished by
the physician to initiate the course of treatment.
375. Incorrect coding may be defined as:
1. Intentional billing of multiple procedure codes for a
group of procedures that are covered by a single, comprehensive code.
2. Utilizing a comprehensive code for a group of procedures.
3. Unintentional billing of multiple procedure codes for
a group of procedures that are covered by a single,
comprehensive code.
4. Complying with CMS guidelines.
376. Correct coding essentially means:
1. Unbundling codes to achieve maximum reimbursement.
2. Using whichever code is most convenient for the physician performing a procedure.
3. Using multiple codes to ensure that at least one code
will be reimbursed.
4. Reporting a group of procedures with appropriate
comprehensive code.
377. Many provider activities during a given procedure
are integral to the procedure and termed as “generic
activities.” Some generic services integral to standard
medical/surgical services include:
1. Draping of the patient
2. Insertion of intravenous access.
3. Cleansing, shaving and prepping the skin.
4. Referring the patient to a different physician.
378. Identify true statements of benefits of coding
compliance:
1. Improvement of quality of data
2. Creation of efficient medical practice
3. Improved and correct reimbursement
4. Increased risk of fraud and abuse investigations
379. In an office setting; place of service (POS) 11: Dr. Ken
is across the street (available by telephone) at the
ambulatory surgical center and a Medicare beneficiary
arrives an hour early for his pump refill. The office nurse,
an R.N., who usually refills the pumps when the doctor is
in the office, refills the pump. How is this service reported
to Medicare?
1. The group can increase its revenue if a different physician or the nurse practitioner does the post-operative
follow-up visits within the global period since this
Medicare Carrier apparently allows payment when a
different provider bills the visit;
2. Report code 95990, under Dr. Ken’s PIN and the nurse’s
name on the claim in the “signature” space
3. Report code 95991, refilling and maintenance of
implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) under Dr. Ken’s
name and PIN
4. Medicare may not be billed for this service
380. Drs. Abbott and Costello are in a group practice and
they employ a nurse practitioner. Dr. Abbott implanted
a permanent tunneled catheter (90 day global) and a
programmable pump (90 day global) to control the pain
condition of a Medicare beneficiary on March 17. On
March 30, when the patient returned for a post operative
check up, Dr. Abbott was on vacation and Dr. Costello did
the post operative check up and sent an encounter form
to billing to record the post-op visit. A new person in
the billing department reported Dr. Costello’s visit using
code 99213 and a diagnosis code of 722.83, which was the
condition reported for the March 17, surgery. Medicare
allowed $59.13 for Dr. Costello’s visit. The office manager
should instruct the physicians and billing staff:
1. The group can increase its revenue if a different physician
or the nurse practitioner does the post-operative followup visits within the global period since Medicare allows
payment when a different provider bills the visit;
2. Instruct the providers that to prevent an overpayment
of this type, the person that sees a patient during a
post operative global period, should indicate on the
encounter form that there is no charge and that the
encounter should be recorded for records
3. The practice can keep the money since Medicare made
a mistake in paying the group for an E&M service for
same condition for which the procedure with a 90-day
global was performed.It isn’t groups fault that Medicare doesn’t process its claim correctly
4. Provide in-service education to the billing/collection
staff relative to global days and refund Medicare because the group is not entitled to payment;
ASIPP
46
381. What are the correct statements about lysis of adhesions?
1. 62264: 1 day
2. 62263: 2 or more days
3.
Bundled services include epidural, fluoro/
epidurography, and transforaminal epidural
4. 62264 must be used to report spinal endoscopy
382. What are add-on codes?
1. Primary procedure has a code
2. Add-on codes are modifier 51 exempt
3. Second level has a separate code
4. Multiple interlaminar epidural codes may be used as
add-on codes
Coding, compliance and Practice Management
are “mixed to order” by a compounding pharmacist.
4. Claims to all payers must include the NDC number
and the “J “code from the Healthcare Common Procedure Coding System (HCPCS) book
SECTION 4: COMLIANCE
Directions: Choose the best answer
387. The training requirements of needle stick safety include
all of the following EXCEPT:
A. Work hours
B. 90 days after initial assignment
C. At a cost to employee
D. Within 365 days after effective date of standard
E. Within 10 years of previous training.
383. The largest risks for physicians are identified under the
False Claims Act surround coding and billing. Which
statement regarding coding and billing under False
Claims Act regulations are accurate?
1. In some regions, billing patients for “no shows”, i.e., 388. Your clinic is placing an advertisement for a new
billing Medicare for services which were not actually
receptionist. You want to make sure the office projects
furnished because the patients failed to keep their apa professional, cool-with-it-now image so you place
pointments, is an indicator of fraud and abuse.
an ad that states: Help Wanted: Female, age 25-35, for
2. Duplicate bills submitted to third party payors under
receptionist position. Must have front office appearance,
the mistaken belief that the original claim has been
and must speak English without accent. Great job
lost or misplaced may indicate a reckless disregard of
security. Send photo with resume. Which of the following
the problem and give rise to false claim liability.
is true?
3. Upcoding, or billing for a more expensive service than
A. An unsuccessful applicant may file an EEOC charge
the one actually performed, can lead to false claim alagainst the clinic for discrimination based on age
legations.
B. An unsuccessful applicant may file an EEOC charge
4. Clustering, which is the practice of coding and chargagainst the clinic for discrimination based on race or
ing one or two middle levels of service codes exclunational origin
sively, under the reasoning that some will be higher,
C. An unsuccessful applicant may file an EEOC charge
some lower, and the charges will average out over an
based on disability discrimination
extended period, is not considered a practice that
D. A successful applicant who is later terminated may have
could lead to a false claims allegation.
a breach of implied contract
E. All of the above
384. What are the some of coding methodologies for injections
affecting multiple levels?
389. Which of the following statements is true?
1. Add-on code methodology
A. As of 2004, nearly every employer in the United States
2. 51 Modifier methodology
has mandatory employment law training obligations
3. Mutually exclusive code methodology
B. Failure to provide adequate employment law training
4. Single code methodology
on harassment, discrimination and safety issues exposes the employer to significant risk of lawsuits, as
385. When discharging a patient for noncompliance the
well as government charges and penalties
physician will:
C. Training pays for itself
1. Establish a pattern of noncompliance in the record
D. It is important to have a written record of what was
2. Describe to the patient that noncompliance will never
covered in the training sessions, and who attended
be tolerated
E. All of the above.
3. Informed the patient in writing
4. Discuss with an attorney
390. You are the sole owner of your medical clinic. One of
your employees is Dr. West, a female physician. For
386. Select all statements that are correct.
several months, she dated your office manager, a male,
1. Medicare does not require an NDC number be inone of the employees she supervised. Immediately after
cluded on the claim for drugs; however some nonthe office manager broke off the relationship, Dr. West
Medicare payers do require this number
demoted him to receptionist and cut his pay in half. She
2. Compounded drugs are drugs mixed to meet a specific
is also threatening to fire him if he does not resume the
prescription order that is not sold by a manufacturer
relationship with her. Your office manager has filed sexual
in the strength or mixture that the patient requires
harassment and retaliation claims against your clinic
3. The “J” codes that are listed in the HCPCS manual do
because of Dr. West’s conduct. Which of the following
not describe the compounded medications since they
is true?
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Coding, compliance and Practice Management
47
A. Your clinic is safe a male cannot file harassment and 394. What are state laws affecting medical practices?
retaliation claims against a femaleand that her wheelA. Balanced Budget Act
chair may be a downer for some patients
B. Medical records confidentiality laws
B. Your clinic is safe the office manager cannot file a claim
C. OSHA
if the relationship had been voluntary and he is not a
D. Needle stick safety
minor
E. Privacy
C. Your clinic is safe you were not aware that they had
been dating and you were not aware that Dr. West 395. What are important aspects of Needlestick Safety and
reduced his pay and position
Prevention Act of 2001
D. Your clinic is safe you have a policy against harassment
A. 24 areas of change
and retaliation and Dr. West signed an agreement to be
B. Two terms were added to definitions
bound by that agreement.
C. It was enacted due to total of over 20 million needle
E. Your clinic is in trouble
sticks a year
D. Risks of contracting disease were minimal
E. Psychological stress was the only issue
391. A 62-year-old patient of yours has refused to pay on a
$427.00 balance. You have researched your compliance 396. Your file clerk, Mary, has filed an EEOC claim alleging
plan, and your auditor’s recommendations. You have
that Bob, your office manager, sexually harassed her.
offered the patient multiple choices to pay over time,
Mary did not resign her job, and you haven’t terminated
and the patient refuses because you are “not doing
Bob. In order to minimize the risk of legal exposure, you
anything”. The patient continually asks for narcotics in
have instructed Bob to steer clear of Mary, and you have
a higher dose, and you have refused, placing the patient
moved her desk into a separate room where she would
on a pharmacokinetically long-acting drug which is
not be required to have any interaction with any of her
unsatisfactory to the patient’s demands. The patient
coworkers. Which of the following statements is (are)
expects to be seen monthly for her medication, but states
true?
that she is not going to pay you. Your next step is to:
A. Your actions were inappropriate. You have now subA. Discontinue the patient/physician relationship due to
jected your clinic to an additional claim of retaliation.
noncompliance of payment.
B. Your caution is justified and appropriate to minimize
B. State to the patient that you will refer her to another
your risk of further claims of harassment while the
provider who may be more amenable to her wishes.
EEOC Charge is pending.
C. Send the patient to collections, and discharge the paC. You should have put Mary on leave pending the outtient, after informing her of your intention in writing.
come of the Charge of Discrimination in order to
D. Do nothing, continue to see the patient as you are
protect the clinic against Mary filing additional claims
concerned about abandonment, and you write off the
against Bob.
balance.
D. You should have placed both Bob and Mary on leave
E. You inform the patient, both verbally and in writing,
pending the outcome of the Charge of Discriminathat you are unable to continue to treat her without a
tion.
demonstration of her responsibility to pay some or all
E. You should have immediately terminated Bob to demof her bill.
onstrate to the EEOC that you take the laws prohibiting discrimination seriously.
392. What are the ramifications of anti-kickback statute on 397. True statement applicable to a patient request for a copy
your practice?
of his or her record :
A. It is a felony - 10 years imprisonment
A. The physician is not required to give the patient any
B. It is a crime to offer, solicit, pay, or receive remunerarecords that were not created or generated by the
tion, in cash or in kind, directly or indirectly, for referpractice.
rals under a federally-funded health care program
B. The provider is required to give a copy of all the reC. Civil penalties - $500,000 per violation
cords.
D. “Multipurpose” Rule
C. Designated records set includes only the medical reE. No safe harbors
cords generated by the provider
D. Medical records may be released only after patient has
393. It is recommended that the Sharps container be emptied
paid his bill in full.
when it is:
E. Patient’s access is limited to only certain areas of mediA. Full
cal record
B. 3/4 full
C. Half full
398. Your pregnant receptionist shows up for work late at least
D. Monthly
3 days a week. She is surly, makes numerous mistakes, and
E. When you are no longer able to close the lid
is insubordinate. You fire her. She files a discrimination
lawsuit against your clinic, based on pregnancy
discrimination. Which of the following is true:
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Coding, compliance and Practice Management
A. An employee who is pregnant has to be given more
Small Group Physician Practices, the OIG recommends
leeway in attendance and office demeanor. You should
educating employees on compliance:
have accommodated her by cutting her some slack.
A. Biannually.
B. Once an employer learns an employee is pregnant, the
B. Before the employee begins work and then only when
employer has the affirmative duty to confer with the
the rules change.
employee and work out a schedule that will fit the
C. Monthly.
pregnant employee’s needs.
D. Semiannually.
C. Pregnancy is not a protected category under the law.
E. Annually.
Your employee has no protection from being terminated simply because she is pregnant.
403. When an employee makes a report to Dr. Smith of
D. You will probably win the suit if you have good records
potential Medicare misbillings, Dr. Smith should:
of her attendance problems, her mistakes, and insubA. Hold a meeting of all relevant personnel so they can ask
ordination, and if you have documentation that you
the reporting person about the problem.
have provided warnings to her that her attendance and
B. Fire the reporting employee if she/he was involved in
work performance must improve.
the misbilling of claims.
E. You will probably win the suit if you can demonstrate
C. Promise the reporting employee that you will keep their
that you have always terminated pregnant employees,
identity confidential.
and that she was treated no differently than any other
D. Ignore the report out of concern that any investigation
pregnant employee you have had.
will reveal that the provider owes substantial money to
the Medicare program.
399. A patient hand delivers a written request for a copy of
E. Contact legal counsel to direct the investigation into the
his medical record to Smith and Jones, PSC, a physician
report.
practice that is a covered entity under HIPAA. The
record contains information faxed to the PSC from other 404. Dr. Smith is about to open the doors to see patients one day
physicians and from the local hospital. The PSC should . .
when there is a knock on the door demanding entrance to
.?Choose the answer that best completes the sentence.
the office. When Dr. Smith answers the door he finds
A. Produce only those records the PSC has created and
a team of FBI agents and police officers brandishing a
withhold the records received from other physicians
document titled “search warrant.” Dr. Smith should:
and from the local hospital.
A. Tell all his staff that they cannot talk to the FBI agents
B. Refuse the request if it is not notarized.
or police officers to prevent staff from making admisC. Refuse the request if it is not signed by a witness.
sions of illegal activity.
D. Produce all the records it has on the patient.
B. Call in to work any staff that are not already on the
E. Only release the portions of the record that the patient
premises so as to allow the Government agents access
needs for treatment due to the minimum necessary
to all information.
rule.
C. Refuse to provide the Government Agents with documents that Dr. Smith believes are attorney/client
400. HIPAA prohibits disclosure of a patient’s personal health
privileged.
information (PHI):
D. Ask the Government agents to wait until Dr. Smith can
A. except to immediate family members when they are in
get his attorney onto the premises.
the patient’s presence
E. Hide any potentially incriminating evidence before the
B. except to the patient’s medical decision-maker when
Government agents find it.
named in a durable power of attorney for healthcare
or advance directive
405. Which of the following statements is correct?
C. except to law enforcement officials when investigating
A. The HIPAA security rule requires that a criminal backcriminal claims
ground check be conducted on everyone.
D. except to the patient’s spouse
B. Physician practices with less than ten full-time employE. except to the patient’s employer when the patient has
ees are not subject to HIPAA.
filed for worker’s compensation
C. A HIPAA-covered physician practice do not need to apply security rule standards to laptop computers owned
401. The HIPAA security rule applies to . . .?Choose the answer
by the practice.
that best completes the sentence.
D. If an employee of a HIPAA-covered physician practice
A. Electronic protected health information only.
works from home and accesses electronic protected
B. All forms of protected health information.
health information via a remote connection, the pracC. Protected health information transmitted electronically
tice has no duty to make sure that its HIPAA security
or telephonically.
standards are followed at the employee’s home.
D. Oral protected health information.
E. If an employee of a HIPAA-covered physician practice
E. Protected health information communicated orally or
works from home and accesses electronic protected
telephonically.
health information via a remote connection, the practice has a duty to make sure that its HIPAA security
402. In the OIG Compliance Program for Individual and
standards are followed at the employee’s home.
ASIPP
Coding, compliance and Practice Management
406. In the pain management facility, labeling is required
for contained regulated waste. Labels are not required
when:
A. Red bags with biohazard labeling are used.
B. On refrigerators that contain labeled blood components.
C. If less than 15 cc of blood 5 g of tissue is placed in a
sealed plastic bag to be transported to a dumpster.
D. When an authorized biohazard transport company will
be handling the waste
E. If policy defines the biohazard as benign
407. Based on the recent AMA study of America’s medical
liability crisis, how many states are considered to be in
the “stable” stage?
A. 21
B. 8
C. 16
D. 12
E. 4
408. Which of the following personally owned assets is not
attachable by creditors in the event of a lawsuit?
A. Money market account
B. Stock brokerage account
C. Savings account
D. Mutual fund
E. Individual retirement account (IRA)
409. Identify true statements about Current Procedural
Technology (CPT) and International Classification of
Diseases (ICD-9) codes?
A. ICD-9 is a systematic listing of procedure or service
accurately defining and assisting with simplified reporting
B. CPT is a systematic listing and coding of procedures
and services performed by physicians
C. ICD-9 identifies each procedure or service with a fivedigit code
D. CPT provides systematic listing of disease classification
and provides alphabetic index to diseases
E. CPT and ICD-9 both provide a tabular list of diseases
410. The current estate tax exemption is $2 million. In which
year is the estate tax exemption reduced to $1 million?
A. 2008
B. 2009
C. 2010
D. 2011
E. 2012
411. How much money would you need in order to provide
$10,000 of inflation-adjusted monthly income for 30
years, assuming 4% inflation and 8% rate of return?
A. 2,195,700
B. b4,635,000
C. 1,985,000
D. 3,417,000
E. 2,985,000
49
412. Which one of the following is considered a referral under
Stark?
A. The designated health service is performed by the referring physician.
B. A request by a pathologist for clinical diagnostic lab
tests and pathological examination services, if (1)
the request results from a consultation initiated by
another physician, and (2) the tests or services are furnished by or under the supervision of the pathologist,
or under the supervision of a pathologist in the same
group practice.
C. A request by a radiologist for diagnostic radiology
services, if (1) the request results from a consultation
initiated by another physician, and (2) the tests or services are furnished by or under the supervision of the
radiologist, or under the supervision of a radiologist
in the same group practice.
D. A request by a radiation oncologist for radiation
therapy, if (1) the request results from a consultation
initiated by another physician, and (2) the tests or
services are furnished by or under the supervision of
the radiation oncologist, or under the supervision of a
radiation oncologist in the same group practice.
E. A request by a physician for a consultation with another
physician.
413. Which of the following is not a characteristic of an
appropriate container for regulated waste?
A. closable
B. leak proof
C. puncture resistant
D. heat resistant
E. labeled
414. Which of the following is not a designated health service
under the Stark law?
A. All hospital services
B. A PET scan
C. Clinical laboratory services
D. Physical therapy
E. Ambulatory Surgery
415. Which of the following is not true with respect to an
employer’s duty to communicate hazards to employees?
A. Labels must include the Biohazard legend found in the
regulation.
B. Red bags or containers may be substituted for labels.
C. The labels shall be fluorescent yellow, orange, or orange-red.
D. All regulated waste, containers, refrigerators and freezers containing blood or other potentially infectious
materials are required to be specifically identified.
E. All of the above.
416. Which of the following is NOT a required legal obligation
imposed upon healthcare providers by the HIPAA
Privacy Rule?
A. Establishing administrative, technical and physical safeguards to protect information.
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Coding, compliance and Practice Management
B. Having each employee sign a confidentiality agreement
with respect to patient records.
C. Developing privacy policies and procedures.
D. Documenting patient complaints regarding the use and
disclosure of their health information.
E. Documenting the provider’s disposition of patient
complaints regarding the use and disclosure of their
health information.
417. Which of the following is not a red flag that prosecutors
look for when deciding whether to prosecute a
prescription drug case against a physician?
A. The physician prescribed an inordinately large quantity
of controlled substances.
B. The physician treats a high volume of patients.
C. The physician issues large numbers of prescriptions.
D. The physician did not conduct a physical examination
of the patient.
E. The physician wrote more than one prescription in
order to spread the fills out.
C. Income requirements
D. Possibility of a future inheritance
E. Life expectancies
422. Choose the answer that includes all the categories of
exceptions under Stark:
A. Ownership and compensation exceptions
B. Compensation exceptions
C. Ownership exceptions
D. Financial exceptions, ownership exceptions, and compensation exceptions
E. Ownership and compensation exceptions, ownership
exceptions, and compensation exceptions
423. The United States Drug Enforcement Administration has
issued a proposed rule concerning multiple prescriptions
of a Schedule II drug. Which of the following is NOT a
true statement concerning the proposed A. The physician
issuing the prescriptions must write instructions on
each prescription (other than the first one) indicating
the earliest date on which a pharmacy may refill a
prescription.
418. Which one of the following is not a tactic commonly used
B. The physician must conclude that issuing the patient
by prosecutors during an investigation?
multiple prescriptions does not create an undue risk
A. Having patients of the suspect physician wear a “wire”
of diversion or abuse.
to an office visit
C. The rule encourages physicians to see patients only once
B. Going through garbage from the physician’s office
every 90 days when prescribing Schedule II drugs.
C. Using informants
D. The issuance of multiple prescriptions is permitted
D. Informing the suspect physician that his or her preunder applicable state laws.
scribing practices are being monitored
E. The physician properly determines that there is a legitiE. Interviewing pharmacists regarding the suspect physimate medical purpose for the patient to be prescribed
cian’s prescribing patterns
that drug and the physician is acting in the usual
course of professional practice.
419. Identify accurate statements describing federal
regulations?
A. The final Stark regulations expressly prohibit an orga- 424. A physician performed interlaminar cervical epidural
under fluoroscopy with documentation of nerve
nization from offering free compliance training.
root filling at 4 levels. Identify proper coding for the
B. To qualify for the in-office ancillary Exception under
procedure.
Stark, the services must be furnished in only the same
A. 64479-59, 64480 - C/T transforaminal and C/T transbuilding.
foraminal additional units
C. A provider may never charge Medicare patients addiB. 62310, 76005-26 - C/T epidural and fluoroscopy
tional fees for services covered by Medicare.
C. 62310 x 1, 64479 x 1, 64480 x 3 -C/T epidural, C/T
D. The HHS Office of Inspector General (OIG) may seek
transforaminal and C/T transforaminal additional
criminal penalties as well as administrative sanctions
units
and civil penalties against violators of the anti-kickD. 62310, 72275-59 and 76005-26 -C/T epidural, epidurback statutes.
ography, and fluoroscopy
E. A provider may never charge Medicare patients addiE. 64479 x 1, 64480 x 3, 76005-26 x 3 -C/T transforaminal,
tional fees for Medicare’s non-covered services.
C/T transforaminal additional units and fluoroscopy
420. Which of the following is NOT considered an immediate
family member for purposes of Stark?
425. What is the true statement about global fee policy?
A. Stepbrother
A. Global fee policy describes packaging or inclusion of
B. Grandparent
certain services in allowance for a surgical procedure
C. Stepparent
B. Global fee policy describes unbundling or combining
D. Nephew
multiple services into a single charge
E. Spouse of grandchild
C. Global package includes preoperative and postoperative services for 120 days
421. Which of the following is NOT a variable in determining
D. Global package includes initial evaluation if performed
retirement income feasibility?
on the same day
A. Inflation
E. Global package includes all diagnostic tests
B. Investment rate of return
ASIPP
Coding, compliance and Practice Management
426. Which of the following statements is incorrect?
A. Physician practices should have a mechanism in place
to identify and refund duplicate payments.
B. Billing for “no-shows” can be considered a false claim
and should be avoided.
C. Psychotherapy is frequently attacked as a service that is
not reasonable and necessary.
D. OIG is focusing on evaluation and management services billed during global surgery periods.
E. Having a policy of sending Medicare a duplicate claim if
the original claim is not paid in 60 days is acceptable.
51
making it an exception to the Federal Anti-Kickback
Law?
A. Gifts offered to a patient that may affect the patient’s
choice of provider or treatment decisions, as long as
certain requirements are met.
B. Compensation arrangements with physicians or other
practitioners that are based upon the volume or value
of referrals for services with the practice, as long as
certain requirements are met.
C. Free medications given to a patient with the intention
of inducing the patient to chose a specific provider, as
long as certain requirements are met.
D. The sale of pharmaceutical samples to beneficiaries, as
long as certain requirements are met.
E. Payments relating to the purchase and sale of physician
practices, as long as certain requirements are met.
427. Which of the following is not a requirement for meeting
the Ambulatory Surgery Center safe harbor to the AntiKickback Statute?
A. The ambulatory surgery center must be certified by
Medicare.
431. When can you give medical information about a patient to
B. The terms on which an investment interest is offered to
another person or entity other than the patient?
an investor must not be related to the volume or value
A. Work Comp Carrier
of referrals the investor could make to the entity.
B. Malpractice lawyer who is suing you
C. Neither the ambulatory surgery center nor other invesC. Life insurance agent
tors may loan money to an investor for the purpose of
D. Patient’s employer
investing in the ambulatory surgery center.
E. Patient’s ex wife
D. All ancillary services performed at the ambulatory surgery center must be directly related to the procedures 432. Which of the following activities and statements are
performed at the ambulatory surgery center, and can
accurate:
be billed separately to federal health care programs.
A. The Office of Inspector General (OIG) always considers
E. The ambulatory surgery center and surgeon investors
a standing order from a physician to a clinical lab to be
must treat patients in a nondiscriminatory manner.
acceptable documentation for medical necessity.
B. An independent lab may submit a claim for a clinical
428. Identify the incorrect statement concerning the 2007 OIG
lab test before results are returned from the reference
Work plan.
lab that performed the test.
A. The 2007 OIG Work plan will evaluate the appropriC. A clinical lab may bill Medicare for services certified by
ateness of prescriptions for Oxycontin for Medicaid
a physician who owns the lab.
beneficiaries.
D. A clinical lab may submit claims for reimbursement
B. The 2007 OIG Work plan will analyze Medicaid paid
under certain conditions, even when the lab thinks
claims data to identify beneficiaries who have received
that the tests may be denied.
significant amounts of Oxycontin and the prescribing
E. A clinical lab may alter a physician’s order without his
physicians.
or her (or authorized individual’s) consent in order to
C. The 2007 OIG Work plan includes a list of planned
bill Medicare more correctly.
investigations of providers.
D. The 2007 OIG Work plan will examine prescribing 433. Choose the correct statement related to Fraud and
patterns for drugs with potential for abuse, including
Abuse.
A. The Anti-kickback Statue allows a clinical lab to increase
Hydrocodone, Xanax, Diazepam, and Soma.
its Medicare business by offering to perform certain tests
E. The 2007 OIG Work plan will determine whether
for free.
physicians received separate payments for evaluation
B. Under Stark physician self-referral rules, a clinical lab that
and management services during the global surgery
receives Medicare referrals from a physician practice may
period.
provide the doctors with free office equipment solely to
store information regarding patient specimens.
429. Which of the following is NOT an element necessary to
C. It is legal for a clinical lab to write off charges for a physiprove a Stark law violation?
cian’s managed care business in exchange for referrals of
A. A referral by a physician
Medicare non-managed care patients.
B. For a designated health service;
D. The clinical labs are not required to ensure that they have
C. Entity has financial relationship with physician or famaccess to the supporting documentation of physicians
ily member
who order services from them.
D. Billed to Medicare or Medicaid
E. A clinical lab may alter a physician’s order without his or
E. Physician has intent to defraud.
her (or authorized individual’s) consent in order to bill
Medicare more correctly.
430. Which of the following is considered a Safe Harbor,
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Coding, compliance and Practice Management
434. A local clinical laboratory provides a phlebotomist free
C. Within 45 days
of charge to a doctor’s office. The phlebotomist takes
D. Within 60 days
specimens from the physician’s office to the lab. When the
E. Never
phlebotomist is not busy drawing blood, the phlebotomist
assists the doctor/s office personnel with filing of records 438. Under Stark Law, what is acceptable from medical
and other clerical duties. What aspects of this scenario, if
representatives?
any, implicate the anti-kickback laws?
A. Golf balls and sports bag
A. Provision by the clinical lab of a phlebotomist free of
B. Free meal of more than modest value and is not accomcharge to the physician.
panied by exchange of information
B. Performance by the phlebotomist of clerical duties in
C. Free stethoscope
the physician’s office.
D. Lunch for staff not connected to an information preC. Phlebotomist taking specimens from physician’s office
sentation
to the lab
E. Gift certificate from a bookstore
D. All of the above.
E. None
439. The designated health services covered by the Stark Law
include eleven categories. Which of the following is not a
435. A hospital wishes to lease space in its building to a
DHS category covered by Stark Law?
group of Interventionalists. Choose the correct stateA. Clinical laboratory services
ment.
B. Physical therapy services
A. The hospital may charge the physicians less than the
C. Radiology services
property’s general market value if they agree not to
D. Ophthalmology services
refer patients elsewhere.
E. Home health services
B. Hospital may provide bonus of $100 for each interventional procedure.
440. Which of the following is NOT one of the seven elements
C. Hospital may share 50% of gross revenues from physiof an effective compliance program?
cal therapy services, with physicians
A. Regular auditing and monitoring
D. Hospital may provide administrative and nursing
B. Designation of a compliance officer, compliance comservices at no cost to physicians, and physicians get
mittee or compliance contacts
reimbursed for these services.
C. Retaliation against employees who report legal or ethiE. Hospital wants to lease the space for the value paid in
cal concerns
their market for like property.
D. Education and training for all personnel in the practice
436. The OIG does not have to exclude an individual from
E. Written practice standards that include a code or stanparticipation in federal healthcare programs in cases
dard of conduct
where:
A. The individual is convicted of a criminal offense related 441. Which one of the following statements regarding the
to the delivery of an item or service under Medicare
Office of Inspector General (OIG) is FALSE?
or Medicaid.
A. The OIG is an implementer of HIPAA’s Health Care
B. The individual is convicted of a criminal offense related
Fraud and Abuse Program.
to the neglect or abuse of a patient in connection with
B. The OIG excludes providers from Medicare, Medicaid,
the delivery of a health care item or service.
and other federal health programs for violating proC. The individual is convicted of any misdemeanor under
gram rules and regulations.
federal or state law relating to the unlawful manuC. The OIG publishes compliance program guidance for
facture, distribution, prescription, or dispensing of a
physicians and small group practices.
controlled substance.
D. Penalties from the OIG may be avoided by the adoption
D. The individual is convicted of any felony relating
of an effective compliance program.
to fraud, theft, embezzlement, breach of fiduciary
E. The OIG considers improper inducements, kickbacks
responsibility, or other financial misconduct under
and self-referrals as the only major risk area for physifederal or state law relating to health care fraud.
cian practices.
E. The individual is convicted of any felony under federal
or state law relating to the unlawful manufacture, dis- 442. Health Insurance Portability and Accountability Act
tribution, prescription, or dispensing of a controlled
established the Health Care Fraud and Abuse Control
substance.
Program primarily to . . .Which one of the following
would not correctly complete this sentence?
437. A compliance officer should report credible evidence
A. Coordinate Federal, state, and local law enforcement
of violation of criminal, civil or administrative law to
efforts relating to health care fraud and abuse.
appropriate federal and state authorities under OIG
B. Provide guidance to the health care industry regarding
Compliance Guidance:
fraudulent practices.
A. Immediately
C. Conduct investigations, audits, and evaluations relatB. Within 30 days
ing to delivery and payment for health care around
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Coding, compliance and Practice Management
the world.
D. Facilitate enforcement of remedies for health care
fraud.
E. Create a national data bank to report adverse actions
against health care providers.
443. True statements about Chief Compliance Officer include
the following:
A. Totally independent position
B. Access to all staff, but not to C.E.O.
C. Assign the compliance plan to supervisor in reception
department
D. Generally a compliance committee will assist
E. Operates independently and confidentially without
informing board of directors
444. Accurate examples of abuse are identified as follows:
A. Occasionally submitting duplicate claims
B. Intentional upcoding
C. Unbundling using appropriate modifiers
D. Using modifier-25 to charge for separate, identifiable
E/M service, on the same day as procedure
E. Collecting approved amount from the patient
445. What are true statements about regular and effective
compliance training?
A. Includes all department heads
B. Includes all employees and vendors
C. Initial training is provided only if employee wants to
learn
D. Regular ongoing training is expensive and not an essential component
E. In response to identified problem to the particular employee
446. Administrator of a pain center identified some risks of
non-compliance. Which one of these is legitimate?
A. An increase in the cost of an investigation and audit
B. No risk of exclusion from government health care
programs.
C. Criminal and civil penalties
D. No risk of termination of private managed care and
insurance contracts
E. Reduction in fee schedule
447. A patient verbally requests that a practice amend his
medical record, as he is not happy with the physician’s
recording of the reason for a particular visit.
A. The physician reviews the record and believes the original entry was accurate and complete, and determines
to deny the patient’s amendment request.
B. The patient verbally requested the change, so the physician is obligated to send a written denial.
C. Simply providing a verbal denial to the patient is considered a HIPAA violation.
D. Patient is entitled for correction under STARK II.
E. Patient is note entitled for correction as patient paid by
cash and no third party is involved
53
448. Which of the following is not something a physician
practice’s policies and procedures concerning OIG
compliance needs to address?
A. Medical directorships
B. Office and equipment leases
C. Gift-giving
D. Publishing
E. Financial arrangements with outside entities to whom
the practice may refer federal health care program
business
449. What is Medicare’s definition of reasonable and necessary
medical services?
A. Services necessary to improve the health of a patient
B. Services for the diagnosis or treatment of an illness or
injury or to improve the functioning of a malformed
body member
C. Services for the diagnosis or treatment of an illness or
injury.
D. Services to improve the functioning of a malformed
body member
E. Services for the treatment of a patient or to improve the
functioning of a malformed body member
450. Which one of the following is not an electronic
transaction governed by the HIPAA Transactions and
Codes Sets Rule?
A. sending a patient’s electronic health record
B. health care claims
C. checking on a patient’s eligibility for health plan
D. coordination of benefits
E. requesting a preauthorization
451. As a physician operating an office practice, you should
avoid basing decisions on personal romantic relationships
outside the office setting, as such allegation would give
rise to a claim of invasion of policy. However, you have an
obligation to assure that the office is free from harassment
by co-workers, including your new physician. If you
believe the physician may be responsible for creating
an adverse effect on the office atmosphere, you should
investigate, and, as with every thing related to medicine,
document, document, document, you investigation.
A. Immediately reporting violations to the Department of
Health and Human Services
B. Training employees regarding the rules and the practices’ policies and procedures, and documenting training and attendance
C. Responding to patient complaints of violations of
the rules within ninety days from the receipt of the
complaint
D. Amending the patient record upon the patient’s request
E. Maintaining maintenance records for the practice’s
physical facility
452. Which of the following is not a work practice control
required by the regulation governing occupational
exposure to bloodborne pathogens?
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Coding, compliance and Practice Management
A. Not eating or drinking in work areas
B. Not smoking in work areas
C. Not storing food in the same refrigerator as blood is
stored
D. Recapping needles using both hands.
E. Washing hands after removing gloves
453. Which of the following is not a required administrative
safeguard under the HIPAA Security Rule?
A. The appointment of a security officer.
B. A risk analysis.
C. The development of policies and procedures
D. Password management
E. Data backup plan
454. Which one of the following is not a major component
of the regulation governing occupational exposure to
bloodborne pathogens?
A. Exposure Control Plan
B. Hepatitis B Vaccinations
C. Testing Employees for Infectious Diseases
D. Post-Exposure Evaluation and Follow-Up
E. Recordkeeping
455. Which of the following is a designated health service
subject to the Stark law?
A. Ambulatory surgery
B. Outpatient prescription drugs
C. Services paid at a composite rate
D. Sleep lab services
E. Cardiac catheterization
for financial misconduct with respect to a healthcare
program.
458. If one knowingly submits or causes to be submitted
a false or fraudulent claim for payment to the federal
government, but with no intent to defraud the
government, this is a violation of which of the following?
A. The Criminal False Claims Act
B. The Civil False Claims Act
C. Stark Law
D. Controlled Substances Act
E. The Federal Anti-Kickback Law
_____________________________________
Directions: Each question below contains
four suggested responses of which one or
more is correct. Select
A if
1, 2 and 3 are correct
B if
1 and 3 are correct
C if
2 and 4 are correct
D if
4 is correct
E if
All (1, 2, 3 and 4) are correct
_____________________________________
459. What are Safe Harbor requirements common to all types
456. OIG must exclude providers from Medicare and
of ASC?
Medicaid participation if they have been convicted of
1. No loans from ASC or other investors
certain criminal offenses. Which of the following is not
2. Returns directly proportional to capital invested
considered a conviction for the purposes of deciding
3. Non-discriminatory treatment
whether to exclude a provider from participation in
4. “One-third income” test - at least one-third of each
Medicare and Medicaid?
physician’s practice income from ASC procedures
A. judgments entered by a court.
B. pleas of guilty accepted by a court.
460. Which of the following statements regarding Hepatitis B
C. pleas of nolo contendre or no contest accepted by a
vaccinations is true?
court.
1. All employees with occupational exposure must receive
D. participation in a first offender program where judgthe hepatitis B vaccine and vaccination series.
ment has been withheld pending completion of the
2. The hepatitis B vaccine and vaccination series should
program.
be provided at no cost to employees.
E. a hung jury.
3. The hepatitis B vaccine must be provided within 10
calendar days of an employee’s initial assignment to a
457. The OIG does not have the discretion to exclude
position with occupational exposure.
individuals and entities from participation in federal
4. The hepatitis B vaccine must be provided within 10
healthcare programs in cases where:
working days of an employee’s initial assignment to a
A. The individual or entity submitted a claim substantially
position with occupational exposure.
in excess of usual charges.
B. The individual or entity provided unnecessary or sub- 461. Your administrative assistant has threatened to file an
standard services.
EEOC Charge against you and the clinic for allowing
C. An individual defaulted on an education loan in cona hostile work environment because she overheard a
nection with medical school loans made or secured
sexually explicit joke being told by a coworker to another
by HHS.
coworker. When you talk to the coworkers, they insist
D. An individual was convicted of driving under the influyour assistant has repeatedly told them very sexually
ence of alcohol or substances.
explicit jokes and that she always laughs more than
E. An individual was convicted of a criminal misdemeanor
anyone else. Are you in big trouble?
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1. No. One joke is not “severe” or “pervasive” conduct and
3. Explanation of appropriate methods for recognizing
does not alone create a “hostile work environment.”
tasks/activities involving exposure
2. No. The conduct must be considered harassing to a
4. Explanation of methods to prevent or reduce exporeasonable person AND to the complaining employee.
sure
If she has a history of telling raunchy jokes, it will be
difficult to prove she was personally offended.
3. Either way, you need to get control of your employees 466. What are true statements about criminal penalties?
and insist they stop telling inappropriate jokes
1. Health care fraud faces - fines, up to 10 years in jail,
4. Yes. An employer is strictly liable to his or her employor both.
ees for sexually explicit jokes at the office.
2. Theft or embezzlement in connection with health care
faces - fines, up to 10 years in jail, or both
3. Obstruction of criminal investigations of health of462. Which of the following is a true statement with respect to
fenses faces - fines, up to 5 years in jail, or both
an Exposure Control Plan?
4. False statements and relating to health care matters
1. An Exposure Control Plan must include an exposure
faces - fines, up to 5 years in jail, or both
determination, procedures for evaluating the circumstances surrounding an exposure incident, and a
schedule and method for implementing the provisions 467. You have been provided with multiple reasons to establish
of the regulations.
a compliance plan: Choose accurate statements
2. An Exposure Control Plan must be in writing.
1. Physicians and other practitioners often do not have
3. The input of non-managerial employees who are rethe financial means to employ a compliance specialsponsible for direct patient care and are potentially
ist, therefore may be more vulnerable to unintentional
exposed to injuries from contaminated sharps must be
violations.
solicited in the identification, evaluation and selection
2. Fewer errors, accurate reimbursement and less chance
of effective engineering and work practice controls
of a CMS audit.
and that input must be documented in the Exposure
3. Lends weight to bill procedures
Control Plan.
4. Provides “total immunity” against any wrong doing.
4. An Exposure Control Plan must include the telephone
number and address of OSHA’s closest regional office.
468. It is recommended that a physician practice identify
463. The Health Insurance Portability and Accountability
a compliance officer, a compliance committee or key
Act in 1996 (HIPAA) states that to meet compliance, the
compliance contacts within the practice. The duties of
practice must:
such an officer, committee or contact might entail . . .
1. Follow all federally mandated codes regarding billing
1. Answering billing questions.
and collections practices
2. Participation in the development of Practice Stan2. Adopt specific security and privacy policies
dards.
3. Allow patient access to medical records
3.
Developing a process to communicate with and
4. Develop an audit trail for medical record access.
disseminate information to individuals within the
practice.
4. Conducting a baseline audit of the practice’s opera464. Dr. Smith has been appointed the Compliance Officer for
tions.
his busy pain practice. Dr. Smith wants to conduct an
audit to ensure that the practice is billing in a compliant
manner. Dr. Smith should:
469. This question contains four suggested responses of which
1. Randomly select records from the past year for review.
one or more is correct.
2. Engage an external auditor with experience in docu1. If a group practice recruits a physician with an income
mentation and coding for chronic pain services to
guarantee from a hospital, a written agreement signed
conduct the audit.
by the hospital, the group practice, and the physician
3. Include a review of the Explanation of Benefit Forms to
is required to meet a Stark law exception
determine whether claims were paid correctly.
2. If a group practice recruits a physician with an income
4. Advise the coders that he is going to be auditing the
guarantee from a hospital, the income guarantee canrecords that they code tomorrow.
not be conditioned on the recruit making referrals to
the hospital
3. If a group practice recruits a physician with an income
465. What are the elements of a training program for needle
guarantee from a hospital, the income guarantee must
stick safety?
be for the purpose of inducing the physician to relo1. General explanation of epidemiology and symptoms
cate.
of bloodborne diseases
4. A group practice that recruits a physician with an in2. Explanation of modes of transmission of bloodborne
come guarantee from a hospital can require the physipathogens
cian to sign a covenant not to compete.
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470. The benefits of implementing a compliance program in a
physician practice include which of the following?
1. Avoiding conflicts with the self-referral and anti-kickback statutes
2. The enhancement of patient care through increased
accuracy in documentation
3. Minimizes billing mistakes and optimizes proper payment of claims
4. A cap on the amount of damages the government can
recover from the practice in a civil False Claims action
471. What are the penalties under the False Claims Act?
1. Three times the amount of damages suffered by the
government
2. A mandatory civil penalty of at least $5,500 and no
more than $11,000 per claim.
3. Submit 50 false claims for $50 each (liability between
$282,500 and $557,500 in damages)
4. Program exclusion
472. Which of the following is a true statement about the
criminal False Claims Act?
1. The criminal False Claims Act makes it a felony to make
or cause to be made any false statement or representation of material fact in any application for any benefit
or payment under a federal health care program.
2. Making false entries in a patient’s chart can be a violation of the criminal False Claims Act.
3. Violating the criminal False Claims Act can result in
exclusion from participation as a provider in federally
funded health care programs.
4. For a violation of the criminal False Claims Act to occur, specific intent to defraud is not required.
473. Possible punishments for violating the Self Referral Laws
(Stark) include . . .
1. Civil money penalties of up to $15,000 per claim
2. Civil money penalties of up to $100,000 per scheme
3. Exclusion from Medicare and Medicaid
4. A term of imprisonment of not more than five years
474. The performance of a comprehensive baseline audit of
the practice’s operations is the initial step in developing
an effective compliance program. The steps of an audit
include:
1. A review of key documents
2. A review of coding and billing practices
3.
The performance of a physician practice walkthrough
4. Interviews of the staff
475. OIG guidance on disciplinary guidelines includes:
1. Written policies which may be discriminatory
2. Written scope of sanctions
3. Not essential to publish standards and guidelines
4. Background investigations for new employees
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Coding, compliance and Practice Management
476. What are some of the important aspects of documentation
of medical necessity?
1. Medicare will reimburse. Irrespective of the procedure,
furnished, not for improvement function, but 20%
pain relief.
2. The physician practice should be able to provide documentation such as a patient’s medical records and
physician’s orders, to support the appropriateness of a
service that the physician has provided.
3. Medicare concurs with physician opinion and patient
request with respect to duration, frequency, and setting a procedure performed.
4. The physician practice should only bill those services
that meet the Medicare standard of being reasonable
and necessary for the diagnosis and treatment of a
patient
477. True statements about fraud and abuse include the
following:
1. Fraud is an intentional deception or misrepresentation
that the individual knows to be false.
2. Abuse is when physician does not believe to be true,
and physician makes knowing that the deception
could result in some unauthorized benefit to himself/
herself or some other person.
3. Abuse is billing Medicare for services that are not
covered.
4. Fraud is coding incorrectly.
478. Choose the accurate statement(s) of fair market value
under the Stark regulations on a physician referral:
1. Fair market value is tied into a number of prohibitions
and exceptions under stark law
2. Fair market value means the price that willing buyer
gives to a willing seller
3. For rental and leases, fair market value is the value
of rental property without taking into account the
property’s intended use
4. Under Stark Law, there are no fair market value exceptions
479.Enforcement weapons against fraud and abuse may
include the following:
1. Anti-kickback statute
2. Needle stick safety
3. Stark Law
4. Americans with Disabilities Act
480. Which of the following can result in the imposition of
civil money penalties?
1. Upcoding.
2. Billing a service as “incident to” a physician’s service
if the physician falsely represented to the patient that
he/she was certified by a medical specialty board.
3. Routinely waiving co-payments for Medicare recipients.
4. Being convicted of a misdemeanor relating to the prescription of controlled substances.
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Coding, compliance and Practice Management
481. Why does the Federal Anti-Kickback Law prohibit
referrals for remuneration?
1. It can distort medical decision making.
2. It can cause a reutilization of services or supplies.
3. It can increase costs to federal healthcare programs.
4. It can result in unfair competition by shutting out
competitors who are unwilling to pay for referrals.
482. What are the true statements in selection of eligible
investors in ASCs:
1. Physicians in position to use facility
2. Employed by the facility or any investor
3. Group practices composed exclusively of physicians to
use facility
4. In position to make or influence referrals
483. True statements about Federal Health Care Offense under
HIPAA are as follows:
1. Offense of “health care fraud” added to criminal statute
2. Only Medicare
3. Fines ($10,000), forfeiture, 10 years imprisonment
4. It is synonymous with Balanced Budget Act
484. Identify accurate statements?
1. A false claim is “knowingly” failing to make inquiry
regarding the accuracy of the claim
2. A false claim is prosecuted by district attorney
3. A false claim is when claimant knows or should know
that the claim was false
4. A false-claim applies only for claims over $10,000
485. What are the steps to compliance of security standards?
1. Administrative safeguards
2. Physical safeguard
3. Technical safeguard
4. Financial viability safeguard
486. What does Health Insurance Portability and
Accountability Act
compliance administrative
simplification 1.
Increases costs associated with
administrative and claims related transactions
2. Establishes a national uniform standards for 8 electronic transactions, and claims attachments
3. Eliminates unique provider identifiers
4. Establishes protections for the privacy and security of
individual health information
487. What are the true statements about federal regulations
impacting ambulatory surgery centers?
1. Immunity from anti-kickback prosecution
2. Ownership of ASCs includes - Physician Ownership, Single Specialty, Multi-Specialty and Hospital/
Physician owned
3. Protection limited to physician investors who either
use facility on regular basis, or practice in same specialty
4. Non-compliance with safe harbors means illegal leading to hefty criminal and civil penalties
488. Which of the following is a true statement with regard to
the Federal Self-Referral Law (Stark)?
1. Stark rules prohibit physicians from referring patients
to hospitals where physicians work.
2. Stark rules prohibit physicians from personally performing the designated health service which they
order for their patients.
3. Stark rules prohibit investments in publicly traded
companies and mutual funds.
4. Stark rules prohibit physicians from making referrals
to a designated health service entity in which the physician has a financial relationship, unless an exception
applies.
489. What are OIG identified risk areas?
1. Billing for items or services not actually rendered
2. Providing medically unnecessary services
3. Joint ventures
4. Physician self-referrals
490. What are some of the true statements about modifiers?
1. A modifier indicates that an encounter or procedure
has been altered by some specific circumstance, but
not changed in its basic definition or code
2. A modifier indicates that an encounter or procedure
has been altered in its basic definition and code.
3.
Common modifiers for interventionalist include
modifier -50 bilateral procedure, and -51 multiple
procedures
4. Common modifiers for interventionalist include -52
-reduced procedure, -59 - distinct procedure, and -25 separate E & M service on the same day of procedure
491. What are permitted disclosures under privacy regulation
without the individual’s permission?
1. Public health activities
2. Judicial and administrative proceedings
3. Health oversight activities and government benefit
4. A request from prosecution in a liability case
492. Choose the accurate statement(s) below:
1. To provide equal access to all patients, a hospital with
high occupancy rate offers a small bonus to doctors for
each patient they discharge in less than 10 days.
2. Hospitals may bill Medicare or Medicaid for experimental drugs used in clinical trials.
3. Hospitals may recruit physicians by offering them productivity bonuses if it requires them not to apply for
privileges at any other hospital.
4. Falsifying trial results is considered fraud, while paying
for doctors enrolling patients in bona fide clinical trials, if properly disclosed, is not fraud.
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493. Multiple factors leading to introduction of OIG
Compliance Plan include:
1. Runaway healthcare costs
2. Balanced Budget Act
3. Operation Restore Trust
4. Successful Healthcare Reform
494. Which of the following is a required administrative
safeguard under the HIPAA Security Rule?
1. Employee training on security policies and procedures
2. Disaster recovery plan
3. Information System Activity Review
4. Risk management
495. The bloodborne pathogens regulations require employers
to maintain certain records.
Which statement(s)
regarding record keeping is/are correct?
1. Employers are required to keep records for each employee with occupational exposure that must include
their name, social security number, hepatitis B vaccination status, post-exposure examination, testing
and follow-up procedures and healthcare opinions
required by the regulation and such records shall be
kept for the duration of the employee’s employment
plus 3 years.
2. Employers are required to keep records for each employee with occupational exposure that must include
their name, social security number, hepatitis B vaccination status, post-exposure examination, testing
and follow-up procedures and healthcare opinions
required by the regulation and such records shall be
kept for the duration of the employee’s employment
plus 30 years.
3.
The training required by the regulations require
that records include the dates of training, contents/
summary of the training sessions, name & qualification of instructors, and name & title of attendees and
such records shall be kept for 30 years from the date on
which the training occurred.
4.
The training required by the regulations require
that records include the dates of training, contents/
summary of the training sessions, name & qualification of instructors, and name & title of attendees and
such records shall be kept for 3 years from the date on
which the training occurred.
496. The following statement or statements accurately reflect
duties and actions of carriers and fiscal intermediaries.
1. When they suspect fraud that involves sensitive issues
or that may get widespread publicity they alert the
Department of Justice
2. A carrier or fiscal intermediary have to notify a provider if it’s going to suspend payments to the provider;
except when they find reliable evidence of fraud or
willful misrepresentation
3. A carrier or fiscal intermediary may exclude a provider
from participation in Medicare, Medicare, or other
federally funded health care program
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Coding, compliance and Practice Management
4. When the HHS Office of Inspector General (OIG) receives a recommendation for a sanction from a carrier
or fiscal intermediary; OIG develops a proposal and
sends it to the affected provider(s)
497. HHS Office of Inspector General (OIG) may exclude
individuals or companies from participation in federal
health care program:
1. If convicted of certain misdemeanors
2. Convicted of any misdemeanor offense related to controlled substances
3. If they refuse to permit examination or duplication
of records that OIG states are needed to determine if
reimbursement was due
4. If whistleblower suits are brought by employees, former employees, or anyone
498. Select the accurate statements?
1. A local nursing home, hires a consulting firm to put
together a defense in an elder abuse case. An attorney
engaged for this purpose would be considered a business associate and an agreement is required.
2. Ambulatory Surgery Centers, Inc. discloses PHI to a
health plan for payment purposes. A business associate agreement is not required.
3. A medical malpractice insurer is given PHI by an
insured to provide a malpractice risk assessment of
a case. An attorney engaged for this purpose would
be considered a business associate and an agreement
is required.
4. None of these entities are considered business associates.
499. A physician practice that owns a Fluoroscopy unit leases
it to a hospital on a per-procedure basis for patients
referred by the practice. It is necessary for the lease to
meet the following criteria:
1. The payment per-unit is at fair market value at inception.
2. The payment does not change during the lease term in
any way that takes into account the volume or value of
referrals among the parties.
3. The payment does not take into account any other
business, including private pay business, generated by
the referring physician.
4. The payment takes into consideration the number of
patients referred to Physical Therapy in the hospital.
500. Use or disclosure of a patient’s protected health
information (PHI) without the patient’s authorization is
permitted for the following purposes:
1. To treat the patient even though the patient is not having an emergency.
2. To get payment from the patient’s insurance
3. Research Activities.
4. To perform certain administrative, financial, legal, and
quality improvement activities.
Coding, compliance and Practice Management
59
501. True statements with regards to non-compliance with
3. Abuse involves errors caused by mistakes or aggressive
Stark Law include the following scenario:
billing or coding inconsistent with accepted practices
1. Three hospitals set up separate corporations to estabthat result in a loss of Medicare funds.
lish a clinical laboratory, with each hospital contribut4. Fraud results in overpayments to a provider $100,000
ing $100,000 capital, signing for debt on an equal baor more, in contrast to abuse which results in overpaysis, owning 1/3 equity and each referring all inpatients
ments of $10 to $99,999.
and outpatients to lab.
2. A physician group sets up imaging center in a mall,
with lease for space is based on % of revenue gener- 506. What are true statements about fraud in medicine in
ated
U.S.A.?
3. A hospital wants to lure a high referring physician.
1. Medicare fee for service error rate was 8% in 2004.
It offers to make her Chair of the medical staff if she
2. A GAO audit reported that in the U.S. approximately
admits all her patients to the hospital. The physician
10% of every health care dollar is lost to fraud annuagrees and does so.
ally.
4. A physician enters into contract with nursing home.
3. Estimated net improper payments of CMS for 2004
This contract provides that for every patient referred,
exceeded $50 billion
the physician receives a gift valued at $50, up to a
4. Fraud and abuse cases include 60% public and 40%
maximum of 6 gifts per year
private.
502. Which of the following is important in defending against 507. What are some of the true statements describing bundling
drug charges?
and unbundling?
1. Having and updating a compliance/risk management
1. Bundling is combining multiple codes or charges into
program.
one comprehensive charge, when separate codes or
2. Keeping abreast of Drug Enforcement Administration
charges are justifiable
policy statements.
2. Unbundling is charging multiple CPT codes when one
3. Complying with State Board of Medical Licensure
code generally describes the service
Policies.
3. Unbundling is charging multiple procedures with the
4. Accurate and complete documentation of patient
primary service that are generally included in primary
charts.
service
4. Bundling and unbundling are essential elements of
proper coding and accurate reimbursement
503. Choose the options that fit the “medical staff incidental
benefits” exception to the Stark Law.
1. A hospital provides free, on-campus parking for physi- 508. Some of the true statements include:
cians and staff while they are working at the hospital.
1. Global period for major procedures is 90 days
2. A hospital provides free meals to physicians that see
2. Procedures with a 10-day global period include adhemore than 10 patients a day.
siolysis and facet joint neurolysis
3. A hospital provides a doctor’s lounge, which is avail3. Global period for minor procedures is day of the proable to all members of the medical staff.
cedure or 10 days
4. A hospital wants to attract physicians by providing
4. Implantables and disc decompression procedures fall
drinks and dinners once a week, at a cost of over $50
into category of 10-day global period
per person.
509. What are the consequences of a violation of the Stark
504. Which of the following include the seven common
Law?:
elements that the HHS Office of Inspector General (OIG)
1. Civil monetary penalties
strongly encourages providers to have in a comprehensive
2. Repayment of all affected claims
compliance program?
3. Exclusion from Medicare
1. Written standards of conduct
4. Assessed up to 3 times of the money
2. Hotline for complaints
3. Disciplinary procedures
4. Procedures to prevent qui tam law suits
510. Which of the following has the OIG identified as a major
risk area for physician practices with respect to Medicare
and Medicaid fraud and abuse?
505. Identify accurate statements describing the difference
1. Coding and billing
between fraud and abuse?
2. Reasonable and necessary services
1. Fraud involves deliberate deception used to get money
3. Documentation
from Medicare that a provider is not owed.
4. Improper inducements, kickbacks and self-referrals
2. There is no difference between fraud and abuse.
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Coding, compliance and Practice Management
511. Pursuant to the Federal Anti-Kickback Law, physician
2. The rental must have a term of at least one year
practices should not have arrangements with which of
3. The rent is for fair market value.
the following entities unless the arrangement is within
4. The rent does not vary with the volume or value of
a Safe Harbor?
referrals
1. Ambulatory surgery centers
2. Clinical laboratories
3. Hospitals
517. Which of the following practices can lead to problems for
4. Durable medical equipment suppliers
physician groups?
1. A group practice bills for services performed by Dr.
Brown, who has not been issued a Medicare provider
512. Which of the following is a true statement with respect to
number, using Dr. Adams’ Medicare provider number
HIPAA Privacy Compliance?
2. Dressings and instruments were included in a fee for
1. Only practices with 10 or more employees need to
a minor procedure, but the dressings were also billed
comply with the HIPAA Privacy Rule.
separately
2. Disclosures for treatment, payment, and health care
3. A group practice has no system in place to screen for
operations must be tracked for accounting of discloNational Correct Coding Initiative restrictions, coding
sures purposes
patterns, and groupings
3. Even if it is discovered that an employee of the practice
4. A group practice relies on a bookkeeper with no trainviolated the HIPAA Privacy Rule, no sanction need be
ing in coding and billing to submit claims to Medicare.
imposed for a minor violation
They have provided the bookkeeper with a sheet of
4. The three major issues with respect to HIPAA privacy
commonly used codes with which to bill
compliance are (a) how to use and disclose protected
health information; (b) the patient’s rights under the
Privacy Rule; and (c) the provider’s legal obligations 518. This question contains four suggested responses of which
under the Privacy Rule
one or more is correct. Select:
1. Workstation use is an addressable physical safeguard
under the HIPAA Security Rule
513. Identify elements of a compliance program:
2. Contingency operations is an addressable physical
1. Written standards of conduct and policies and prosafeguard under the HIPAA Security Rule
cedures
3. Audit controls are an addressable technical safeguard
2. Occasional education and training
under the HIPAA Security Rule
3. Process to receive complaints and protect them
4. Automatic logoff is an addressable technical safeguard
4. Elimination of monitoring and auditing
under the HIPAA Security Rule
514. What are some of the true statements about bilateral 519. The Health Insurance Portability and Accountability Act
codes?
(HIPAA):
1. Bilateral codes include transforaminal, facet joint
1. Is also referred to as the Kennedy-Kassebaum Health
interventions, and SI joint injections
Reform Bill of 1996.
2. Facet joint neurolysis codes may not be billed as bilat2. Provides the office of Inspector General and the Federal, and require modifiers 59 and 51
eral Bureau of Investigations (FBI) with broad powers
3. Unlisted codes may not be used as bilateral codes
to identify and prosecute health care fraud and abuse.
4. Bilateral codes include intercostal nerve blocks, sympa3. Makes correct medical coding mandatory.
thetic blocks, and occipital nerve blocks
4. Includes patient privacy provisions.
515. Compliance officer is providing the annual report. What 520. This question contains four suggested responses of which
are indications of non-compliance?
one or more is correct. Select:
1. Claim problems
1. Developing a mechanism for responding to and cor2. Staff problems
recting identified problems is important in developing
3. Accounting issues
a corrective action plan
4. Your documentation had 1% error rate
2. Developing warning indicators is important in developing a corrective action plan
3. Open door policies are important in implementing a
516. Which of the following is a requirement for the rental of
compliance plan
space or equipment exception under the Stark law?
4. Sanction policies are not required for an effective
1. The rental must be documented by a signed written
compliance plan
agreement
ASIPP
Answers
Coding, compliance and
Practice Management
1. Answer: D
Explanation:
Proper medical record documentation includes the
following:
Why did the patient present for care?
What was done?
Where were the services rendered?
When is the patient to return or what is the plan of
action?
Will there be follow-up tests or procedures ordered?
Source: Laxmaiah Manchikanti, MD
2. Answer: C
Explanation:
Physical therapy is provided upon evaluation and
examination of a patient in accordance with the plan of
care, treatment frequency and duration, and functional
goals that were established by a physical therapist. Physical
therapy services cannot be initiated by physical therapist
assistants.
Source: Medicare Benefit Policy Chapter 15, 230.1,
Practice of Physical Therapist
Source: Marsha J. Thiel, RN, MA
3. Answer: C
Explanation:
The description of CPT code 99211 includes the
statement, “that may not require the presence of a
physician”. Medicare allows an R.N. to report code 99211
as an “incident to” service, i.e., the physician must be in the
office. Services such as an evaluation when a patient
comesto pick up a prescription refill or a patient that is
seen for adrug screen are clinical examples listed in
Appendix C of the CPT Manual. Regardless of the extent
of the R.N.’s service, (work performed, length of time
spent) the only appropriate code h/she may report is a
Level I, 99211.
Source: Medicare Carriers Manual 100-4; CPT Manual
Source: Joanne Mehmert, CPC, Sep 2005
4. Answer: C
Explanation:
The critical components of evaluation and management
services are:
History
Examination
Decision-making
Other four components are:
Counseling
Coordination of care
Nature of presenting problem
Time
5. Answer: C
Explanation:
History of Present Illness
* Brief (1-3)
Level 1 & 2
* Extended (4+)
Level 3 and above
or
Status of 3+
multiple chronic conditions
6. Answer: E
Explanation:
Past, Family, Social History
* None
For Level 1 & 2 office visits
Subsequent Hospital Care, F.U. Consultations,
Subsequent Nursing Home Care
* Pertinent Level 3
One (1) specific item from ANY of the three
categories
* Complete - Comprehensive
62
New Service
One (1) specific item from EACH of the three categories
Follow-up
One (1) specific item from EACH of the two categories
or
Either Update or Repeat all items
7. Answer: E
Explanation:
Medical records function to:
keep the practitioner out of the slammer
support “medical necessity”
reduce medical errors & professional liability exposure
reduce audit exposure
facilitate claim review
support insurance billing
provide clinical data for education
provide clinical data for research
promote continuity of care among physicians
indicate quality of care
8. Answer: D
Explanation:
Physical therapist assistants do not have provider
numbers. Services provided by a physical therapist
assistant may be billed by the supervising physical
therapist if the physical therapist is in the clinic. The visit
cannot be billed by the supervising PT if the PT is not
present in the clinic. Medicare does not allow PTA’s to bill
work that they do incident to a physician who may be
present. In this case therefore, there are no options for
billing for the visit and it would be a no charge visit.
Source: Medlearn Matters #SE0533
Source: Marsha J. Thiel, RN, MA
9. Answer: B
Explanation:
A) This response is incorrect as it is generally used for the
assessment of mental health disorders.
B) This response is correct. Individual behavioral health
intervention is the code to use when the focus of a
psychologist’s services is the amelioration of an
individual’s medical problem.
C) This response is incorrect, as it is generally used for a
psychosocial assessment of a medical problem.
D) This response is incorrect, as it is generally used to
designate individual services of a psychologist whose
treatment is designed to ameliorate a mental health
problem.
E) This response is incorrect, as it is generally used for
rehabilitation services.
CPT 2006 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY. p. 163
Source: Marsha J. Thiel, RN, MA
ASIPP
10. Answer: D
Explanation:
Review Of Systems
* Problem-Pertinent
Positive and negative responses related to problems
identified in the HPI
* Extended
Positive and negative responses related to 2 - 9 systems
* Complete
Ten Systems must be reviewed
or
In place of documenting negative responses to the
remaining systems (up to 10), May note all other systems
negative
11. Answer: C
Explanation:
If a provider is overseeing the therapy of more than one
patient during a period of time, he or she must bill 97150
since he or she is not furnishing constant attendance to a
single patient. The therapist is required to be in constant
attendance but one on one patient contact is not required
This is an un-timed code and can only be charged onetime
per patient per visit. The therapeutic exercise code
identifies one on one instruction and is a timed code. A
physical therapist can provide direct one to one patient
contact with only one patient at a time.
Source: Federal Register November 22, 1996, page 59542;
Transmittal #1753, May 17, 2002.
Source: Marsha J. Thiel, RN, MA
12. Answer: C
Explanation:
The total treatment time was 50 minutes which supports
three units billed with the “8 Minute Rule. The 8 minute
rule applies to all timed PT CPT codes that require direct,
one to one contact by the PT provider. It states that for any
single, timed CPT code, providers bill a single 15’ unit for
treatment greater than or equal to eight minutes and less
than 23 minutes. Two units would be billed for treatment
23 minutes to less than 38 minutes. If more than one CPT
code is billed during a calendar day, then the total number
of units that can be billed is constrained by the total
treatment time.
Source: WPS Communiqué May 2005, PHYSMED-009
Source: Marsha J. Thiel, RN, MA
13. Answer: B
Explanation:
The NCCI was first published in 1996 and is updated by
AdminiStar Federal every quarter. The purpose of the
NCCI is to identify and isolate inappropriate coding,
unbundling and other improper coding. Carriers must
incorporate the NCCI into their claims processing; they do
not have discretion to pay services that the NCCI
identifies as “bundled” unless an applicable modifier is
63
appended.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
14. Answer: E
Source: Marsha J. Thiel, RN, MA
Medicare’s requirement that the physician be “in the
office”may not pertain to other insurers unless the
payer specifiesthat they apply. Many states allow a general
delegation of authority with responsibility retained by the
physician without requiring on-premises supervision.
In situations where the provider is not participating,
Medicare rules may be the best option for billing nonphysician practitioner services.
15. Answer: D
16. Answer: E
Explanation:
Medical records function to:
keep the practitioner out of the slammer
support “medical necessity”
reduce medical errors & professional liability exposure
reduce audit exposure
facilitate claim review
support insurance billing
provide clinical data for education
provide clinical data for research
promote continuity of care among physicians
indicate quality of care
17. Answer: B
18. Answer: C
Explanation:
Reference: www.cms.gov; Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Carriers are required to maintain CAC’s which are
intended to provide a formal mechanism for physicians in
the State to be informed and participate in the
development of coverage decisions in an advisory
capacity. CMS instructed Medicare Carriers by means of
Transmittal #106, March 4, 2005, that it is mandatory to
include Interventional Pain Management Specialists on
CAC Membership.
Source: CMS Web site: www.cms.gov; Chapter III
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
19. Answer: B
Explanation:
Billing rules for services provided by non-physician
providers vary from payer to payer. Non-Medicare payers
may reimburse non-physicians differently. Providers
should review their participation agreements for all of
their contracted payers as well as the State laws in which
they are providing services. In cases where physicians, as
the collaborating physician, have complete leeway to
delegate services that are within the non-physician’s scope
of practice, the services will generally be reported as if
rendered by the physician.
Source: “The Ins and Outs of “incident –To
Reimbursement” by Alice Gosfield, J.D., Family Practice
Management, November/December 2001.
Source: Joanne Mehmert, CPC, Sep 2005
20. Answer: E
Explanation:
Patients threatening lawsuit should not alter appropriate
medical care, and judgment should not be impaired by
fear.Proper medical care supersedes baseless threats,
particularly when legitimate prescribing practices are
followed. When a patient / physician relationship must be
terminated, appropriate cautions and policies are in place
to avoid being accused of abandonment. Abandonment is
when a patient might result in injury or has been injured
by a physician’s refusal to treat, defined. Usually by 30days, a patient must be given a reasonable amount of time
to find a substitute to care provide her; otherwise, there
is a breach of duty, which is the foundation of medical
malpractice.
The duty of treatment is defined by community standard,
and that of the profession and not at the physician’s
discretion. The patient’s overall health status should be
addressed, and alternatives to care, appropriate to a
treatment course for best outcome must to be
acknowledged. This is where offering detoxification may
be this patient’s only choice.
Prescribing medications for any length of time in a patient
that is suspected or known of a diversion is an
inappropriate patient for a controlled substance.
Providing a controlled substance to a person known to
divert his contributory to trafficking, and places the
physician at risk.
Source: Hans C. Hansen, MD
21. Answer: D
Explanation:
The term “incident to” is primarily a CMS description for
items and services that are furnished as a part of the
patient’s normal course of treatment and are incidental
(contributory or ancillary) to a patient’s care. Drugs that
cannot be self administered (other than local anesthetics)
are reported and paid separately, most supplies are
included in the global payment.
Source: Medicare Carriers Manual, 100-4, Chapter 12;
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
ASIPP
64
Source: Joanne Mehmert, CPC, Sep 2005
22. Answer: C
Explanation:
The materials list of ingredients, and chemical
composition.
The Material Safety Data Sheets, MSDS, are mandatory for
medical offices and should be displayed, or found by
employees on demand, usually kept in a binder. These lists
are frequently printed by the company, and labeled on the
device or container for quick reference. An example might
be a cleaning solvent, or a container with potentially
dangerous organic content, such as insecticide.
Source: Hans C. Hansen, MD
23. Answer: E
Explanation:
Vendors, have a financial motive to demonstrate a benefit
to the practice. It is easy for a vendor to show templated
output documents, that may justify a CPT Level 4, and
entice the physician to consider up-coding the work
performed. It is incumbent upon the physician, that only
work performed is documented. Templates are met with a
high level of scrutiny during an audit. Do all of the
templates appear the same? Were you sold a system that
efficiently up-codes, and hence a revenue generating tool,
as opposed to a work flow tool? The physician will in time
meet salespeople who really have nothing to lose but
everything to gain, and the digital sales industry has no
regulation. The physician, however, is in one of the most
regulated environments in business, and has everything to
lose. The best approach with any vendor is to listen,
review the system, but verify, and apply principals of a
valid compliance program to assess the flexibility of the
electronic medical record. The medical record should be
flexible enough to offer many templates, reflecting only the
work performed, and not a standard, regurgitated
document, which will fall into question should an audit
occur.
Source: Hans C. Hansen, MD
24. Answer: B
Explanation:
The nurse practitioner may work independently and bill
under his or her provider number, but obtain only 85% of
the fee. The electronic medical record is irrelevant. If the
physician is immediately available, onsite, and the nurse
practitioner is present examining the patient in a
collaborative environment with the physician, then the
physician’s services may be billed at 100% “Incident To” .
If the physician is not immediately available to the site,
irrespective of telephone conversations, the practice may
bill 85% of the physician’s fee. The electronic medical
record will (or should) account for incident to,
documenting when the physician is present and when not
in the presence when a physician extender is utilized.
Source: Hans C. Hansen, MD
25. Answer: D
Explanation:
ASIPP
It is incumbent upon the physician’s practice to be
compliant. A troubling feature of the electronic medical
record is the ease of standard templates to emerge as a one
and only approach to billing and coding. Just as the billing
sheet contains all levels of code, and not pre-selected 2, 3,
or 4, for example, a template created by a non-physician,
applicable to all patients, and all providers, has no validity
in a true compliance plan. A physician is only allowed to
bill for elements that they are personally involved in, and a
template does not always reflect true work performed.
Unfortunate up-coding or down-coding may occur
placing the practice at risk.
Source: Hans C. Hansen, MD
26. Answer: D
Source: Laxmaiah Manchikanti, MD
27. Answer: B
28. Answer: A
Explanation:
EBM as plausible response
* Emphasizes
- Examination of evidence for clinical research
- Systematic collection of clinical studies
- Synthesis of evidence
* De-emphasizes
- Intuition
- Unsystematic experience
- Biological rationale (surrogates)
Source: Laxmaiah Manchikanti, MD
29. Answer: C
Explanation:
Physicians may bill and be paid for ancillary services that
are “incident to” services rendered by non-physician,
auxiliary personnel in the physician’s private office setting,
as long as supervision requirements are satisfied. The
physician must be physically on-site and immediately
available when the auxiliary practitioner is providing
services.
Source: See Medicare Carriers Manual, Part 3, Claims
Process, § 2050.
Source: Erin Brisbay McMahon, JD, Sep 2005
30. Answer: C
Explanation:
The electronic medical record is a secure record that does
not allow access to unregistered or unnecessary personnel,
payor sources, or other entities that could disturb a HIPAA
compliant environment. Policy and procedures should be
in place with each electronic medical record to assure that
no breach of confidentiality is realized.
Source: Hans C. Hansen, MD
31. Answer: A
Explanation:
65
The Physician is permitted to withhold certain portions of
a patient’s record under limited circumstances including
when the protected health information requested includes
reference to another person and the physician has
determined that access to the information is reasonably
likely to cause substantial harm to the person who has
provided the information.
Although the general rule is that a patient must be
provided full access to his or her information. Certain
exception to this rule apply in this scenario.
C.To the extent that interventional measures do not
adequately control pain, adjuvant opioids should not be
withheld
D.correct answer
E.At some point serious and repeated non-compliance
with reasonable restrictions patient use and abuse of
controlled pain medications require the physician to refuse
to continue prescribing controlled substance medications
Source: William Allen, JD
35. Answer: D
Explanation:
Guideline Development Methodology
Source: Laxmaiah Manchikanti, MD
32. Answer: A
Explanation:
Service must be:
Safe and effective
Not experimental or investigational
Appropriate, including the duration and frequency that is
considered appropriate for the service, in terms of whether
it is:
- Furnished in accordance with accepted standards of
medical practice for the diagnosis or treatment of the
patient’s condition or to improve the function
- Furnished in a setting appropriate to the patient’s
medical needs and condition
- Ordered and/or furnished by qualified personnel
- One that meets, but does not exceed, the patient’s
medical need.
Source: Laxmaiah Manchikanti, MD
33. Answer: E
Explanation:
This is a somewhat difficult area for a physician to grasp.
A patient who expresses a lifestyle contradictory to what
the physician would consider conducive to a patientphysician relationship, does not necessarily mean that the
physician is allowed to drop the patient. Antidiscrimination suits have been settled against the practice
based on personal views of the physician, irrespective of
the fact that the physician had given names of other
physicians that would treat the patient. The ACLU Chief
Council Michael Small states “discrimination, whether it
in the workplace or in the doctor’s office, can never be
tolerated”. All businesses open to the public must treat
their clients/patients equally without regard to race, sexual
orientation, or gender.
Source: Hans C. Hansen, MD
34. Answer: D
Explanation:
A.Patients with pain should receive treatment for pain
even if they manifest addiction, so long as they are
involved in appropriate treatment for substance addiction
B.Patients with pain should receive treatment for pain
even if they manifest addiction
Expert-Opinion Method
Unstructured, fast
Inexpensive
Informal
One point of view (potential conflict of interest)
Evidence considerations implicit
Expertise defined by content only
Possible disagreement among experts
Biased strategy for sampling research findings
Consensus Method
Structured, time consuming
Expensive
Formal
Different viewpoints (many stakeholders)
Evidence considerations implicit
Different stakeholder values
Consensus may be at expense of evidence
Possibly biased strategy for sampling research
Evidence-Based Method
Structured, time consuming
Expensive
Formal
Explicit, reproducible method
Evidence considerations explicit
Formal, rigorous methodology
All methods and decisions available for scrutiny
Rigorous and explicit strategy for sampling
Source: Laxmaiah Manchikanti, MD
36. Answer: A
Explanation:
A.Such agreements do not meet criteria for legally valid
contracts
B.Any of the other answers could be valid
characterizations of these agreements
Source: William Allen, JD
37. Answer: C
Source: Laxmaiah Manchikanti, MD
38. Answer: A
Explanation:
In common language, we consider it negligence if one
imposes a careless or unreasonable risk of harm upon
ASIPP
66
another. The legal criteria for determining negligence are
as follows:
1. the professional must have a duty to the affected party
2. the professional must breach that duty
3. the affected party must experience a harm; and
4. the harm must be caused by the breach of duty.
This principle affirms the need for medical competence. It
is clear that medical mistakes occur, however, this
principle articulates a fundamental commitment on the
part of health care professionals to protect their patients
from harm.
Source: Gurpreet Singh Padda MD MBA
39. Answer: D
Explanation:
The legal criteria for determining negligence require all of
the following:
1. the professional must have a duty to the affected party
2. the professional must breach that duty
3. the affected party must experience a harm; and
4. the harm must be caused by the breach of duty.
Curbside consultation creates no physician patient
relationship.
Source: Gurpreet Singh Padda MD MBA
40. Answer: C
Explanation:
A verbal approval does not satisfy the 21 CFR 56.109(c)
requirement for a signed consent document, as outlined in
21 CFR 50.27(a). However, it is acceptable to send the
informed consent document to the legally authorized
representative (LAR) by facsimile and conduct the consent
interview by telephone when the LAR can read the consent
as it is discussed. If the LAR agrees, he/she can sign the
consent and return the signed document to the clinical
investigator by facsimile.
Source: Gurpreet Singh Padda MD MBA
41. Answer: C
Explanation:
How do you know when you have said enough about a
certain decision? Most of the literature and law in this area
suggest one of three approaches:
* reasonable physician standard: what would a typical
physician say about this intervention? This standard allows
the physician to determine what information is
appropriate to disclose. However, it is probably not
enough, since most research in this area shows that the
typical physician tells the patient very little. This standard
is also generally considered inconsistent with the goals of
informed consent as the focus is on the physician rather
than on what the patient needs to know.
*reasonable patient standard: what would the average
patient need to know in order to be an informed
ASIPP
participant in the decision? This standard focuses on
considering what a patient would need to know in order to
understand the decision at hand.
* subjective standard: what would this patient need to
know and understand in order to make an informed
decision? This standard is the most challenging to
incorporate into practice, since it requires tailoring
information to each patient.
Most states have legislation or legal cases that determine
the required standard for informed consent. The best
approach to the question of how much information is
enough is one that meets both your professional obligation
to provide the best care and respects the patient as a
person with the right to a voice in health care decisions.
Source: Laxmaiah Manchikanti, MD
42. Answer: C
Explanation:
The general rule is that a physician can bill both a
procedure and either a new patient visit
or a consult on the same date of service when there is a
significant and separately identifiable evaluation and
management service performed. In this case, the issue is
whether the E&M code is a consult or a new patient visit.
Because the referring physician had done all he could for
the patient, he really isn’t interested in the pain physician’s
opinion; he just wants the pain physician to treat the
patient. Therefore, the hallmark of a consult, i.e., a request
for an opinion, is not present. Thus, a new patient
visit must be coded.
Medicare Claims Processing Manual, Chapter 12, Section
30.6.10.A.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
43. Answer: B
Explanation:
Two E&M services may be billed on different dates of
service, even if less than 24 hours have transpired between
the services. The initial inpatient hospital care code is
used, rather than the subsequent hospital care code,
because the emergency room is an outpatient setting, so
the admit to the hospital is the initial inpatient service.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.9.1.B.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
44. Answer: D
Explanation:
Medicare does not require the office personnel to be
credentialed as a mid-level practitioner in order to bill an
E&M code incident to the physician. As long as the RN is
trained and performs tasks within her state licensure, and
the service performed is typically incident to what a
physician would perform, and the level billed is relatively
67
low, i.e., level 1 or 2, a RN can be billed incident to a
physician who is in the office at the time of the visit. 99211
is limited to a nurse visit which does not require the
presence of the physician, which is not the case heresince
the physician had a face-to-face encounter with thepatient.
.A level 3 is not appropriate because the medical decision
making was straightforward, regardless of the presence of
the physician and the nurse.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.4.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
45. Answer: A
Explanation:
In the hospital, unlike in the office, if time is the
predominant basis for coding a level, the time can consist
of both face to face time and unit/floor time. In the office,
on the other hand, the total time used in calculating the
level of the visit is limited to face to face time. Answers c.
and d. are outpatient codes, not applicable to an inpatient
setting. Answer e. is false.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.1.A.; CPT 2005, p. 4, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
46. Answer: E (All)
Explanation:
LEVEL 1 - PROBLEM FOCUSED
Limited Exam of Affected Body Area.
1-5 Elements in one or more area(s)/systems(s)
LEVEL 2 - EXPANDED PROBLEM FOCUSED LIMITED
Exam of affected body area and other symptomatic or
related organ systems.
6 Elements in one or more area(s)/systems.
LEVEL 3- DETAILED EXTENDED - DETAILED
Exam of Affected Body Area and other symptomatic or
related organ systems.
At least 2 elements from each of 6 area(s)/system(s) OR
At least 12 elements in 2 or more area(s)/system(s)
LEVEL 4 & 5 - COMPREHENSIVE
At least 18 Elements from at least 9 area(s)/system(s).
47. Answer: E (All)
Explanation:
Bullet Methodology
* History
- History - 8 possible factors
- ROS - 14 possible systems
- PFSH - 3 possible histories
- Single organ system
- Multi-system
* Medical Decision Making
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
48. Answer: C (2 & 4)
Explanation:
1)Modalities such as ultrasound and electrical stimulation
can be performed by a PTA when they are part of the
designated plan of treatment.
2)Initial evaluation, examination, and diagnosis require
the clinical decision making skills of a physical therapist
and therefore cannot be carried out by a PTA.
3)PTA’s are able to and should document a patient’s
progression at each visit.
4)Discharge documentation requires clinical decision
making and again, must be done by PT
Source: Guide to Physical Therapist Practice
Source: Marsha Thiel, RN, MA
49. Answer: D (4 Only)
Explanation:
Medicare requires beneficiaries receiving physical therapy
services to see their ordering physician or a member of the
physician’s group practice within 60 days of starting PT if
PT care is to continue beyond 60 days. The beneficiary is
then required to see the physician every 30 days thereafter
if therapy is ongoing.
Source: www.cms.hhs.gov/manuals/pm_trans/R5BP.pdf,
CMS Manual, Pub 100-02, Medicare Benefit Policy,
Transmittal 5, January 9, 2004
Source: Marsha Thiel, RN, MA, Sep 2005
50. Answer: A (1,2, & 3)
Explanation:
Clinical Psychologists will be reimbursed for providing
direct services to patients, interpreting psychometric
testing and time it takes to write the report. CP generally
do not bill for coordination of care or other types of case
management services, and would not generally be
expecting to get reimbursed for these services if they did
bill for them.
CPT 2005 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY
Source: Marsha J. Thiel, RN, MA
51. Answer: C (2 & 4)
Explanation:
INTERVENTIONAL PROCEDURE DOCUMENTATION
* Exam
ASIPP
68
1. History & Physical
2. Medical necessity
3. Procedure
FACILITY Requires 3 of 3
OFFICE Requires 2 of 3
Other
Musculoskeletal
Cardiovascular
Eyes
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
52. Answer: E (All)
53. Answer: B (1 & 3)
Explanation:
1. Physical examination may be conducted either by
choosing general multi-system examination or a single
system examination.
2. A single system examination utilizing psychiatric,
respiratory, or skin is insufficient. It should include
musculoskeletal or neurological
3. To cover appropriate physical examination in the above
patient, the examination should consist of a general multisystem examination or a single system examination
encompassing musculoskeletal or neurological systems.
4. Single system examination of musculoskeletal system
involves examination of all components in
musculoskeletal system and no other examination is
required in musculoskeletal system, constitutional,
cardiovascular-peripheral, lymphatic and skin
evaluation.
54. Answer: B (1 & 3)
Explanation:
MEDICAL DECISION MAKING - THREE
COMPONENTS
* Review of Records/Investigations
Requested , Obtained, Reviewed, Analyzed
* Diagnoses/Mgmt Options
Minimal, Limited, Multiple, Extensive
* Risk of significant complications, morbidity, mortality
Associated with presenting problems, diagnostic
procedures, management options.
55. Answer: E (All)
Explanation:
Physical Examination - II
If the planned anesthesia includes intravenous sedation,
regional or general anesthesia, there should be:
* An assessment of the patient’s mental status
Information
* An examination specific to the proposed procedure
Single System Examination
Musculoskeletal
Neurological
Cardiovascular
Ears, nose, mouth, and throat
Eyes
Genitourinary – female
Genitourinary – male
Gastrointestinal
Hematologic/lymphatic/immunologic
Psychiatric
Respiratory
Skin
* An examination specific to any co-morbid conditions
Musculoskeletal System Examination
Primary
Musculoskeletal
Other
Constitutional
Cardiovascular – Peripheral
Lymphatic
Skin
Neurological System Examination
Primary
Neurological
ASIPP
* Documentation of the results of an auscultatory
examination of the heart and lungs, and
* An assessment and written statement about the patient’s
general health.
56. Answer: A (1,2, & 3)
Explanation:
Certification documentation requires a stated treatment
frequency and duration, an identified certification period
that is thirty days from the time of the physical therapy
evaluation, and a treatment plan to address functional and
measurable goals. Mention of previous PT is not
necessary but may be helpful in establishing the chronicity
of a condition. The treatment duration is required to be a
stated and defined period, but does not need to be thirty
days.
Source: CMS Manual, Pub 100-02, Medicare Benefit
Policy, Transmittal 34, Chapter 15, Sections 220 and 230
Source: Marsha J. Thiel, RN, MA
57. Answer: A (1,2, & 3)
Explanation:
69
A medical record serves the following functions and
provides benefits
1. The government recognizes that sponsors need such
data to determine whether they conduct a statistically valid
study.
1. Indicates quality of care
2. Promotes continuity of care among physicians
But, HIPAA requires that the physician and a
researcher draw up a business associate agreement.
3. Provides clinical data for research
4. Reduces audit exposure
Other Functions:
Keeps practitioner out of prison
The agreement must specify that the sole purpose of the
review is to prepare a research protocol or similar
preliminary document, that no protected information will
be removed from the physician’s office to another location,
and that the review is the necessary first step in fulfilling
the goals of the research.
Supports “medical necessity”
Reduces medical errors & professional liability exposure
2. If a physician is performing the study with a
pharmaceutical company, he does not require a business
associate agreement.
Facilitates claim review
Supports insurance billing
Provides clinical data for education
58. Answer: A (1,2, & 3)
Source: Manchikanti L, Board Review 2005
59. Answer: A (1,2, & 3)
60. Answer: A (1,2, & 3)
Explanation:
Psychologist assessment generally consists psychometric
testing, review of the medical record and diagnostic
interview. Psychologists do not perform physical exams
when performing psychological assessments.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
61. Answer: B (1 & 3)
Explanation:
The role of the EMR is not to eliminate access tools; it is
for data management, and data assessment. It is also a risk
reduction tool. The EMR’s role first and foremost is to
safely retrieve information, in a secure environment.
There is no one single tool that allows the EMR to
eliminate pagers, telephones, etc. Expecting an EMR to be
a multitasking tool diminishes the effectiveness of the
primary purpose of the EMR; that being electronic
paperless storage of the medical record and patient data
management.
Source: Hans C. Hansen, MD
Even though the physician is performing a function on
behalf of the drug company, it is not the physician’s
business associate because the pharmaceutical company is
not performing a function on behalf of the physician.
Covered entities are limited to health plans, clearing
houses, and providers that conduct one or more HIPAA
transactions electronically.
However, the physician needs a contract that spells out
the terms of participation in the research study, including
payments for services rendered.
3. Under HIPAA, physician or physician’s employees may
contact patients to ask whether they are interested in
participating in a research study.
However, if someone else – like an independent researcher,
etc., contacts the patients, HIPAA requirements must be
met.
HIPAA requirements include that before someone other
than the physician or a member of the physician’s staff
contacts a patient, the physician must enter into a business
associate contract with this person, obtain proper patient
authorization, or ask an Institutional Review Board to
waive the normal patient-authorization requirement.
4. The patient may suspend his or her rights at any time
until the end of the research.
However, if a patient consents to this suspension
beforehand, the patient is also entitled to know that
patient rights will be reinstated upon completion of the
study.
Source: Laxmaiah Manchikanti, MD
62. Answer: C (2 & 4)
Explanation:
63. Answer: A (1,2, & 3)
ASIPP
70
Explanation:
Reimbursement at the ASC is set by CPT guidelines, and
should not necessarily be affected by the EMR. in the
office setting improves documentation for specific
evaluation and management codes, and improves
diagnostic considerations. The Ambulatory Surgery
Center will best utilize an EMR to improve
communication, and to enhance inter-physician
communication. The EMR should also help the
Ambulatory Surgery Center document procedures, and
improve the medico-legal risk of documentation deletions
or errors.
Source: Hans C. Hansen, MD
64. Answer: A (1,2, & 3)
65. Answer: E (All)
Explanation:
DOCUMENTATION OF PROCEDURE
PREOPERATIVE: Informed consent, discussion and plan,
preparation
INTRAOPERATIVE: Monitoring, preparation, sedation,
position, description
POSTOPERATIVE: Monitoring, complications
DISCHARGE/DISPOSITION: Status, instructions, return
appointment
66. Answer: E (All)
Explanation:
Principles of Quality Clinical Policies include the
following:
Evidence-based approach
Consensus with disclosure
Defined process for development
Standardized criteria for assessing literature
Levels of strength of recommendations
Identify participants
Incorporation societal/ethcial/cost issues
67. Answer: A (1,2, & 3)
Explanation:
The electronic medical record performs each of the
roles of enhancing quality of care, decreasing
cost, and improving quality of life of the providers, if
implementation of the proper tools, hardware, and
training is afforded the practice.
The EMR should be considered a risk reduction
tool, and not an item where further contamination or loss
of data could be incurred. The purpose of the EMR is
convenience, safety, and improved productivity.
Source: Hans C. Hansen, MD
68. Answer: E (All)
Explanation:
Fifth not included in the question is
ASIPP
1.Statement of the material risks.
2.Statement of the expected outcome and the likelihood of
success.
3. Statement of alternative procedures or treatments and
supporting information regarding those alternatives.
4. Statement of the effect of no treatment, the effect on the
prognosis, and material risks associated with no treatment.
Other: Statement of the nature and purpose of the
proposed treatment.
69. Answer: B (1 & 3)
Explanation:
To comply with the recommended mandates in the
medical record, the record should be timely and legible,
secure, and uniquely identify the patient, confidential,
contain a recent history and physical to be completed
within 24 hours of procedure, and contain preoperative,
intraoperative and postoperative nursing notes. At the
time the ASC experiences patient contact, medical decision
making is already completed for the procedure. The
ASC’s position is to assist in best documentation of
the procedure, and to assist the physician in supportive
documentation.
Source: Hans C. Hansen, MD
70. Answer: B (1 & 3)
Explanation:
Explanations under www.dol.gov/esa----Information for
Medical Providers
“Ask the injured Worker for her/his accepted conditions.
If s/he doesn’t know these, s/he can contact her Employing
Agency or OWCP district office for this information, or
you can contact the Employing Agency directly. The
Privacy Act prohibits OWCP and ASC from disclosing
this information to anyone other than the Injured Worker.”
“To be paid for treating federal employees covered by the
FECA, you must enroll. As of March 31. 2004, all bills
submitted by non-enrolled Providers will be returned
along with instructions on how to enroll. Enrollment is
free and is simply a registration process to ensure proper
payments. It is not a PPO enrollment.”
“Level 1 procedures (for example, Office Visits, MRI’s,
Routine Diagnostic Tests) do not require authorization.
Level 2, 3 and 4 procedures require authorization”
“An authorization is not required when an Injured Worker
is referred by her/his treating physician to a specialist for a
consultation. However, you must be enrolled as a
Provider to be paid for the consultation visit.”
“You may request authorization online at
http://owcp.dol.acs-inc.com. Or you may fax the
appropriate Medical Authorization form and supporting
documentation to 800-215-4901. The Medical
71
Authorization forms are available online at
http//owcp.dol.acs-inc.com.” You may not call for
authorization.
Source: Marsha Thiel, RN, MA, Sep 2005
71. Answer: A (1,2, & 3)
Explanation:
Hydrocodone requires liver participation in breakdown,
and is believed that some of the bio-activity and pain relief
characteristics of hydrocodone are derived from
hydrocodone breakdown components, one being
hydromorphone. Oxycodone and Morphine have been
used in end-stage liver disease effectively, with the
understanding that there is no ideal drug. In Morphine’s
case, breakdown products, particularly glucuronides, may
accumulate, particularly if there is renal excretion issues.
These glucuronides may result in dysphoria. Oxycodone
has breakdown components as well, but is very well
tolerated, particularly in the elderly. Hydromorphone
again, has a long-standing safety profile, and is tolerated
well by patients with liver disease, and is excreted
predictably. Each drug should be scrutinized by the
concept of elimination. The liver and kidneys are the two
principal organs of elimination, where the kidney is
responsible for the excretion of chemically unaltered drug.
The liver is the primary path of metabolism, but other
organs may also contribute after metabolism, therefore
explaining the effective elimination of a number of drugs
when liver function is poor.
Source: Hans C. Hansen, MD
72. Answer: C (2 & 4)
Explanation:
Payer fee schedules seldom address the payment of
supplies nor are there any codes listed for surgical trays
and/or supplies. Unless the contractual agreement
specifically prohibits the physician from reporting
supplies, it is appropriate to bill separately for the
supplies. More expensive equipment and supplies should
be carved out to ensure adequate reimbursement.
Source: Hans C. Hansen, MD
74. Answer: D (4 Only)
Explanation:
It is recommended that patients who are focused on
controlled substances, particularly those that ask for
medications by name, be addressed from a risk
management perspective. Patients do not necessarily need
a controlled substance simply because the statement of
“pain” is made. Assessment of function and quality of life
indices is reflected in the medical record. If controlled
substances are recommended, the schedule of the drug
does not reflect potency. The schedule suggests abuse
potential, and therefore, Darvocet® has the same
habituation potential as oxycodone, and is not necessarily
“milder”.
Source: Hans C. Hansen, MD
75. Answer: A (1, 2 & 3)
Explanation:
If a physician chooses not to treat a patient, he/she may do
so by statutes of involuntary servitude.
Source: Hans C. Hansen, MD
76. Answer: A (1,2, & 3)
Explanation:
A HEDON file is not relevant to the EMR data storage.
The advantage of an EMR is data retrieval and the access to
understanding this data is important to the provider, and
to the front office. It should be in an easily understood
formulation.
Source: Hans C. Hansen, MD
77. Answer: E (All)
Explanation:
Potential Pitfalls
Geographic Bias
Advocacy Bias
Oversimplification
Resistance to Change
Source: Laxmaiah Manchikanti, MD
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
78. Answer: C
Explanation:
management of the accounts receivable is essential to
maintain good cash flow. In keeping the total balance of
73. Answer: A (1, 2 & 3)
accounts greater than 80% means that the accounts are
Explanation:
being managed and properly worked. Any lower
To avoid allegations of abandonment the patient, the
percentage would indicate that the accounts receivable are
practice must have no barriers to communication with the
not being managed.
physician, understanding that the office will accommodate,
Source: Trent Roark,MBA
and be responsive to a patient’s financial distress, but open
communication is necessary. If a patient is unable to pay,
79. Answer: E
and the process was formally, in writing, elaborated with
Explanation:
the patient, it is felt that the patient has received sufficient
All of those elements convey to the employee the
notice to withdraw care. 30-days notice usually applies,
importance you place on the evaluation process and on the
but for risk management purposes, particularly as
information and direction you are imparting.
individual states vary, a policy should be developed with
Source: Judith Holmes
practice council to discharge patients for non-payment to
avoid allegations on discrimination or abandonment.
80. Answer: A
ASIPP
72
Explanation:
An NCD is made after a comprehensive evaluation process
that often includes a technology assessment by an
expert(s) outside CMS and/or the CMS Coverage Advisory
Committee. NCD’s are made according to a process
detailed in a Federal Register Notice dated April 27, 1999
(64 FR 22619). An NCD is binding on all Medicare
carriers, fiscal intermediaries, quality improvement
organizations, health maintenance organizations
(Medicare), competitive medical plans and health care
prepayment plans.
Source: CMS website www.cms.gov
Source: Joanne Mehmert, CPC, Sep 2005
81. Answer: C
Explanation:
Private payers’ bundling of claims will have a negative
effect on the practice revenue stream over a period of time;
however, it is often so subtle that it is unlikely to be
recognized until the bundling has been going on for a long
time. The only effective means to stay tuned to payer
payment/bundling patterns is by continuous monitoring
of the reason for claim denials. Billing personnel should
look for an ambiguous reason for non-payment such as
“when you report multiple related services on the same
day for a patient, insurer bases benefit payments on the
primary service”.
Source: American Medical Association Model Managed
Contract: Supplement 6, “Downcoding and Bundling of
Claims: What Physicians Need to Know About These
Payment Problems
Source: Joanne Mehmert, CPC, Sep 2005
82. Answer: C
Explanation:
The five levels of review are: 1) appeal to the Medicare
contractor for a re-consideration of the initial
determination, 2) Qualified Independent Contractor
(“QIC”) or Hearing Officer employed by the Carrier, 3)
ALJ hearing which can be held by videoconference where
the technology is available, 4) Departmental Appeals
Board review (“DAB”), and 5) Judicial review in U.S.
District Court.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. Federal Register March 25, 2005 and
June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
83. Answer: A
Explanation:
When the Carrier sends its initial determination, a
provider or beneficiary has 120 days to file a request for
reconsideration. After each subsequent unfavorable
determination is received, the provider has 60 days to
request a review at the next level.
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005. Federal
Register March 25, 2005 and June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
84. Answer: D
Explanation:
Medicaid may deny a service stating that it is not medically
necessary and where Medicare has a statutory appeals
process that a provider can follow step by step, Medicaid is
State specific. There is no “standard” Medicaid review
process.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. Federal Register March 25, 2005 and
June 30, 2005.
Source: Joanne Mehmert, CPC, Sep 2005
85. Answer: C
Explanation:
Generally, once a claim is pre-authorized/pre-approved,
especially when the pre-approval is obtained in writing, a
physician has an effective argument if the insurer changes
its mind. Payers seldom, if ever, guarantee payment when
they authorize treatment.
Source:Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
86. Answer: D
Explanation:
As a physician operating an office practice, you should
avoid basing decisions on personal romantic relationships
outside the office setting, as such allegation would give
rise to a claim of invasion of policy.
However, you have an obligation to assure that the office is
free from harassment by co-workers, including your new
physician. If you believe the physician may be responsible
for creating an adverse effect on the office atmosphere, you
should investigate, and, as with every thing related to
medicine, document, document, document, you
investigation.
Source: Judith Holmes
87. Answer: A
Explanation:
under law, Medicare cannot pay a “clean” claim within 10
days of receipt. This means that it is essential to file the
claim as soon as possible to start the pay clock running. If
it takes a practice 2 days to file a claim, that meanspayment
will not be received, at best, until 12 days after service. The
goal should be to file the claim the next morning to
improve cash flow.
Source: Trent Roark,MBA
88. Answer: C
ASIPP
73
Explanation:
Assuming she can establish the elements of a racial and/or
age discrimination claim, the clerk could also allege
constructive discharge based upon the facts presented. A
constructive discharge claim exists:
a)when an employer makes conditions so intolerable that
it would force a reasonable employee to resign her
employment and
b)the employer either created the conditions or knew
about them and permitted them to continue.
Important note: You would have a better defense to a
potential lawsuit if you could produce documentation of
not only her performance deficiencies, but also your
repeated warnings to her that she must improve.
Testimony of poor performance without
contemporaneous documentation is often not effective.
Americans with Disabilities Act (ADA)
Overall learning points:
Although the ADA is a federal Act that applies only to
employers with 50 or more employees, physicians
practicing in groups of all sizes must know the general
ADA requirements for two reasons. First, most states have
laws very similar to the ADA and apply to employers with
far fewer employees. Second, the actions of physicians in a
clinic or hospital setting may subject that facility to
liability based on the physician’s conduct - DEFINITELY a
CLM (Career Limiting Move).
Source: Judith Holmes
89. Answer: A
Explanation:
There is generally no need for a witness in an evaluation
meeting unless you anticipate the employee to become
confrontational. In general, the manager should have been
providing feedback during the entire evaluation period
and so the employee should have no surprises during the
evaluation meeting. (Coffee and doughnuts are a nice
touch but optional).
Source: Judith Holmes
90. Answer: E
Explanation:
Use clear unambiguous language so that you and the
employee have objective standards by which to measure
successful performance
Source: Judith Holmes
91. Answer: D
Explanation:
There is really nothing legally that would prohibit a
physician from treating a family member of a plaintiff, but
it is a risky decision. Comments might be made that could
be misconstrued or constructed to be deleterious to the
physician during the upcoming action. Furthermore, it
may be possible that the family member legitimately or
illegitimately develops a complication in attempts to
establish a pattern. Collusion cannot be ruled out, which
places the physician in an awkward position of constantly
second guessing each visit. Furthermore, the family
member could testify about office policy procedure,
experiences, and behavior patterns of the physician.
Universities are not immune from lawsuits and patient
dumping can be considered abandonment.
It is best to probably severe ties with the patient that has a
family member involved in litigation with you or a partner.
Source: Hans C. Hansen, MD
92. Answer: B
Explanation:
The injured person may sue for an injunction to prevent
the continuation of the tortuous conduct or for monetary
damages. Among the types of damages the injured party
may recover are: loss of earnings capacity, pain and
suffering, and reasonable medical expenses. They include
both present and future expected losses.
There are numerous specific torts including trespass,
assault, battery, negligence, products liability, and
intentional infliction of emotional distress. Torts fall into
three general categories: intentional torts (e.g.,
intentionally hitting a person); negligent torts (causing an
accident by failing to obey traffic rules); and strict liability
torts (e.g., liability for making and selling defective
products - See Products Liability). Intentional torts are
those wrongs which the defendant knew or should have
known would occur through their actions or inactions.
Negligent torts occur when the defendant’s actions were
unreasonably unsafe. Strict liability wrongs do not depend
on the degree of carefulness by the defendant, but are
established when a particular action causes damage. Tort
law is state law created through judges (common law) and
by legislatures (statutory law).
Source: Gurpreet Singh Padda MD MBA
93. Answer: E
Explanation:
The National Practitioner Data Bank (NPDB) was
established under Title IV-B and B of Public Law 99-660,
42 U.S.C. Section 11101-11152, “The Health Care Quality
Improvement Act of 1986.” The NPDB, which is
maintained by the Department of Health and Human
Services (DHHS), contains a record of adverse clinical
privileging, licensure, and professional society
membership actions taken primarily against physicians
and dentists, and medical malpractice payments made on
behalf of all health care practitioners who hold a license or
other certification of competency. Groups that have access
to the NPDB include hospitals, other health care entities
that conduct peer review and provide or arrange for care,
state boards of medical or dental examiners, and other
health care practitioner state boards. Individual
practitioners are also able to self-query the NPDB. The
reporting of information to the NPDB is restricted to
medical malpractice payers, state licensing medical boards
ASIPP
74
and dental examiners, professional societies that conduct
formal peer review, and hospitals and health care entities.
Source: Gurpreet Singh Padda MD MBA
94. Answer: E
Explanation:
tracking the physician productivity is essential to compare
the productivity of one physician to another. Once done, a
decision needs to be made as to whether a physician is
under-producing compared to the other physicians so that
correction can be made.If a physician has a high rate of
no-charge patients, the physician is not covering their
overhead. Again, correction can then be taken.
Source: Trent Roark,MBA
95. Answer: D
96. Answer: E
Explanation:
It is essential to have controls and then audit to make sure
that the controls are working. Segregation of duties allows
a “check and balance” to be implemented to minimize
theft and fraud. Competitive bidding will eliminate the
opportunity for “kick back”and allow the best price to be
obtained.
Source: Trent Roark,MBA
97. Answer: C
Source: Laxmaiah Manchikanti, MD
98. Answer: B
Explanation:
Having the right trained staff and number of staff,
including physicians will help you meet the patient
demand. Measuring the efficiency, growth, and financial
results is essential to determining if changes need to be
made. Patient satisfaction is essential to grow a practice.
Word of mouth is the number one referral source of
patients.
Source: Trent Roark,MBA
99. Answer: C
Explanation:
the Medical Director. It is important to have a peer who
can address productivity issues and protocols with the
medical staff. Anyone else does not have a medical license.
All medical issues should be addressed by the Medical
Director once input is received from the medical staff,
clinical staff (if appropriate) and administration.
Source: Trent Roark,MBA
100. Answer: B
Explanation:
A.Incorrect. Description of ICD-9
B.Correct.
C.Incorrect. Description of HCPCS
D.Incorrect
E.Incorrect. CPT-4 was not developed by CMS.
Source: Marsha Thiel, RN, MA
ASIPP
101. Answer: A
Explanation:
ratio of Current Assets to Current Liabilities. This ratio
will tell you if you have enough current assets to cover
your current liabilities. Current means that the asset or
liability can be sold or paid within a year.
Source: Trent Roark,MBA
102. Answer: B
Source: Hans C. Hansen, MD
103. Answer: B
Explanation:
Employers are responsible for completing an Injury and
Illness Incident Form 301 within seven calendar days after
receiving information that a recordable work-related
injury or illness has occurred. An equivalent form can be
used if that form contains all the information asked for on
the OSHA 301
Supporting Documentation:
http://www.osha.gov/recordkeeping/index.html THEN
SELECT recording forms then select OPEN FORMS pdf
PAGE 10 OF 12
Source: Marsha Thiel, RN, MA, Sep 2005
104. Answer: D
Explanation:
A financial budget provides information regarding
revenues and expenses and whether or not the company is
achieving its financial goals. It does not provide clinical
information on the flow of patients through the office.
Source: Marsha Thiel, RN, MA, Sep 2005
105. Answer: B
Explanation:
An impact analysis applies the rates in a new or revised fee
schedule to services provided in the past. This analysis
will show what total charges would have been in a prior
period based on a new fee schedule. The historical data
should be weighted for the types of services provided
because a large portion of a provider’s charges are often
from a few key services. The analysis should be done
before the fee changes are implemented.
Source: Marsha Thiel, RN, MA, Sep 2005
106. Answer: D
Explanation:
The market-drive approach assumes that the patients are
price sensitive and are also aware of the cost differences
among providers.
Source: Marsha Thiel, RN, MA, Sep 2005
107. Answer: A
Explanation:
The correct answer is a - $1,400. The following vendors
are due to be paid today: Company B, Company C, and
Company D.
Source: Marsha Thiel, RN, MA, Sep 2005
75
108. Answer: D
Explanation:
Cash of $40,000, accounts receivable of $60,000 and
equipment of $10,000 are the assets.
Source: Marsha Thiel, RN, MA, Sep 2005
109. Answer: C
110. Answer: B
111. Answer: B
Explanation:
The concept of risk management is an often-overlooked
critical element of a physician’s practice, ensuring safety to
the patient, and longevity of a trouble-free career. Risk is
nothing more than a potential for loss. In the arena of
controlled substances, state and federal regulatory agencies
scrutinize controlled substance prescribing habitry, as
well as licensing boards. Patients are sometimes highly
motivated by financial or physiologic pressures to obtain,
misuse, or divert controlled substances. The bar is set very
high for the prescribing physician to monitor prescribing
policies and procedures, and to reevaluate on a regular
basis to enhance patient and physician compliance. Some
pain management practices have realized that risk
management is so important and such a daunting task,that
assigned risk management officers monitor policy and
procedure, reporting to the physician administration
directly.
Source: Hans C. Hansen, MD
112. Answer: C
Explanation:
Under the cash method of accounting, revenue is recorded
when received and expenses recorded when paid.
Therefore, you would record $40,000 of revenue and
$10,000 in expenses.
Source: Marsha Thiel, RN, MA, Sep 2005
113. Answer: A
Source: Laxmaiah Manchikanti, MD
114. Answer: D
Explanation:
While discounts not applied correctly or in a timely
manner may affect aging they would have a minimal effect
on the collection ratio which involves dividing the net
collected amount by gross charges for a particular time
frame.
Source: Marsha Thiel, RN, MA, Sep 2005
115. Answer: B
Explanation:
They are moving some of the objectionable provisions to
the policy and procedure manuals, but by reference, these
become part of the contract.
Source: Marsha Thiel, RN, MA, Sep 2005
116. Answer: A
Explanation:
Communication error is the most common type of error
inthe outpatient setting.It is then followed by discontinuity
of care, and then by abnormal lab result follow up. The
next four errors, although not as common, are well suited
to the EMR as heralding alerts. These include missing
values and poor charting, prescribing errors of dosage
choice, allergy or interaction, clinical mistakes of
knowledge or skills, which would include improper
diagnosis, and the ubiquitous “other”. “Other” is actually
quite high. This would include lost charts, improper
filing, and violation of confidentiality to name a few. At
8%, or 8 out of 100 charts, applying to the typical daily
practice seeing 100 patients a day, this category “other” is
actually a very high and unacceptable number. The EMR
will assist in reducing this number.
Source: Hans C. Hansen, MD
117. Answer: A
Explanation:
The function of the Practice Management Software
includes all aspects of patient management including
appointment, procedure scheduling, communication,
creating bills, managing accounts receivable, and creating
reports. The provider is an important part of the software,
but more so in the back office. The Practice Management
Software responsibility is to ensure the vital functions of
the support system to the provider. This is independent of
clinical input.
Source: Hans C. Hansen, MD
118. Answer: B
Explanation:
The back office is associated with the clinical service side
of the electronic medical record. Input can be from a
number of sources, being a verbal integration into the
medical record, dictated and then transcribed cut and
pasted, data input by keyboard, or touch screen, and even
possibly by a pad or pen system.The key component of the
back office, however, is the provider interface.
Source: Hans C. Hansen, MD
119. Answer: D
Explanation:
recall and no show patients need to be contacted to
reschedule the appointment. Going through charts to
contact patients who have not returned for some time is
another opportunity. Screenings and seminars allow for
the introduction of the practice to the community. Having
these programs in your practice allows the participant to
find your location and be impressed by your practice
environment. Paying for referrals is illegal and carries
civil and criminal penalties.
Source: Trent Roark,MBA
120. Answer: E
Explanation:
The next course of action is to explore the issues with the
patient.
ASIPP
76
121. Answer: B
Source: Raj, Pain Review 2nd Edition
122. Answer: A
Explanation:
“Incident to” is a concern for CMS, and a potential source
for fraud and abuse. It is the duty of the practice to
determine whether the physician extender, nurse
practitioner, or PA, is meeting the appropriate guidelines
that CMS requires for “incident to” billing. It is
incumbent upon the pain management physician to know
these rules if an extender is being utilized. To bill at 100%
physician fee, the physician is immediately available onsite,
intimately involved in medical decision making with
support of the nurse practitioner and PA in follow up
visits. The physician will see the patient at first encounter,
define diagnosis, and course of care. Follow up will
typically be at the third to fifth visit by the physician,
ensuring correct diagnosis and treatment pathway. The
physician extender may follow up with the patient,assist in
management of the patient, and bill at 100% if the
physician is onsite and immediately available. The
extender should only bill 85% if the physician is not
immediately available, or is not involved in the initial
encounter. In all incidences, the physician should be
involved in medical decision making. Even if the extender
has their own provider numbers, these “incident to”
criteria must be met to apply the 100% physician fee. If an
extender bills under their own provider number, typically
only an 85% physician fee criteria will be met. Many
practices adopt the policy of just billing at the straight85%
fee to avoid regulatory scrutiny, and to avoid the pitfalls of
non-compliance, particularly during an audit.
Source: Hans C. Hansen, MD
123. Answer: E
Source: Laxmaiah Manchikanti, MD
124. Answer: D
Explanation:
Level of supplies in inventory does not affect net
collections.
Source: Marsha Thiel, RN, MA, Sep 2005
125. Answer: A
Explanation:
Federal Regulations are:
Promulgated by:
Enforced by:
Congress
(DOJ) Department
of Justice
CMS
(FBI) Federal Bureau
of Investigation
OIG
(OIG) Office of
Inspector General
Local Medicare carriers
Courts
Source: Laxmaiah Manchikanti, MD
126. Answer: E
Source: Weinberg M, Board Review 2004
ASIPP
127. Answer: E
Source: Weinberg M, Board Review 2004
128. Answer: C
Source: Weinberg M, Board Review 2004
129. Answer: A
Source: Raj, Pain Review 2nd Edition
130. Answer: B
131. Answer: D
Explanation:
Delays in processing refunds will artificially increase the
payments recorded and in turn cause aging numbers to
remain steady or even decrease.
Source: Marsha Thiel, RN, MA, Sep 2005
132. Answer: B
Explanation:
Management of contractual discounts and bad-debt writeoffs ensure that they
are legitimate and maintain the integrity in AR reports.
Source: Marsha Thiel, RN, MA, Sep 2005
133. Answer: C
Explanation:
Answer (c) is not correct. The regulations provide that the
source individual’s blood shall be tested as soon as
feasible and after consent is obtained in order to determine
HBV and HIV infectivity. If consent is not obtained, the
employer shall establish that legally required consent
cannot be obtained. However, when the source
individual’s consent is not required by law, the source
individual’s blood, if available, shall be tested and the
results documented.
Source: 29 CFR 1910.1030 (f)(3).
Source: Erin Brisbay McMahon, JD, Sep 2005
134. Answer: D
Source: Laxmaiah Manchikanti, MD
135. Answer: C
Explanation:
In order to be actionable “hostile work environment”
harassment, it must be shown that the office atmosphere
was permeated with inappropriate sexual jokes and
conduct. It takes more than one joke by one person onone
day to maintain a cause of action for sexual harassment. In
order to take advantage of the affirmative defense to a
harassment suit, an employer must demonstrate that the
clinic has a procedure to report harassment claims, and
that the employee failed to comply with the reporting
policy.
Source: Judith H. Holmes, JD
136. Answer: B
Explanation:
77
A.There is no good evidence from well designed long
term studies to date
B.Correct answer
C.Superiority of strong opioids is shown only for pain
relief, not functionality
D.Superiority shown only for strong opioids, not for
weak opioids
E.Evidence shows effectiveness for strong opioids for
both nociceptive and neuropathic pain
Source: William Allen, JD
137. Answer: D
Explanation:
An average practice of this size will include two nurses (or
1.5 FTE’s), two MA’s, Nurse Extenders, (or 1.5 FTE’s),
two secretaries, one billing specialist and an office
manager.
Source: Marcy T Rogers,M.Ed.
138. Answer: E
Explanation:
Industries such as manufacturing and construction and an
active waterfront port translates into numerous worker
injuries. Having access to a large airport can draw patients
in from other regions that do not have adequate care
available.
Source: Marcy T Rogers,M.Ed.
139. Answer: B
Explanation:
The national Committee for Quality Assurance does not
perceive physician reimbursement as a quality of care
indicator.
Source: Marcy T Rogers,M.Ed.
140. Answer: C
Explanation:
Proper employee management requires communication,
creating agreed upon goals, dealing with individual
agendas that conflict with group’s, recognition of
employee’s efforts, dealing with training and experience
issues, and regularly updating systems & procedures.
Source: Marcy T Rogers,M.Ed.
141. Answer: A
Explanation:
Turnover creates chaos. Invest in your employees and you
will save time by not having to retrain new ones.
Source: Marcy T Rogers,M.Ed.
142. Answer: A
Explanation:
The privacy rule allows patients to request amendments of
their records including amendments to billing records.
The provider is not obligated to make the amendment if
the provider believes that the original information (the
diagnosis in this scenario) was accurate as submitted. In
fact, from a billing compliance standpoint, the provider
should not make the amendment if the original
information was accurate and complete.
A provider is given 60 days to act on amendment requests
and providers are always permitted to deny amendment
request when the information is accurate and complete
when originally recorded.
Source:Manchikanti L Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005.
Source: Erin Brisbay McMahon, JD, Sep 2005
143. Answer: B
Explanation:
Answer: B. The Freedom of Information Act (FOIA)
specifically requires Government agencies to provide
information to citizens, with certain exceptions, upon
request. The exceptions include documents related to
national security and the like.The FOIA exceptions do not
apply to Medicare policies. Dr. Jones should specifically
mention the FOIA in her document request.
A.HIPAA relates to the privacy and security of patient
identifiable health information. HIPAA does not relate to
specific Medicare policies.
C.The Medicare Act details how the Medicare program
will be administered but does not address a physician’s
right to policy information.
D.There is no such Act.
E.There is no such Act.
Source: Vicki Myckowiak, Esq.
144. Answer: B
Explanation:
Inadvertent disclosures of protected health information
are required to be included in an accounting of disclosures.
Source: 45 CFR 164.528.
Source: Erin Brisbay McMahon, JD, Sep 2005
145. Answer: D
Source: marsha J. Thiel, RN, MA
146. Answer: A
Source: Laxmaiah Manchikanti, MD
147. Answer: D
Explanation:
The intent of a harasser is not relevantit is the effect on the
victim that is important. In order for conduct to create a
hostile work environment, the conduct must be either
severe or pervasive. One tasteless joke is not enough to be
either severe or pervasive. A clinic may be responsible for
harassing conduct by on non employee such as a drug
representative if the clinic allows the conduct to occur at
the clinic. In order to be unlawful harassment, conduct
must be based on someone’s membership in a protected
category such as race, religion, age, national origin,
disability, or gender. Chronic tardiness is not a protected
category
Source: Judith H. Holmes, JD
ASIPP
78
148. Answer: D
Explanation:
A covered entity must assess whether an addressable
implementation specification is appropriate and
reasonable for it in light of its security risks.
Source: 45 CFR 164.306.
Source: Erin Brisbay McMahon, JD, Sep 2005
149. Answer: D
Explanation:
One of the elements of a claim of “hostile work
environment” harassment claim is that the conduct must
be unwelcome. Mary’s conduct in the office, her wardrobe
choices, and her personal relationship with Steve all
demonstrate that Steve’s attention is not unwelcome, but
rather is appreciated. The fact that Mary complained to
your administrator instead of the person designated in the
handbook is irrelevant because both the administrator and
HR director are members of the management team.
Source: Judith H. Holmes, JD
150. Answer: D
Explanation:
In the cash method of accounting, revenue is recorded
when received and expenses recorded when paid.
Therefore, you would record $47,000 of revenue and
$16,000 in expenses. (47,000 – 16,000 = 31,000).
Source: Marsha J. Thiel, RN, MA
151. Answer: A
Explanation:
Open communication to and from all areas of the practice
allow for more accurate information, shared responsibility
and better decision making. One group pushing their own
agenda down to another group will result in resentment,
less motivation, less openness, and worse decision making.
Source: Trent Roark,MBA
152. Answer: D
Explanation:
A.Less than 20% of medical care is based on EBM.
B.Certain conditions get more attention due to
commercial interests than others
C.The science of what works best and why is expanding
rapidly and is difficult to stay abreast.
D.The gap between the science and practice averages 17
years.
E.Less than 25% of patients are inclined to be compliant
with a designated guideline (EBM)
Source: Laxmaiah Manchikanti, MD
153. Answer: E
Explanation:
Answer: E. The first level of appeal is a reconsideration of
the negative decision by the Medicare Carrier.
B.The Administrative Law Judge is the third level of
appeal. The Administrative Law Judge is bound by the
Carrier polices. S/he cannot make a finding that the policy
is wrong or unjust.
ASIPP
C.Federal District Court is the last level of the Medicare
appeal process.
D.Reconsideration by a Qualified Independent Contractor
is the second level of appeal and the first time the denials
are reviewed by someone who does not work for the
Medicare Carrier.
E.There is no such thing as Medicare arbitration.
Source: Vicki Myckowiak, Esq.
154. Answer: C
Explanation:
Cash of $34,000, accounts receivable of $90,000 and
equipment of $15,000 are the practice assets.
Source: Marsha J. Thiel, RN, MA
155. Answer: B
Explanation:
Checks and balances should be in place to detect errors or
irregularities by front line employees at the time the
irregularity occurs. This is the first line of defense for
managing problems
Source: Marsha J. Thiel, RN, MA
156. Answer: C
Explanation:
You must always be prepared before recruiting and
hiring.There should be a current job description for every
position in the practice, Along with a current employee
handbook defining all rules, policies and data pertinent to
the practice. Interviews should be carefully structured so
only questions that fall within the parameters of being
non-biased and not asking mandated as inappropriate by
federal and state law.
Source: Alan S Whiteman,PhD,FACMPE
157. Answer: A
Explanation:
The most cost effective way is begin contacting others for
leads on potential candidates. Both the hospital(s) and
other offices may have good candidates on file whom they
cannot utilize at this time. This has the potential of saving
you time and money, since they have paid for ads, screened
the applicants and possibly completed background checks.
Source: Alan S Whiteman,PhD,FACMPE
158. Answer: A
Explanation:
If the Medicare auditor cannot read the records s/he is
likely to deny the services. It is best to dictate all illegible
records; but the records should be dictated word for word
to match the written record.
B.The Medicare reviewer may not be a physician. Even if
the reviewer is a physician, s/he is not obligated to try to
read illegible handwriting.
C.The dictated records should be sent in with the copies of
the medical records. If Dr. Jones sends them in before she
sends in the records they may be lost by Medicare. If Dr.
Jones sends them in after the copies of the medical records
they may not get reviewed.
D.Medicare will allow Dr. Jones to send in word for word
79
dictations of the medical records.
E.Dr. Jones should never change the original medical
record. If necessary, Dr. Jones can make an appropriate
amendment to the medical record.
Source: Vicki Myckowiak, Esq.
159. Answer: c
Explanation:
The retail industry has a very low injury rate relative to the
construction industry. In addition, marketing to payers,
carriers and attorneys can produce very beneficial
relationships. By educating these sources of your services,
you are securing referrals from influential decision makers.
Source: Marcy T Rogers,M.Ed.
160. Answer: B
Explanation:
If it is higher than 60 days, your billing and collections
operation needs to be analyzed. The higher the number of
days, the less chance of ever collecting these charges.
Source: Marcy T Rogers,M.Ed.
161. Answer: B
Explanation:
The correct answer is a - $1,580. The following vendors
are due to be paid today: Company B, Company C, and
Company D.
Source: Marsha J. Thiel, RN, MA
162. Answer: C
Explanation:
Your receptionist does not have a valid claim against the
clinic for either discrimination or hostile work
environment harassment. In order to bring such an action,
she must demonstrate she was harassed or discriminated
against because she is a member of a category protected by
federal or state law. Those categories do not include
political affiliation. Employees do not have an absolute
right to express their personal beliefs if it is disruptive.
You are not required to warn an employee before you
terminate her, although your defense will be stronger if
you can demonstrate she has violated specific office
policies, and if you have evidence she has been warned in
the past.
Source: Judith H. Holmes, JD
providers to be of a benefit to the patient, as well as to take
positive steps to prevent and to remove harm from the
patient.
D. The Principle of Justice is usually defined as a form of
fairness, or as Aristotle once said, “giving to each that
which is his due.” This implies the fair distribution of
goods in society and requires that we look at the role of
entitlement. The question of distributive justice also seems
to hinge on the fact that some goods and services are in
short supply, there is not enough to go around, thus some
fair means of allocating scarce resources must be
determined.
E. Egalitarianism is the basis of the French Constitution.
Source: Gurpreet Singh Padda MD MBA
164. Answer: E
Explanation:
This is a no brainer but important to teach the
policies that must be implemented by all employers.The U.
S. Supreme Court decisions of Faragher and Ellerth must
be discussed and understood.
Source: Judith Homes, Sep 2005
165. Answer: A
Explanation:
Explanation: Although it is not advisable, asking an
employee out for a date and getting turned down ONCE is
not harassing. The big caveat is that if the physician has
authority over the employee, and he later takes any adverse
action against him or her (fires her, doesn’t promote her,
switches her to an undesirable work schedule, etc.) there is
a great danger of the physician being accused of “quid pro
quo” or economic harassment. This is very serious
because it only takes one adverse employment action to
expose a physician and/or the clinic to liability for sexual
harassment.
Source: Judith Homes, Sep 2005
B. The Principle of Nonmaleficence requires of us that we
not intentionally create a needless harm or injury to the
patient, either through acts of commission or omission.
166. Answer: A
Explanation:
Explanation: Harassment is only unlawful if it is directed
at a protected category. Although yelling at your staff is
obnoxious and unprofessional, it is not unlawful if you yell
at everyone- that is, if you are an “equal opportunity
yeller.” If you treat everyone the same way and do not
discriminate by yelling more often at women or Hispanics
or older workers, etc. then you simply need a lesson in
deportment. With respect to “old geezer” and other ageist
comments, even if you direct the comments toward
yourself, other older workers may use that as evidence of
age discrimination and harassment. With respect to C, if
the computer screen may be viewed by nurses who need to
put files on your desk, or if you computer may be seen as
people who walk into or past your office, that may be used
as evidence of the existence of a hostile work environment
Source: Judith Homes, Sep 2005
C. The Principle of Beneficence is the duty of health care
167. Answer: A
163. Answer: E
Explanation:
A. Respect for Autonomy means that the patient has the
capacity to act intentionally, with understanding, and
without controlling influences that would mitigate against
a free and voluntary act. This principle is the basis for the
practice of “informed consent” in the physician/patient
transaction regarding health care
ASIPP
80
Explanation:
In any research on human beings, each potential subject
must be adequately informed of the aims, methods,
anticipated benefits and potential hazards of the study and
the discomfort it may entail. He or she should be informed
that he or she is at liberty to abstain from participation in
the study and that he or she is free to withdraw his or her
consent to participation at any time. The physician should
then obtain the subject’s freely-given informed consent,
preferably in writing.
Source: Gurpreet Singh Padda MD MBA
168. Answer: B
Explanation:
Training is to be provided at the time of initial assignment
to tasks where occupational exposure may take place, at
least annually thereafter, and additional training when
changes such as modification of tasks or procedures or
institution of new tasks or procedures affect the
employee’s occupational exposure.
Source: 29 CFR 1910.1030(g)(2).
Source: Erin Brisbay McMahon, JD, Sep 2005
169. Answer: B
Source: Judith Homes, Sep 2005
170. Answer: C
Explanation:
Explanation: Whether or not the conduct is sexually
harassing depends on whether the invitations for dates are
unwelcome. We don’t have enough information to
determine that critical element. For example, is the
receptionist married to someone else and has she
repeatedly told him to stop emailing her? Or do they have
an ongoing romantic relationship and she looks forward
to receiving the invitations? A and D are not correct – an
employer has a right to know what his employees are
doing during work hours using the employer’s office
equipment.
Source: Judith Homes, Sep 2005
171. Answer: C
Explanation:
Explanation:Most employers believe they can’t control an
independent visitor’s conduct while they are at the
workplace. That is not true. In fact, an employer has a duty
to protect employees from unwanted sexual conduct,
including the conduct of third parties. Answer D is not
correct because, unless the employer actually witnesses the
conduct,making accusations and possibly causing the drug
rep to lose his job will subject the employer to
unnecessary liability. Use that approach only as a last ditch
effort. Obviously Answer E is an overreaction, and
Answers A & B are not appropriate reactions, since
ignoring the problem can subject the employer to a claim
that the employer tolerated a hostile work environment.
Source: Judith Homes, Sep 2005
172. Answer: A
ASIPP
Explanation:
Is there such a thing as presumed/implied consent?
The patient’s consent should only be “presumed”, rather
than obtained, in emergency situations when the patient is
unconscious or incompetent and no surrogate decision
maker is available. In general, the patient’s presence in the
hospital ward, ICU or clinic does not represent implied
consent to all treatment and procedures. The patient’s
wishes and values may be quite different than the values of
the physician’s. While the principle of respect for person
obligates you to do your best to include the patient in the
health care decisions that affect his life and body, the
principle of beneficence may require you to act on the
patient’s behalf when his life is at stake.
Source: Gurpreet Singh Padda MD MBA
173. Answer: B
Explanation:
The HIPAA Privacy Rule requires a covered health care
provider with direct treatment relationships with
individuals to give the notice to every individual no later
than the date of first service delivery to the individual and
to make a good faith effort to obtain the individual’s
written acknowledgment of receipt of the notice. If the
provider maintains an office or other physical site where
she provides health care directly to individuals, the
provider must also post the notice in the facility in a clear
and prominent location where individuals are likely to see
it, as well as make the notice available to those who ask for
a copy.
Source: 45 CFR 164.520(c).
Source: Erin Brisbay McMahon, JD, Sep 2005
174. Answer: C
Explanation:
The person who conducts the consent interview should be
knowledgeable about the study and able to answer
questions. FDA does not specify who this individual
should be. Some sponsors and some IRBs require the
clinical investigator to personally conduct the consent
interview. However, if someone other than the clinical
investigator conducts the interview and obtains consent,
this responsibility should be formally delegated by the
clinical investigator and the person so delegated should
have received appropriate training to perform this activity.
Source: Gurpreet Singh Padda MD MBA
175. Answer: D
Explanation:
Explanation: Informed consent is the process by which a
fully informed patient can participate in choices about his
health care.It originates from the legal and ethical right the
patient has to direct what happens to his body and from
the ethical duty of the physician to involve the patient in
his health care. Although written consent in a clinical
situation is recommended, it is not required. For example:
consent to examine by taking a patient history.
Source: Gurpreet Singh Padda MD MBA
81
176. Answer: E
Explanation:
The most important goal of informed consent is that the
patient have an opportunity to be an informed participant
in his health care decisions. It is generally accepted that
complete informed consent includes a discussion of the
following elements:
* the nature of the decision/procedure
* reasonable alternatives to the proposed intervention
* the relevant risks, benefits, and uncertainties related to
each alternative
* assessment of patient understanding
* the acceptance of the intervention by the patient
Source: Gurpreet Singh Padda MD MBA
180. Answer: D
Explanation:
Heat and cold therapies, therapeutic exercises,
hydrotherapy,massage, are included as part of the physical
therapy treatment modality.
Source: Waldman, Pain Management Vol 2
Source: Lora Brown, MD
181. Answer: B
Explanation:
Explanation: Sacroilitis has a prevalence of 35% in patients
with prior lumbar fusion.
Source: Maigne JY, Planchon CA. Sacroiliac joint pain after
lumbar fusion. A study with anesthetic blocks. Eur Spine J
2005;14:654-658.
Source: Lora Brown, MD
177. Answer: C
Explanation:
Explanation: With “economic harassment,” it only takes
182. Answer: D
one incident to find an employer liable. The key points are
Explanation:
that the head of the medical group or clinic does not even
Homeopathy utilizes?diluted agents that, in undiluted
need to know the improper conduct took place – it is
doses, produce similar symptoms in the healthy.
enough that the employee received an adverse employment
Acupuncture is a technique of inserting and manipulating
action after refusing a supervisors sexually-oriented
filiform needles into “acupuncture points” on the body.
request.
Chiropractic involves alignment of the spine to affect the
nervous system and thereby treat medical disorders.
Environmental harassment has four elements: 1) The
Ayurveda uses use of herbs, metals, massage, and other
conduct is unwelcome; 2) The conduct is directed at a
products and techniques with the intent of cleansing the
protected category; 3) the conduct is offensive to the
body and restoring balance. Massage therapy utilizes
recipient and to a “reasonable person;” and 4) the conduct
manual therapy for relaxation, flexibility, muscle
is severe OR pervasive.
relaxation, and pain treatment.
Source: Judith Homes, Sep 2005
Source: National Center for Complementary and
Alternative Medicine, nccam.nih.gov
178. Answer: C
Source: Lora Brown, MD
Explanation:
Facet joint injections/ MBB, sacroiliac joint injections,
183. Answer: D (4 Only)
provocative discography, and selective nerve root/
Explanation:
transforaminal injections are all considered diagnostic
Physical therapy is provided upon evaluation and
procedures. Selective nerve root/ transforaminal injections
examination of a patient in accordance with the plan of
have diagnostic and therapeutic indications.
care, treatment frequency and duration, and functional
Vertebroplasty is a therapeutic procedure involving
goals that were established by a physical therapist. Physical
cement augmentation of fractured vertebral bodies.
therapy services cannot be initiated by physical therapist
Source: Principles of Documentation, Billing, Coding, and
assistants.
Practice Management for the Interventional Pain
Physician, Manchikanti,.
Source: Medicare Benefit Policy Chapter 15, 230.1,
Source: Lora Brown, MD
Practice of Physical Therapist
Source: Marsha Thiel, RN, MA, Sep 2005
179. Answer: D
Explanation:
184. Answer: B (1 & 3)
Chronic pain is a complex process that responds best to
Explanation:
multidimensional care. Functional Capacity Evaluation
Physical therapy services cannot be billed incident to a
(FCE) is a systematic process of assessing an individual’s
physician who is not involved in the patient’s care,
physical capacities and functional abilities. The FCE
regardless of whether or not physician supervision of
matches human performance levels to the demands of a
ancillary personnel is met. Physical therapists can accept
specific job or work activity or occupation. It is not used as
referrals for physical therapy from providers outside of a
a treatment modality.
group practice they are employees of if they have their
own Medicare provider numbers to bill under.
Source: The American Occupational Therapy Association
Source: Lora Brown, MD
Source: WPS- PHYSMED-004, WPS National Coverage
ASIPP
82
Provision, Incident To Billing
Source: Marsha Thiel, RN, MA, Sep 2005
185. Answer: B (1 & 3)
Explanation:
A Clinical Psychologist should follow all appropriate state
and federal guidelines). The CP is eligible to obtain a
Medicare provider number and should bill under this
number. Clinical Psychologists are licensed to practice
independently in all 50 states and are generally not billed
incident to interventional pain physicians because in most
cases interventional pain physicians would not have the
requisite training and skill set to appropriately supervise
the work of a pain psychologist.
employment decisions, such as hiring and firing, do not
engage in discriminatory conduct. You have a better
chance of prevailing on a discrimination claim if you have
good documentation to show a legitimate reason for the
termination, such as poor work quality.
Source: Judith Homes, Sep 2005
189. Answer: E (All)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
190. Answer: A (1,2, & 3)
Explanation:
The roles listed are legitimate roles of a psychologist
within a pain clinic.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
186. Answer: E (All)
Explanation:
Doctoral level clinical psychologists are licensed to
practice independently within a scope of practice that
includes the assessment, diagnosis, and treatment of
mental health disorders; assessment and treatment, but
not diagnosis, of physical health disorders; hospital
privileges, in many states; as well as consultation;
supervision; research; teaching.
191. Answer: B (1 & 3)
Explanation:
An example of screening requirements are the following
form the state of Minnesota.
http://www.revisor.leg.state.mn.us/stats/148A/
Source: Marsha Thiel, RN, MA, Sep 2005
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
187. Answer: D (4 Only)
Explanation:
1. A business that stocks inventory for sale to the public
must use the accrual method of accounting
2. Revenue is recorded when earned under the accrual
method of accounting
3. Accrual accounting will even out the revenue and
expenses over time
4. Under the cash method of accounting, expenses are
recorded when cash is paid out
Source: Marsha Thiel, RN, MA, Sep 2005
188. Answer: A (1,2, & 3)
Explanation:
Explanation: Age discrimination complaint may be made
by those who are 40 years or older. The issue of age
discrimination is a growing concern as the “baby
boomers” continue to age and demand their rights. It is
important to keep ageist comments out of the workplace
and to make certain that those individuals responsible for
ASIPP
192. Answer: E (All)
Explanation:
The provisions of the Needlestick Safety and Prevention
Act did not include penalties for increased injuries of
employers who fail to comply with the provisions of the
Needlestick Safety and Prevision Act.
American Society of Interventional Pain Physicians page
235,236,237
http://www.osha.gov/SLTC/bloodbornepathogens/index.h
tml _ for some reason you can not click on this web site
from here you need to copy this email address then paste it
to your internet and select go.
http://www.osha.gov/pls/oshaweb/owadisp.show_docume
nt?p_table=NEWS_RELEASES&p_id=36
1910.1030(c)(1)(iv) The Exposure Control Plan shall be
reviewed and updated at least annually and whenever
necessary to reflect new or modified tasks and procedures
which affect occupational exposure and to reflect new or
revised employee positions with occupational exposure.
The review and update of such plans shall also:
1910.1030(c)(1)(iv)(A) Reflect changes in technology that
eliminate or reduce exposure to bloodborne pathogens;
and 1910.1030(c)(1)(iv)(B) Document annually
consideration and implementation of appropriate
commercially available and effective safer medical devices
designed to eliminate or minimize occupational exposure.
83
1910.1030(c)(1)(v) An employer, who is required to
establish an Exposure Control Plan shall solicit input
from non-managerial employees responsible for direct
patient care who are potentially exposed to injuries from
contaminated sharps in the identification, evaluation, and
selection of effective engineering and work practice
controls and shall document the solicitation in the
Exposure Control Plan
Source: Marsha Thiel, RN, MA, Sep 2005
193. Answer: E (All)
Source: Weinberg M, Board Review 2004
194. Answer: E (All)
Explanation:
This is a common occurrence when individuals are
unaware of proper interview techniques and legal issues.
The safest and best interview technique is to learn the
appropriate questions (if unsure ask
nothing that doesn’t appear on the application) and keep
the process formal. Using questions that lead to a dialogue
is the best approach. If a candidate offers information you
can proceed on the track they initiate. Common sense says
stay away from personal or potentially sensitive issues to
avoid problems.
Source: Alan S Whiteman,PhD,FACMPE
195. Answer: B (1 & 3)
Explanation:
Program Safeguard Contractors
* Show up unannounced
* Want to talk to MD
* Don’t have to talk
Money is almost never the prime motivator. Individuals
should strive to create an environment that motivates
employees and makes them feel safe and comfortable.
Source: Alan S Whiteman,PhD,FACMPE
198. Answer: A (1,2, & 3)
Explanation:
Medicare and an increasing number of non-Medicare
payers allow a higher payment for procedures and services
performed in POS 11. Medicare calculates the higher
payment based on a component called “practice expense”.
A physician must incur the entire expense of the practice
to justifiably report POS 11 as the site of service.
Source: Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005; Medicare Physician’s Fee Schedule
(MPFS)
Source: Joanne Mehmert, CPC, Sep 2005
199. Answer: A (1,2, & 3)
Explanation:
OSHA training is required at hiring, and suggested
annually thereafter, and is a part of an active compliance
environment. A major event does not necessarily reflect
poor training, but should reveal an appropriate response
in policies and procedures within the practice.Incidents
will occur, and the employee/owner is ready.
Source: Hans C. Hansen, MD
200. Answer: D (4 Only)
Explanation:
OSHA training is considered mandatory and the employer
can be fined if adherence is not followed. Refresher
courses are suggested annually, or when a serious violation
occurs, or when a major change in OSHA statutes is
placed.
* Call attorney immediately
* Example
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
196. Answer: D (4 Only)
Explanation:
Direct supervision requires the PT to be present and
immediately available for direction and supervision; it is
the supervision level required in a physical therapy private
practice setting, unless state practice requirements are
more stringent, in which case those requirements must be
followed. Although the PT and PTA are working within a
medical clinic, because PTA services are billed by the
supervising PT, they are considered to be a part of a
physical therapy private practice.
Source: APTA website, H.O.D. 06-00-15-26
Source: Marsha Thiel, RN, MA, Sep 2005
197. Answer: A (1,2, & 3)
Explanation:
OSHA training, and familiarity with Blood Borne
pathogens in particular, is important to the pain
management practitioner. Failure to follow this directive
may lead to expensive and cumbersome fines and
sanctions. OSHA training is included for all members of
the practice, or those that might be in contact with a risk
environment. This includes independent contractors, and
full-time, part-time or leased employees.
Source: Hans C. Hansen, MD
201. Answer: A (1,2, & 3)
Source: Hans C. Hansen, MD
202. Answer: A (1,2, & 3)
Explanation:
Hazardous chemicals require each of the above and an
antidote if available. These important safety items are
defined by OSHA. MSDS files should be kept in view, or
easily retrieved. Glass is an option for containment, but
not required.
Source: Hans C. Hansen, MD
ASIPP
84
203. Answer: D (4 Only)
Explanation:
Drug manufacturers are required to submit their average
sales price to CMS every quarter. The data will include
almost all Medicare Part B drugs not paid on a cost or
prospective payment basis. Medicare’s payment to the
provider is equal to the lesser of 106 percent of the average
sales price or 106 percent of the wholesale acquisition cost
of the Health Care Common Procedure Coding System
(“HCPCS”) drug. Physicians can download a complete
list of the drugs and the payment for each every quarter.
Source: CMS web site www.cms.gov. Medicare Program;
Revisions to Payment Policies Under the Physician Fee
Schedule for Calendar Year 2005 – CMS-1429-FC, on
display at the Office of the Federal Register November 2,
2004.
Source: Joanne Mehmert, CPC, Sep 2005
204. Answer: C (2 & 4)
Explanation:
1. If a provider employs, contracts or enters into an
arrangement with an individual or company that the
provider “knows or should know” is excluded from
Medicare or Medicaid, the provider is liable for a civil
money penalty of up to $10,000.
2. Individual or companies must be excluded under the
following circumstances.
¨A criminal offense conviction related to items or services
covered by Medicare or Medicaid.
¨A criminal offense conviction relating to patient abuse or
neglect (the patient doesn’t have to be a Medicare or
Medicaid beneficiary).
¨A felony conviction related to health care fraud or “any
act of omission”under Medicare, Medicaid,or other
health care program financed in whole or in part by
federal, state or local governments. The felonies
include fraud, theft, embezzlement and breach of fiduciary
responsibility.
¨A felony conviction relating to controlled substances,
including unlawful manufacture, distribution, prescription
or dispensing of a controlled substance.
A person or company is considered to be convicted when
any of the following has happened.
¨A conviction has been entered against an individual or
company by a federal, state or local court, regardless of
whether there’s a post-trial motion or appeal pending, or
whether conviction or other record of the criminal
conduct has been expunged or removed.
¨A federal, state or local court has made a finding of guilt
against an individual or company.
¨A federal, state or local court has accepted a guilty please
or a plea of nolo contendere by an individual or company.
¨An individual or company has entered into participation
in a first offender, deferred adjudication or other program
or arrangement where the conviction has been withheld.
ASIPP
3. For offenses requiring mandatory exclusion, the
minimum period is five years, with one exception: In the
case of providers convicted of program-related crimes,
HHS can waive the exclusion of a company or individual
that is either a sole community physician or the sole source
of essential specialized services in a community.
4. The Balanced Budget Act of 1997 included a threestrikes-and-you’re-out provision, under which an
individual convicted on one previous occasion of one or
more exclusion offenses will be excluded from Medicare
or Medicaid for at least 10years, and a person convicted on
two or more previous occasions of one or more exclusion
offenses will be permanently excluded.
Source: Laxmaiah Manchikanti, MD
205. Answer: A (1,2, & 3)
Source: Hans C. Hansen, MD
206. Answer: C (2 & 4)
Source: Hans C. Hansen, MD
207. Answer: A (1, 2 & 3)
Explanation:
A considerable number of patients fall into the category, of
a variant of personality disorder. According to the Journal
American Family Physician, Leonard J. Haas, PhD et al.
volume 72 number 10, sub-clinical personality disorders
interfere with the patient-physician relationship. These
patients may become dependant, demanding and selfdestructive. This is a common patient we see in the Pain
Management setting. Operant conditioning is irrelevant.
Source: Hans C. Hansen, MD
208. Answer: A (1, 2 & 3)
Explanation:
Undiagnosed psychopathology in the pain management
population is a significant concern. A patient health
questionnaire is sometimes useful, including simple
questions as to lifestyle, interactions with individuals, and
directed questions to diagnose depression and anxiety.
Questions should determine complaints of altered sleep,
which shouldn’t be confused with depression and mood
alterations such as dysphoria, anxiety, and potential for
substance abuse. Patients with undiagnosed psychiatric
illnesses have increased incidences of drug abuse,
diversion and misuse, as well an increased risk
management concern for the pain management physician
Source: Hans C. Hansen, MD
209. Answer: C (2 & 4)
Explanation:
Experts and risk managers have some disagreement about
this point, but agree that non-compliance should be
documented in the chart. Putting too many specifics into
the discharge letter might allow for a patient to formulate
a debate, or allege inappropriate discharge. Better put, “the
patient-physician relationship based on trust and
compliance has eroded, and therefore I must withdraw as
85
your physician”. The exact reason for discharge may
ultimately avoid confusion, but the termination letter
should not be written to evoke anger.
Source: Hans C. Hansen, MD
210. Answer: A (1, 2 & 3)
Source: Hans C. Hansen, MD
211. Answer: A (1,2, & 3)
Explanation:
Citations and enforcement policy are a necessary part of
OSHA. Fines can be imposed financially, or far more
punitive in nature (prison) depending on the infraction.
Willful risk of an employee from an employer might result
in civil and criminal prosecution, with generally an
expensive outcome. Spill kits and personal protective gear
must be readily available, not necessarily at the site of a
spill.
Source: Hans C. Hansen, MD
212. Answer: A (1, 2 & 3)
Explanation:
If an exposure incident occurs, the employer’s
responsibility is to document the routes of exposure and
how the exposure occurred, placed in an appropriate
documentation manual. If an injury occurs, an OSHA 300
form must also be displayed, prominently in a place of
commonality, such as a lunchroom. Furthermore, the
employer must attempt to identify the vector source,
obtain consent and test the individual serology, and
provide the employee needed information about test
results. If the employee does not want testing, 90 days may
be offered for retesting
Source: Hans C. Hansen, MD
213. Answer: D (4 Only)
Explanation:
Answer (4) is wrong; it is not a required reporting
element.
Source: 42 CFR 411.361.
Source: Erin Brisbay McMahon, JD, Sep 2005
214. Answer: A (1,2, & 3)
Explanation:
Income Statement includes the Revenue less the Expenses
which leaves the Net Income. The income statement is a
snap shot taken at a moment in time – usually monthly.
Source: Trent Roark,MBA
215. Answer: A (1,2, & 3)
Explanation:
The Balance Sheet is a financial picture of all the assets
owned, the money owed and the owners value in the
company. This statement is updated monthly, but reflects
the ongoing financial position of the company since it
started.
Source: Trent Roark,MBA
216. Answer: B (1 & 3)
Explanation:
1965 - Health Care Law
Called for by Theodore Roosevelt in 1912
Signed by Lyndon Johnson in 1965
1972 - Addition of Medicaid
1983 - PPS, DRG’s
1993 - Health Security Act of Clinton
- Failed because it was ‘not credible’
1992 - RBRVS
2000 - HOPD – PPS
1995 - Balanced Budget Act
1996 - Health Insurance Portability and Accountability Act
2003 - Medicare prescription drug, improvement and
modernization act of 2003
217. Answer: A (1,2, & 3)
Explanation:
Mystery Shopper will evaluate the practice from the
patient’s point of view. Surveys can be useful if designed
correctly, but can’t be overused. It is important with
surveys that you get a large return of surveys on your
sample size. Testimonials are important because a patient
willing to speak on behalf of their experience is the
strongest source of referral.
Source: Trent Roark,MBA
218. Answer: A (1,2, & 3)
Explanation:
Most states do not require a consent form. What is
required is informed consent.
Source: Raj P, Practical Management of Pain, 3rd Ed.
219. Answer: B (1 & 3)
Explanation:
Explanation:This is not as outlandish as it sounds.
Harassment and discrimination against employees of
mideastern origin are on the rise since 9/11. It is critical to
adopt a zero tolerance policy. Inappropriate racial or
ethnic jokes and mocking an employee’s accent are not
acceptable merely because the “target” did not hear the
remarks or because you only “overheard.” If you know
about the conduct and do nothing, you and the clinic are
at risk.
Source: Judith Homes, Sep 2005
220. Answer: A (1,2, & 3)
Explanation:
The final determination of culpability or lack thereof is
contingent on determining whether the physician followed
standards of practice for his or her specialty.
Source: Hall and Chantigan.
221. Answer: C (2 & 4)
Explanation:
1.There is no such defense as Waiver of Payment. There is
a defense called Waiver of Liability. Waiver of Liability
which states that a providers may be entitled to payment
for services determined not reasonable and necessary inthe
ASIPP
86
audit if the provider can show that s/he did not know, and
could not reasonably have been expected to know, that
payment would not be made.
2.The treating physician rule supports the medical
necessity of the services provided. The treating physician
rules states that the treating physician, who has examined
the patient and is most familiar with the patient’s
condition, is in the best position to make medical necessity
determinations. The treating physician rule is available in
most States.
3.There is no defense called the “innocent error rule.”
4.provider is considered without fault if s/he exercised
reasonable care in billing for and accepting payment, i.e.
the provider complied with all pertinent regulations, made
full disclosure of all material facts, and on the basis of
information available had a reasonable basis for assuming
payment was correct.
Source: Vicki Myckowiak, Esq.
222. Answer: E (All)
Explanation:
1. Worker’s compensation claimants must allow access to
medical records any time they are requested by the payee.
2. Agent(s) on behalf of the Centers for Medicare and
Medicaid Services have access to medical records of any
patient receiving Medicare benefits. 3. Private insurers
must ask the permission of the patient to view the medical
records. 4. Mental health records, even though they may be
part of the medical record, may not be released without
the specific consent of the patient in many states. It is
important to clarify what laws are in effect regarding
mental health records in your particular state.If specific
consent is required, unauthorized release of mental health
records may result in damages against the clinic or
physician involved.
Source: Anastasio J. Am Med Rec Assoc 1990; 61:52-61.
Griffith, Med Staff Couns 1991; 5:31-37.
223. Answer: B (1 & 3)
Explanation:
QUI TAM (Whistleblower Act)
1Suits are usually brought by employees
2 If the government proceeds with the suit, the
whistleblower receives 15 to 25% of settlement.
3 Individuals can bring suit against violators of Federal
laws on their own behalf as well as the government’s
4 If the government does not proceed and the individual
continues, he receives 25 to 30% of the settlement
Source: Laxmaiah Manchikanti, MD
224. Answer: A (1, 2 & 3)
Explanation:
In our healthcare system, “the patient-physician
relationship has resulted in many stressors over the past
number of years, particularly the managed care system has
increased patient mistrust” Theodosakis, J. et al. Don’t Let
Your HMO Kill You: How to Wake Up Your Doctor, Take
ASIPP
Control of Your Health, and Make Managed Care Work
for You. New York: Routledge 2000. Patients are
dissatisfied with their visits when they don’t feel nursing
staff has time, physician has time, and that they are not
being heard. A correlation to mistrust, and lack of patient
satisfaction is related to time of encounter, and ability of
the patient to contact the staff either during business
hours or on-call, after hours. Patients have high levels of
expectations, and when these expectations are unmet,
patients become more demanding and they feel the
physician is less responsive their needs. This may result in
alteration of patient-physician relationship, at the least, or
increased malpractice risk and unnecessary accusations of
poor care.
Source: Hans C. Hansen, MD
225. Answer: B (1 & 3)
Explanation:
The tasks performed by the EMR do not necessarily allow
for direct patient access to the records. That is a potentially
desirable feature, but should be controlled at the front and
back office. The tasks performed by the EMR include:
chart documentation, transcription, prescription writing
and database, order entry, and results reporting inpatient
reports, triage of telephone communications, and secure
messaging systems. Furthermore, the software should be
able to interface with other systems, assisting in support,
and capability of multiple users. A very strong advantage
of the EMR is remote data access.
Source: Hans C. Hansen, MD
226. Answer: B (1 & 3)
Explanation:
Objectives of Physician Program
Encourage coordination of Part A and Part B Services
Promote efficiency through investment in administra
tive structure and process Reward physicians for
improving health outcomes
227. Answer: D (4 Only)
Explanation:
CMS denies acupuncture as not reasonable and necessary
under §1862(a)(1) of the Social Security Act (SSA). This
service has commonly been thought to be “non covered”
and many providers did not have an ABN signed for
acupuncture services provided to a Medicare Beneficiary.
At present all acupuncture services are denied as not
reasonable and necessary and require an ABN.
Source: Joanne Mehmert, CPC, Sep 2005
228. Answer: B (1 & 3)
Explanation:
The practice should have a general idea of the cost to
provide its specific services and whether or not the insurer
will compensate it beyond the practice expense. When an
insurer attaches a list of codes it will often include many
codes that an interventional pain specialist seldom or
never performs. It is not unusual for a practice to lose
money when it signs a “blank contract”.
87
A physician practice can and should say “no” when a
contractual agreement does not pay enough to add
revenue to the practice. The practice should carefully
review its patient demographics and understand the
economic impact of every contract before signing.
Source: AMA Model contract, Fourth Edition 2005; 15
Questions to ask before signing a managed care contract.
Source: Joanne Mehmert, CPC, Sep 2005
229. Answer: E (All)
Explanation:
Each of these can be a major factor in your profitability.
Source: Marcy T Rogers,M.Ed.
230. Answer: E (All)
Explanation:
Medicare +Choice organizations must have a process that
is very similar to the appeal process that applies to
Medicare Part B carriers. Complete information may be
found on the CMS web site.
Source: www.cms.hhs.gov/healthplans/appeals
Source: Joanne Mehmert, CPC, Sep 2005
231. Answer: B (1 & 3)
Explanation:
Desired Outcome Measures for Clinical Policies
Improved Quality of Care
Improved Consistency of Care
Better Resource Utilization
Improved Provider Satisfaction
Lower Health Care Expenditures
Decreased Liability
Source: Laxmaiah Manchikanti, MD
232. Answer: A (1,2, & 3)
Explanation:
Conclusions: Clinical Policies
Expensive and labor intensive to develop and maintain
Actual impact on the quality of care is nearly
impossible to determine
Probable indirect positive benefits of this effort
Increased acceptance of concept of “standards”
Increased attention to our individual practices of
medicine, especially over time
Decreased practive variation
Pay for performance
Source: Laxmaiah Manchikanti, MD
233. Answer: C (2 & 4)
Explanation:
An employee may have a claim of harassment even though
some people don’t find the conduct or language offensive,
even if the comments were not directed to that employee,
and even if the harasser and victim are the same sex or
race.Under certain circumstances, the employer will have a
defense to a harassment suit if the victim did notcomplain,
but the victim’s failure to complain will not insulate an
employer from an EEOC claim and subsequent costly
lawsuit
Source: Judith Holmes
234. Answer: D (4 Only)
Explanation:
General Partnership offers Limited Liability to all owners,
but does allow owners the benefit of creating business
losses.
Source: Marcy T Rogers,M.Ed.
235. Answer: B (1 & 3)
Explanation:
Goals and objectives encourage improvement, while
performance requirements mandate that an unsatisfactory
employee improve or face the consequences. Both goals
and requirements are elements of an effective employee
evaluation
Source: Judith Holmes
236. Answer: A (1,2, & 3)
Explanation:
1.Dr. Jones must provide Medicare with copies of the
requested records within the time limit set forth in the
Medicare audit letter. She must be sure to send the records
to Medicare in a manner that gets them to Medicare by
the due date.
2.It is acceptable to request additional time to respond to
Medicare, but Medicare does not have to allow additional
time so it is important to begin the audit defense process,
including the copying of all requested records, promptly
upon receipt of the Medicare audit letter.
3.Dr. Jones should send the records certified mail, return
receipt requested so that she can prove that he sent the
records to Medicare in a timely manner.
4.Dr. Jones must provide Medicare with all requested
records and is not permitted to pick and choose what to
send.
Source: Vicki Myckowiak, Esq.
237. Answer: D (4 Only)
Explanation:
The first step when a claim denial is received is to review
the EOB and the denial reason. When the claim denial is
“medical necessity” or “bundled services”, CPT coding
conventions, instructions in the CPT Manual, articles
published in the CPT Assistant, NCCI and the payer’s
medical policy, (if available), should be reviewed to ensure
that an accurate claim was submitted. When claim
accuracy is confirmed, proceed with an appeal following
the payer’s procedure.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005. AMA Model Contract
Source: Joanne Mehmert, CPC, Sep 2005
238. Answer: A (1,2, & 3)
Explanation:
Sacroiliac joint injections have not been studied for cost
ASIPP
88
effectiveness.
Reference:
“Interventional Techniques: Evidence-based Practice
Guidelines in the Management of Chronic Spinal Pain”
Boswell et al, Pain Physician 2007;10:7-111.
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Physician, Manchikanti, page 83.
Source: Lora Brown, MD
239. Answer: A (1,2, & 3)
Explanation:
Explanation: Chronic pain is defined as pain that lasts
longer than
Reference: Merskey H and Bogduk N, eds. Classification of
chronic pain: descriptions of chronic pain syndromes and
definitions of pain terms. Report by the International
Association for the Study of Pain Task Force on Taxonomy.
2nd ed. Seattle: IASP Press, 1994.
Source: Lora Brown, MD
240. Answer: C
Explanation:
The quantity of the “J” codes is listed in various forms that
must be taken into consideration when calculating the
number of units/services to report. For example, Depo
Medrol, a commonly used drug for epidural injections
comes in 3 different amounts, (J1020, 20 mg, J1030, 40 mg
and J1040, 80 mg) and is one of the least complicated
drugs to bill. When 80 mgs of Depo is administered,
report J1040 x 1 unit.
Aristocort Forte is described as J3302, per 5 mg. When 40
mg is administered, the number of units/services will be
listed as ‘8’ since it will take 8 units of 5 mg each to reach a
dosage of 40 mg. It is particularly important to coordinate
with the provider to ensure that h/she documents the
amount of the drug used and lists the name and amount
on the charge ticket in such a manner that the coding
person bills the correct number of units.
The most straightforward method for most coding/billing
staff is to describe the drug on the charge ticket using the
same measurement that is listed in the HCPCS “J” code
description. The provider’s documentation should state
the amount given using the same description, (e.g., units,
cc’s, mg).
Source: Joanne Mehmert, CPC, Sep 2005
241. Answer: B
Explanation:
Since the drug is “unlisted” the description J3490 does not
include an amount; therefore the number of services listed
in 24G is “1”. A complete description of the substance and
amount administered is listed in the informational field,
which is Box 19 on a paper claim 1500. The insurance
payer wants to know what drug and how much of the drug
was administered.
ASIPP
An NDC number listed in the “information” field will
provide an exact description. There are some
circumstances (compound drugs used in pumps) where
the invoice may be required or would provide necessary
information for the payer to determine payment; however
as a general rule, it is not necessary to attach an invoice.
Source: Medicare policies; HCPCS Manual
Source: Joanne Mehmert, CPC, Sep 2005
242. Answer: A
Explanation:
Explanation: Physicians practices should not seek
reimbursement for a service that is not warranted by a
patient’s documented medical condition. It is not safe to
assume that the reason a service is ordered can be inferred
from chart entries.
Source: 65 Fed. Reg. at 59439. In order to determine
whether a service is reasonable and necessary, the
physician must apply the appropriate local medical review
policy
(“LMRP”). For more information on LMRPs, go to
www.lmrp.net.
Source: Erin Brisbay McMahon, JD, Sep 2005
243. Answer: C
244. Answer: A
Explanation:
* Upcoding:
- Largest risk area outside of unbundling.
- Compliance with documentation guidelines is
important.
- Must assure that level of care meets presenting
problem(s) of patient.
* Medicare will investigate up-coding & down-coding.
Source: Laxmaiah Manchikanti, MD
245. Answer: E
Explanation:
The following are general observations about professional
courtesy arrangements for physicians to consider:
* Regular or and consistent extension of professional
courtesy by waiving the entire fee for services rendered to
a group of persons (including employees, physicians or
their family members) may not implicate any of OIG’s
fraud and abuse authorities if membership in the group
receiving the courtesy is determined in a way that does not
take into account directly or indirectly any group
member’s ability to refer to or otherwise generate federal
health care program business for, the physician.
* Regular or consistent extension of professional courtesy
by waiving otherwise applicable copayments for services
rendered to a group of persons (including employees,
89
physicians or their family members), would not implicate
the Anti-Kickback Statute if membership in the group is
determined in a way that does not take into account
directly or indirectly any group member’s ability to
refer to, orotherwise general federal health care program
business for, the physician.
Source: Laxmaiah Manchikanti, MD
246. Answer: D
Explanation:
A new patient visit occurs if the patient has not been seen
in 3 years by the physician or anyone in the same speciality
in his group. A complete H&P is separately billable since it
was above and beyond the usual pre-procedure visit that is
bundled into the procedure.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.7.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
247. Answer: C
Explanation:
This visit accomplishes the same thing that the usual preprocedure visit accomplishes, i.e., it confirms that the
clinical indications still warrant the procedure, that the
prior procedure was useful to some extent, and that there
is no patient condition precluding the procedure from
taking place. As such, the visit is not above and beyond, or
separate and distinct from the usual pre-procedure visit
that is bundled into the procedure, and as such, the visit
cannot be separately billed.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
248. Answer: C
Explanation:
An inpatient consult code can be billed even if the
physician has previously seen the patient in his own
practice. A consult, whether inpatient or outpatient is not
dependent on whether the patient is a new or established
patient. A consult is dependent on a referring physician
requesting an opinion from the consulting physician.
CPT Coding Manual Current Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
249. Answer: A
Explanation:
While a physician can bill a follow-up inpatient consult, in
order to do so, the physician must be requested to provide
another consult by the referring physician. Unless the
physician receives a second consult request, follow-up
visits for inpatients are coded as subsequent hospital care
codes. A confirmatory consult is generally for second
opinions.
CPT 2005, pp. 12, 16, 18, Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
250. Answer: A
Explanation:
A. The DME must meet six requirements in order to be
billed as in-office ancillary services:
1. It is needed by the patient to move or leave the
doctor’s office, or is a blood glucose monitor.
2. It is provided to treat the condition that brought the
patient to the physician and in the “same building”
3. It is given by the physician or another physician or
employee in a group practice.
4. The physician or group practice meets all DME
supplier standards
5. The arrangement doesn’t violate any billing laws or
the Anti-Kickback Statute.
6. All other in-office ancillary requirements are met.
B. Providers only need to self disclose to OIG in certain
situations. They do not need to self disclose every time
they receive an overpayment from Medicare. However,
every provider must learn when OIG views an
overpayment as a deliberate attempt to defraud Medicare
instead of the result of a harmless error.
If the circumstances surrounding the billing error
resemble any of the situations described below, consider
voluntary disclosure and return of the over payment.
Otherwise, a refund may be sufficient.
* The situation is the result of a willful disregard for fraud
and abuse laws.
* The situation is a systematic problem that occurred over
a long period of time.
* The provider has not such mechanisms as a compliance
plan in place.
* The provider took no action once the problem was
discovered.
C. Once a provider realized that he or she has received an
overpayment, the provider is statutorily obligated to
return it to Medicare. This includes instances where the
provider receives an overpayment due to an unintended
mistake on their part.
D. According to the Centers for Medicare & Medicaid
Services (CMS), there are three levels of supervision.
General supervision means the procedure is furnished
under the physician’s overall direction and control, but the
doctor’s presence is not required during the procedure.
(The physician remains responsible for training nonphysician personnel and for maintaining all necessary
equipment and supplies.)
Direct supervision means the physician must be present in
the office suite and immediately available to furnish
assistance and direction throughout the performance of a
procedure. It does not mean that the physician must be
present in the room when the procedure is performed.
ASIPP
90
Personal supervision means a physician must be in
attendance in the room during the performance of the
procedure.
E. Whistleblowers who are discharged, demoted,
suspended with or without pay, threatened, harassed or in
any other manner discriminated against by theiremployers
in the terms and conditions of employment are entitled to
relief. That includes reinstatement with the same seniority,
two times the amount of back pay, interest on the back
pay and compensation for any damages, including
attorney’s fees.
Source: Laxmaiah Manchikanti, MD
251. Answer: D
Explanation:
D. Under the Social Security Act (SSA) Medicare patients
have the right to submit a written request for an itemized
statement to any physician, provider, supplier, or any other
health care provider for any item or service provided to the
patient by the provider.
After receiving a request, the provider has 30 days to
furnish an itemized statement describing each item or
service provided to the patient. Providers that fail to
honor a request may be subject to a civil monetary penalty
of $100 for each unfulfilled request. In addition, the
provider may not charge the beneficiary for the itemized
statements.
Source: Laxmaiah Manchikanti, MD
252. Answer: D
Explanation:
Effective May 24, 2004, CMS implemented its clarification
of the Preamble of the Proposed Rule for the Medicate
Physician Fee Schedule on November 1, 2001 (66 Fed Reg
55267) which stated, “The billing number of the ordering
physician (or other practitioner) should not be used if that
person did not directly supervise the auxiliary personnel.”
In Question VII above, the doctor that established the plan
of care (Dr. Bob) is the “ordering provider” and Dr. Jim is
the “supervising provider”.
CMS sent Change Request #3138, dated April 23, 2004 to
Medicare Carriers that further clarifies where physician’s
Provider Information Numbers and names should be
reported when both an ordering provider and a
supervising provider are involved in a service.
Source: Medicare Carriers Manual 100-04, Medicare
Claims Processing; Transmittal 148, April 23, 2004, CMS
website, Medlearn Matters #MM3138
253. Answer: A
Explanation:
It is appropriate to report code 72295-26, the supervision
and interpretation code, for each level for which a
ASIPP
diagnostic study is performed, films taken and a report is
written. The fluoroscopic guidance code, 77003 is not
separately reported since fluoroscopic guidance is included
in the supervision and interpretation codes
Source: CPT Assistant: Code and Guideline Changes, A
Comprehensive Review November 1999; CPT Assistant
Coding Consultation Questions and Answers, April 2003.
Source: Joanne Mehmert, CPC, Sep 2005
254. Answer: A
Explanation:
Medicare (and many non-Medicare insurers) pays a global
facility fee to an ASC that includes fluoroscopic guidance;
it would be a duplicate payment if the physician were paid
a global fee for the fluoroscopic guidance. When a
procedure is performed in a facility setting, modifier -26,
the professional component, is appended to the
radiological codes. The physician should lease the
equipment to the ASC.
Source: Medicare Contractors Manual, 100-04, Chapter
14, §10.2
Source: Joanne Mehmert, CPC, Sep 2005
255. Answer: C
Explanation:
Code 72275, is a supervision and interpretation code that
includes code 77003. The use of fluoroscopy (77003) is
included in the supervision and interpretation codes and
should not be separately reported
Source: CPT coding Manual; Manchikanti L, Principles
and Practice of Documentation, Billing, Coding, and
Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
256. Answer: B
Explanation:
In the provider’s office (POS 11), h/she owns/leases the
radiological equipment and is entitled to the global
payment (professional and technical components). The
CPT code is submitted without a modifier to indicate that
the provider is entitled to the global reimbursement.
Source: CPT Coding Manual, CPT Coding Conventions;
Manchikanti L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
257. Answer: E
Explanation:
Although documentation of the history, including the
review of systems and past, family, and social history, is
normally required in a new patient visit, in the limited
event that the physician spends more than 50% of the visit
counseling or coordinating care, the physician can bill the
E&M level according to the time that physicians usually
spend with the patient for that particular level. In a 99205,
the physician typically spends 60 minutes with the patient.
91
The physician also documented that he counseled or
coordinated care about 1or more of the following required
areas: (1) diagnostic results, impressions, and/or
recommended diagnostic studies; (2) prognosis, (3) risks
and benefits of management or treatment options; (4)
instructions for management/treatment and/or follow-up;
(5) importance with compliance with chosen
management/treatment options; (6) risk factor reduction;
and (7) patient and family education.
Although it is true that the patient can fill out the review
of systems, and it is true that the nurse can fill out the past,
family and social histories, coding a level 3 would be
undercoding for a 60-minute visit, which would eliminate
answers a, b, and c. Answer d has no element of truth.
Chapter 12, Medicare Claims Processing Manual, Section
30.6.1; CPT Coding Manual Current Professional Edition
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
258. Answer: C
Explanation:
The 25 modifier is defined as a significant and separately
identifiable E&M service above and beyond or separate
and distinct from the usual pre-procedure visit that is
related to the procedure. In this case, the headaches are
different from the low back procedure. While we
encourage the physician to dictate a separate note for the
separate E&M service for the headaches - so
as to differentiate it from the low back complaint that is
bundled into the procedure - there is no requirement for a
separate dictation. The E&M code would have a headache
diagnosis, not a low back diagnosis.
apply. Since the procedure is performed for the same
purpose as the patient complaints are,no evaluation
coding may be done in this scenario.
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
261. Answer: D
Source: Laxmaiah Manchikanti, MD
262. Answer: A
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
263. Answer: B
Explanation:
Many physicians incorrectly bill an initial hospital care
code for the first time they see the patient during a
hospital stay. However, only the admitting physician, in
this case the surgeon, can bill an initial hospital care code.
If the pain physician is not the admitting physician, he
must bill a subsequent hospital care code, unless he
can bill an inpatient consult. In the above scenario, an
inpatient consult is not billable because the factual
scenario stipulates that the surgeon referred the patient for
treatment, not for an opinion from the pain physician. A
consult cannot be billed unless the patient is referred for
an opinion.
Source: CPT Coding Manual Current Professional Edition
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
CPT Coding Manual Current Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
259. Answer: D
Explanation:
CPT 62264 has a 10-day global period. Since the
procedure was performed within 10 days, basically the
statement in D is accurate. However, the procedure may be
charged with an attached note with modifier -78 return to
the operating room for a related procedure during the
postoperative period. The visit may not be charged alone,
since this is in the 10-day global period.
264. Answer: D
Explanation:
CPT Coding Manual Current Professional Edition
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
260. Answer: B
Explanation:
The correct answer is 62273 – epidural blood patch. For
continuos intrathecal catheterization, the global period is
one day. Consequently, the global period rules do not
265. Answer: A
Explanation:
Standard
A degree of quality, level of achievement, regarded as
desirable and necessary for some
purpose.
Guidelines
Systematically developed statements to help practitioners
and patients make decisions about
appropriate health care for specific clinical circumstances.
Source: Laxmaiah Manchikanti, MD
266. Answer: C
Explanation:
ASIPP
92
The CPT Code, which is applicable to all payers, defines
code 64447 as “including daily management for anesthetic
agent administration.” Therefore, when billing 64447, you
are already billing for the post-op rounds, and no separate
code can be billed. Medicare’s Physician’s Fee Schedule
contains a 10 day global for this and all other continuous
catheter codes, other than a continuous epidural catheter,
which does not have global period.
CPT Coding Manual Current Professional Edition;
Medicare’s Physician’s Fee Schedule, 2005
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
267. Answer: C
Explanation:
The Medicare Global Surgical Package bundles E&M
services relating to a complication that does not result in
return to the operating room, if those services occur
during the global period for that code. The code for
percutaneous implantation of electrodes, 63650, has a 90day global, so a visit for complications from the surgery is
bundled into the surgical payment and is not billable.
Medicare Claims Processing Manual, Chapter 12, Section
40.1.A.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
268. Answer: D
Explanation:
You don’t code the underlying E&M code with time as the
primary ingredient because there was no counseling. So,
you code the underlying E&M code as per the
documentation requirements. An expanded problem
focused history and exam, together with low medical
decision making is 99213. However, as long as the
additional 30 minutes is spent face to face with the patient,
the CPT Code allows the billing of an “add-on” E&M
code, 99354, provided that the physician spends at least 30
extra minutes in excess of the time usually accorded to the
underlying E&M code (15 minutes for 99213). In this case,
the physician spent 45 minutes which equates to 998213 &
99354.
CPT Coding Manual Current Professional Edition;
Medicare Claims Processing Manual, Chapter 12, Section
30.6.15.1.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
269. Answer: B
Explanation:
The government has prosecuted physicians for routinely
coding double the typical time for a particular E&M code.
One cannot routinely bill level 5 for a 15-minute visit, no
matter how much documentation is generated by the
EMR. Otherwise, the physician ends up billing 18 hours in
a 9-hour day.
Source: U.S. v. Mayer (U.S. Dst. TN 2000).
ASIPP
270. Answer: E
Explanation:
A new fall for a prior surgical patient warrants a
comprehensive history and exam. Since established patient
visits only require 2 of the 3 E&M components, and since
a comprehensive history and exam qualify for a level 5, the
correct code is level 5, regardless of the third element.
CPT Coding Manual Current Professional Edition.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
271. Answer: B
Explanation:
Overriding the technical documentation requirements for
E&M coding is medical necessity. If an established
patient’s complaints are the same as in his prior visits, and
those complaints are controlled with medication, andthere
is no change in the medication, which is refilled with the
same drug and dosage, and there is no counseling, this is a
classic level 2 office visit, which should take no longer
than 10 minutes. If the physician voluntarily, in order to
increase billing, performs an unnecessary comprehensive
exam, the exam will be disregarded on audit. 42 U.S.C.
1395y excludes from Medicare coverage services which
“are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member.”
42 U.S.C. 1395y.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
272. Answer: C
Explanation:
Although a procedure and a consult can be billed on the
same date, a consult is not billable in this case because the
referring physician did not request the pain physician’s
opinion, rather, he referred the patient for treatment.
Therefore, the new patient visit and the epidural are both
billed. They can both be billed because a new patient visit
can be billed in addition to a procedure on the same date.
CPT 2005, pp. 12, 16, 18, Professional Edition.I have some
issues with some of the verbiage and the reference to
substantiate the answer for this question. The AMA and
CMS agree that an E&M must be significantly, separately
identifiable if reported on the day of a procedure. I agree
with the basic premise of the question; however I do not
think the question clearly identifies a separate reason for a
level 4 E&M service. Pages 12, (hospital care codes) 16
(hospital & office follow up codes) & 18 (ER codes) of
CPT 2005 do not substantiate the answers. I believe the
question should be worded differently or deleted.
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
273. Answer: E
Explanation:
93
Intercostal nerve blocks are not covered by bilateral
coding. CPT 64421 describes multiple intercostal nerve
blocks. Consequently, no modifiers are required. CPT
77002 describes the fluoroscopic visualization of nonspinal procedures. CPT 77003 is limited to the spine area.
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
274. Answer: C
Explanation:
The receptionist did not perform an office visit and the
physician did not have any contact with her patient. The
CPT codes assume that a qualified person will perform
and document a service and while an employee does not
necessarily have to be a nurse or clinician to report a 5
minute office visit, the employee should have enough
training to perform and document a minimal service. In
the circumstance described above, an office visit was not
performed by the doctor.
Source: CPT Coding Instructions
Source: Joanne Mehmert, CPC
275. Answer: C
Source: Laxmaiah Manchikanti, MD
276. Answer: D
Explanation:
Source:Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Nonphysician Practitioners §30.6.7
and 1995 or 1997 E&M Coding Guidelines.
Source: Joanne Mehmert, CPC
277. Answer: E
Explanation:
When physicians receive drugs at no cost from a
pharmaceutical company as samples, or to participate in
clinical studies, no charge should be submitted to any
payer.
Source: Joanne Mehmert, CPC
278. Answer: D
Source: Laxmaiah Manchikanti, MD
279. Answer: D
Source: Laxmaiah Manchikanti, MD
280. Answer: D
Source: Laxmaiah Manchikanti, MD
281. Answer: C
Explanation:
Mary Ann, a Physician’s Assistant, may bill services she
provides to Medicare beneficiaries under her own name
and number; she must accept assignment.
Physician’s Assistants may bill Medicare under their own
name & number or as ‘incident to’ when all of the ‘incident
to’ requirements are met. PA’s must accept Medicare
assignment. A PA may provide services to Medicare
beneficiaries and bill under their own number when the
physician is not in the office. All PA services are subject to
state law licensing regulations.
Source: Medicare Benefit Policy Manual Chapter 15 and
Medicare Claims Processing Manual Chapter 12
Source: Joanne Mehmert, CPC
282. Answer: B
Explanation:
Incident to’ services’ may not be reported to Medicare
when they are provided in a hospital outpatient clinic. The
provider should review non-Medicare payer policies or
write to the payers and inquire about their policies.
Medicare allows the doctor to report shared services, in a
facility setting. A shared service is when both the nonphysician and the physician provide a service to thepatient.
Non-Medicare payers do not always have the same
regulations as Medicare for NPP billing. Medicare does
not allow incident to services in a facility setting.
Source: Medicare Benefit Policy Manual Chapter 15 and
Medicare Claims Processing Manual Chapter 12.
Source: Joanne Mehmert, CPC
283. Answer: A
Explanation:
Dr. Merriman bears the technical expense of the C-arm.
Even though he doesn’t own the equipment, he is entitled
to the global payment. CPT Codes are in effect on January
1, of each year, there is no longer a grace period.
Source: The Health Insurance Portability and
Accountability Act, (HIPAA) transaction and code set rule
requires usage of the medical code set that is valid at the
time the service is provided. As of January 1, 2005, the 90
day grace period for billing discontinued codes was
eliminated.
Source: Joanne Mehmert, CPC
284. Answer: B
Explanation:
Even though the CPT Manual showing all of the code
changes is released in November every year, the CPT code
changes may not be reported until January 1, of the
following year in which they take effect.
Source: The Health Insurance Portability and
Accountability Act, (HIPAA) transaction and code set rule
requires usage of the medical code set that is valid at the
time the service is provided.
Source: Joanne Mehmert, CPC
ASIPP
94
285. Answer: C
Source: Cole EB, Board Review 2003
286. Answer: D
Explanation:
The American Medical Association (AMA) establishes
codes and code definitions. The Relative Value Update
Committee (RUC) makes recommendations relative to the
physician’s expenses and work values to be considered for
payment. When the AMA bundles a specific component
into a CPT code and publishes the instructions in the CPT
Manual, providers should not report codes that are
contrary to CPT instructions.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005; General Coding Guidelines
Source: Joanne Mehmert, CPC
287. Answer: A
Source: Laxmaiah Manchikanti, MD
288. Answer: A
Explanation:
Administration of multiple epidural injections during the
same session is not only unusual but also is considered as
abuse. As a general rule, a physician is not reimbursed for
more than one epidural steroid injection for the region
(i.e., lumbar/sacral).
Source: Laxmaiah Manchikanti, MD
289. Answer: B
290. Answer: A
291. Answer: D
292. Answer: B
Source: Laxmaiah Manchikanti, MD
293. Answer: B
294. Answer: A
295. Answer: B
296. Answer: D
Explanation:
* Down Coding
- Largest area of loss of revenue outside disbundling.
- Compliance with guidelines is important.
- Must assure proper coding of the level of service.
Source: Laxmaiah Manchikanti, MD
297. Answer: B
298. Answer: E
ASIPP
Explanation:
Documentation Summary
Never: Bill for items or services not rendered or not
provided as claimed
Submit claims for equipment, medical supplies and
services that are not reasonable and necessary
Double bill resulting in duplicate payment
Bill for non-covered services as if covered Knowingly
misuse provider identification numbers, which results in
improper billing
Unbundle (billing for each component of the service
instead of billing or using an all-inclusive code)
Upcode the level of service provided
Source: Laxmaiah Manchikanti, MD
299. Answer: C
Explanation:
Albeit payers may have a plan to create, or have created,
software that can compare facility and physician
professional charges, the primary reason to report the
‘place’ that the service was provided is to ensure that the
physician is paid a site of service differential when
appropriate.
Source: Medicare Physician’s Fee Schedule and nonMedicare payer fee schedules
Source: Joanne Mehmert, CPC
300. Answer: B
Explanation:
In both the inpatient hospital setting and the NF setting, a
request for a second opinion would be made through the
attending physician or physician of record. If an initial
consultation is requested of another physician or qualified
NPP by the attending physician and meets the
requirements for a consultation service (as identified in
Section A) then the appropriate Initial Inpatient
Consultation code shall be reported by the consultant. If
the service does not meet the consultation requirements,
then the E/M service shall be reported using the
Subsequent Hospital Care codes (99231 – 99233)
Source: Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Nonphysician Practitioners
§30.6.10 (D)
Source: Joanne Mehmert, CPC
301. Answer: E
Explanation:
Medicare claims processing Manual 30.6.10 (E)
Source:
http://www.cms.hhs.gov/manuals/downloads/clm104c12.
pdf.
Source: Joanne Mehmert, CPC
302. Answer: B
Explanation:
CCI edits are developed around CPT/AMA coding
conventions and instructions; however not all of the CPT
95
instructions and/or coding conventions are set forth in
NCCI. Administar Federal looks at several factors when
updating the NCCI.
Source: National Correct Coding Initiative is updated
quarterly. Download is available on the CMS web site:
http://cms.hhs.gov/physicians/cciedits/default.asp.
Source: Joanne Mehmert, CPC
303. Answer: C
Explanation:
While it is possible that a patient may find out if a doctor
doesn’t make equal collection efforts and write to the
newspaper. A primary reason to make equal collection
effort for all patients is that, according to Herb Kuhn,
Director Center for Medicare Management Centers for
Medicare and Medicaid Services, “Medicare wants parity
to protect the program and all patients, not just our
beneficiaries”.
The above quote is an excerpt from Mr. Kuhn’s testimony
before the House Energy & Commerce Subcommittee on
Oversight & Investigations June 24, 2004,
Source: Joanne Mehmert, CPC
304. Answer: C
Explanation:
In 2005, the Office of the Inspector General (OIG) released
an inspection report which
indicated that 40 percent of code pairs billed with modifier
59 in fiscal year 2003 did not meet program requirements,
resulting in an estimated $59 million in improper
payments.
The report also said that 35 percent of claims for E/M
services allowed by Medicare in 2002 did not meet
program requirements, resulting in $538 million in
improper payments. Modifier 25 was also used
unnecessarily on a large number of claims, and while such
use may not lead to improper payments, it fails to meet
program requirements.
Source: News Release issued by the Inspector General
December 12, 2005
Source: Joanne Mehmert, CPC
305. Answer: B
Explanation:
CMS may initiate a Reconsideration Process under certain
circumstances. details of which can be found on the CMS
web site.
Source: CMS Web site:
http://www.cms.hhs.gov/DeterminationProcess/ Scroll to
Federal Register
Notice: Medicare Program: Review of National Coverage
Determinations and Local Coverage
Determination (PDF.267KB)
Source: Joanne Mehmert, CPC
306. Answer: B
Explanation:
Needles, syringes, and local anesthetic (lidocaine), are
supplies that are bundled into the majority of the surgical
procedure codes. Supplies are considered to be included in
the payment for the procedure, i.e., the “global surgical
fee”.
Pulse oximetry is pre, intra, and post operative care that is
bundled into the procedure, i.e., paid in the global fee.
A drug or substance (Depo Medrol) that a patient cannot
self administer is separately paid and is considered
“incident to” the physician’s service.
Source: Medicare Carrier Manual, 100-4, Chapter 12
Source: Joanne Mehmert, CPC
307. Answer: B
Explanation:
Needle EMG localization is reported one time per session
according to CPT coding conventions. Likewise the
injection code 64613 is reported one time per session
regardless of the number of injections or number of
muscles injected. J0587 is listed per 100 mg, to determine
the number of units to report, divide the amount injected
by the listed dosage: 2500/100 = 25
Source: Joanne Mehmert, CPC
308. Answer: C
Explanation:
Code 72275, is a supervision and interpretation code that
includes code 76005. The use of fluoroscopy (77003) is
included in all of the supervision and interpretation codes
and should not be separately reported.
Source: CPT coding Manual; Manchikanti L, Principles
and Practice of Documentation, Billing, Coding, and
Practice Management 2005 and 2007 CPT Coding changes
Source: Joanne Mehmert, CPC
309. Answer: C
Explanation:
Explanation: Dr. Lincoln’s primary specialty is 09,
Interventional Pain, and Dr. Washington’s specialty
designation is 05, Anesthesia. Medicare allows a new
patient visit when a physician in a different specialty sees a
patient, despite the fact that they are members of the same
group practice. To report a specific level for a new patient
visit, all of the work elements must meet the criteria
described by the code.
Source: : Medicare Claims Processing Manual, 100-04
Chapter 12 Physicians/Non-physician Practitioners
§30.6.7 and 1995 or 1997 E&M Coding Guidelines.
Source: Joanne Mehmert, CPC
310. Answer: A
Explanation:
All three elements must meet the required level for a new
ASIPP
96
patient visit or a consult. Dr. Bush’s notes clearly state that
he does not treat the condition for which Ms. Chaney is
complaining and he expects Dr. McCain to assume
treatment of the condition. Medicare recently clarified that
when a physician sends a patient to a specialist to
managing the patient’s complete care for the
Source: Joanne Mehmert, CPC
311. Answer: B
Explanation:
The overriding principle is medical necessity. The patient
is described is stable, with his pain well controlled, and is
taking the medication as prescribed. The doctor did not
change dosage, the patient had no complaints, and the
doctor did not spend time counseling. The comprehensive
history was not medically necessary for this patient at this
time; the physician used the template to increase the level
of service.
Source: Code of Federal Regulations 42 U.S.C. 1395y
excludes from Medicare coverage services which “are not
reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a
malformed body member”.
Source: Joanne Mehmert, CPC
312. Answer: B
Source: Laxmaiah Manchikanti, MD
313. Answer: D
Explanation:
CPT instructions specifically preclude the reporting of any
daily care when code 64448 is reported. The descriptions
and instructions in the CPT Manual for this code and the
other continuous catheters for pain control are clearly
stated.
Source: CPT Coding Manual
Source: Joanne Mehmert, CPC
314. Answer: B
Source: Laxmaiah Manchikanti, MD
315. Answer: B
Explanation:
I suggested adding the kind of hx, exam and decision to
test
whether the candidate understands that all three elements
must be met.
Source: Laxmaiah Manchikanti, MD
316. Answer: D
317. Answer: C
Source: Laxmaiah Manchikanti, MD
318. Answer: C
319. Answer: D
Source: Laxmaiah Manchikanti, MD
ASIPP
320. Answer: C
Source: Laxmaiah Manchikanti, MD
321. Answer: B
Source: Laxmaiah Manchikanti, MD
322. Answer: C
Source: Laxmaiah Manchikanti, MD
323. Answer: C
Source: Laxmaiah Manchikanti, MD
324. Answer: D
Source: Laxmaiah Manchikanti, MD
325. Answer: B
Explanation:
The AMA instructions are clear that a diagnostic report
requires a formal radiologic report. Language added in the
2007 CPT Manual explains further: “Results are the
technical component of a service. Testing leads to results;
results lead to interpretation. Reports are the work
product of the interpretation of numerous test results. A
statement such as: an epidurogram was performed”, does
not meet the AMA’s documentation requirements.
Source: CPT Assistant November 1999, January 2000, and
August 2000. CPT Changes, an Insider’s View, 2000.
Source: Joanne Mehmert, CPC
326. Answer: B
Explanation:
Explanation: The government has prosecuted physicians
for routinely coding double the typical time for the level of
E&M service. Medical necessity is the overriding
consideration. Regardless of the amount of documentation
an EMR generates, if the need isn’t there and the physician
spent half of the usual time,it is not appropriate to report
a higher level of service. Modifier 25 should not be
required for a Medicare claim for a new patient visit when
a procedure is performed. In December 2005, the Office of
Inspector General (OIG) released a report that indicated
that modifier –25 was used (in 2002) unnecessarily on a
large number of claims where it did not result in improper
payments; however, it did not meet program
requirements. There may be exceptions to this principle
since Part B Carriers do not always program the same
claim edits.
Source: Code of Federal Regulations 42 U.S.C., 1395y; U.S.
v Mayer (U.S. District TN 2000)
Source: Joanne Mehmert, CPC
327. Answer: D
Explanation:
Source: CMS Medicare Learning Network Brochure: The
Medicare Appeals Process
http://www.cms.hhs.gov/MLNProducts/downloads/Medic
areAppealsProcess.pdf
97
Source: Joanne Mehmert, CPC
328. Answer: B
Explanation:
Applies for a loan to buy a home with a 30 year mortgage
A patient’s medical record has a number of purposes;
however, the medical record is not a factor in the approval
process for a home loan application. When the medical
record is incomplete and illegible, it may compromise a
patient’s healthcare. Medical records are the foundation of
quality patient care and are used to provide appropriate
care to patients.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005; General Coding Guidelines. CMS web
site, 1995 and 1997 Documentation Guidelines for
Evaluation and Management Services.
Source: Joanne Mehmert, CPC
329. Answer: C
Explanation:
Medical record documentation is required to record
pertinent facts, findings and observations about a person’s
health history. When a patient has treatment in a facility,
there are a number of federal and state regulations in place
to prevent errors in treatment and ensure high quality
treatment. The amount that the facility charges is separate
from the medical care of the patient.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005; General Coding Guidelines
Source: Joanne Mehmert, CPC
330. Answer: B
Explanation:
Ask Mrs. Simpson to sign an Advanced Beneficiary Notice.
Dr. may charge Mrs. Simpson his usual fee of $500;
Medicare only pays for services that are reasonable and
medically necessary. A prophylactic service provided for
the patient’s convenience is not payable by Medicare. An
ABN is obtained when the doctor believes that a service
that is usually covered may not be covered under a specific
circumstance. The physician may collect the usual fee for
the service when an ABN is appropriately executed.
Source: CMS web site, Beneficiary Notices Intiiative
(BNI):
www.cms.hhs.gov/BNI/02_ABNGAABNL.asp#TopOfPage
Source: Joanne Mehmert, CPC
331. Answer: C
Explanation:
A lawyer is not a health care provider credentialed by
Medicare. Claims for all diagnostic and consultation
services require the referring/ordering physician’s name
and provider number in Box 17 and 17a. In addition, CMS
will require the National Provider Identifiers (NPI) on
claims. As of the date this question is written (3/11/07),
NPIs will replace the health care provider identifiers that
are currently in use on May 23, 2007.
Source: CMS web site claims processing manuals and
MLN Matters Number: SE0712, Common Billing Errors
to Avoid when Billing Medicare Carriers
Source: Joanne Mehmert, CPC
332. Answer: B
333. Answer: C
Explanation:
since there is currently a National Coverage Decision that
Prolotherapy is not a covered service; the Part B Carrier
may not cover this service.
A National Coverage Decision (NCD) is made after a
comprehensive evaluation process that often includes a
technology assessment by an expert(s) outside CMS
and/or the CMS Coverage Advisory Committee. NCD’s
are made according to a process detailed in a Federal
Register Notice dated April 27, 1999 (64 FR 22619) and
revised Federal Register / Vol. 68, No. 187 / Friday,
September 26, 2003 / Notices (55634).
An NCD is binding on all Medicare carriers, fiscal
intermediaries, quality improvement organizations, health
maintenance organizations (Medicare), competitive
medical plans and health care prepayment plans
Source: Joanne Mehmert, CPC
334. Answer: B
Explanation:
The Joint Commission has been accrediting hospitals for
more than 50 years. Its accreditation is a nationwide seal of
approval that indicates a hospital meets high performance
standards.
Source: Joanne Mehmert, CPC
335. Answer: B
336. Answer: D
Explanation:
The ASC medical record is an important document and
should be completed and signed by the physician as soon
as possible after discharge. The time frame should not
exceed 10 days.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005; General Coding Guidelines
Source: Joanne Mehmert, CPC
337. Answer: D
338. Answer: A
339. Answer: E
ASIPP
98
340. Answer: D
341. Answer: B
342. Answer: D
343. Answer: A
Explanation:
The typical patient that is borderline will try to pull you
into their world, that is often mismanaged and chaotic.
They will have very little insight into understanding their
dependent personality characteristics, and sometimes
develop a crisis to obtain attention. This is particularly
concerning with controlled substance management or
when utilizing interventional procedures in the
management of pain. This type of patient will tend to have
more side effects, follow up phone calls, and demand time
of the staff which are consuming and lead to inefficient use
of staff resources. Skills to manage a difficult patient,
include: validation, behavioral interventions,
communication, teaching, and behavior modification.
Dialectical behavioral management of difficult patient
includes the patients validation of their problem, and
intervention, as well as teaching staff and patient. The
most successful approach in this arena is to reassure the
patient that there is good and bad behaviors and that
perfection is not always expected, and rules are in place for
predictability, and compliance. Good and bad are not
mutually exclusive, and may coexist. This is the
“management” part of pain management.
A 64-year-old Hispanic male arrives at the pain
management center for “evaluation and treatment.” Not
felt to be an interventional candidate, the pain
management physician chooses a multimodality
course of treatment inclusive of controlled substances.
The individual returns two weeks later in follow-up with
his original bag of medications, and did not fill any of the
prescriptions that the pain management physician had
written for treatment.
The pain management physician questions the patient,
and the dialogue deteriorates when the physician insists
that the patient be more responsible. The patient leaves
and is a “no show” at next scheduled visit.
Source: Hans C. Hansen, MD
344. Answer: D
345. Answer: C
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
346. Answer: D
347. Answer: E (All)
Explanation:
Unbundling is when a provider bills separately for items,
services or procedures that should be billed together under
one code. This practice also sometimes is called
fragmenting or exploding.
ASIPP
1. Separate procedures: If provided as a more
comprehensive procedure, “separate procedure” codes
should be submitted with their related and more
comprehensive codes.
2. Most extensive procedures: When CPT descriptors
designate several procedures of increasing complexity,
only the code describing the most extensive procedure
actually performed should be submitted.
3. With/without services: Certain code designate several
procedures performed with or without other services.
Submit only the code for the service actually performed.
4. Sex designation: When code descriptors identify
procedures requiring a designation for male or female,
submit only the appropriate code.
5. Standards of medical practice: For Medicare, all
services necessary to perform a given procedure are
considered included in that procedure. Even if
independent CPT codes exist for these ancillary services,
Medicare considers billing for these independent CPT
codes “unbundling,” so don’t do it.
6. Laboratory panels: When a codes exists for a grouping
or panel of lab tests, bill it – don’t submit codes for
individual lab tests.
7. Sequential procedures: If a doctor finds it necessary to
attempt several procedures in direct succession to
accomplish the same end in a patient encounter, bill for
only the procedure that was successfully accomplished.
(This applies mainly to limited procedures that are
unsuccessful, showing the need for more comprehensive
procedure.) However, procedures performed at the same
session that are diagnostic in nature and establish the
decision to perform the more comprehensive service may
be separately billed.
8. Modifier -59: This modifier is used to indicate a
distinct procedural service done on the same day as other
services. However, it does not replace modifiers -25, -51,
-76 or -79. The -59 modifier is used only after the other
modifiers are analyzed and no other modifier fits the
service.
9. Anesthesia performed during medical/surgical
procedures: Medicare prohibits payment of a separate fee
for anesthesia when the same doctor provides anesthesia
and performs the medical/surgical procedure. So don’t
submit codes describing anesthesia services necessary to
provide anesthesia with primary procedure/service codes.
Source: Laxmaiah Manchikanti, MD
348. Answer: E (All)
Explanation:
The drug must be an expense to the practice; a physician
practice may not bill a drug for which it did not pay. When
99
the patient “brown bags” the drug, it is not billable. Brown
bagging is when a patient brings the drug that h/she paid
for, or the pharmacy billed to the insurer. Drugs furnished
by a manufacturer to be used for clinical trials or drug
samples are other examples of non-billable drugs.
When the “J” code does not accurately describe the drug
administered, an unlisted code should be reported such as
for a compounded drug. The practice should also be
familiar with its local Medicare Carrier coverage
decisions relative the conditions for which drugs are
covered. Some Medicare carriers do not cover Botulinum
toxin (Bo-Tox) injections that are administered for
headache pain. In this circumstance, neither the drug nor
the injection will be covered.
Several of the Medicare carriers also have policies where
they require the practice to report an unlisted drug when a
compound medication is used for a pump refill. Close
attention should be given to all aspects of billing for drugs.
Source: Medicare Contractors Manual, 100-04, Chapter
14; Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
349. Answer: D (4 Only)
Explanation:
Although a number of private payers use the NCCI to edit
claims, it is not a mandatory requirement. HIPAA does not
regulate private payer policy benefits and claims payment.
Source: CMS website www.cms.gov. Manchikanti L,
Principles and Practice of Documentation, Billing,
Coding, and Practice Management 2005.
Source: Joanne Mehmert, CPC, Sep 2005
350. Answer: D (4 Only)
Explanation:
In addition to compliance with the Transaction and Code
Sets Rule, a clean claim should have the CPT and/or
HCPCS code(s) that accurately represents the service the
provider rendered, it should not have unbundled codes
following CPT coding conventions, and it should have the
ICD-9 code that correctly identifies the condition for
which the service was rendered.
Source: L, Principles and Practice of Documentation,
Billing, Coding, and Practice Management 2005
Source: Joanne Mehmert, CPC, Sep 2005
351. Answer: A (1,2, & 3)
Explanation:
Consultation
An opinion is requested
Patient is not referred
3 R’s
Request for opinion is received
Render the service/opinion
Report back
Source: Laxmaiah Manchikanti, MD
352. Answer: D (4 Only)
Explanation:
* CPT History
1966 – First edition
1970 – Second edition
1973 – Third edition
1977 – Fourth edition
1983 – HCFA adopts CPT
1983 – CPT- editorial page
1983 – Annual updates
1988 – Minibooks
Source: Laxmaiah Manchikanti, MD
353. Answer: C (2 & 4)
Explanation:
Payer fee schedules seldom address the payment of
supplies nor are there any codes listed for surgical trays
and/or supplies. Unless the contractual agreement
specifically prohibits the physician from reporting
supplies, it is appropriate to bill separately for the
supplies. More expensive equipment and supplies should
be carved out to ensure adequate reimbursement.
Source: Manchikanti L, Principles and Practice of
Documentation, Billing, Coding, and Practice
Management 2005
Source: Joanne Mehmert, CPC
354. Answer: A (1,2, & 3)
Explanation:
Interventional Pain Management Coding
1. Evaluation and Management
2. Surgery
General
Pelvis and hip joint
Nervous system
Spine and spinal cord
Extracranial nerves, peripheral nerves and autonomic
nervous system
3. Radiology (needle placement, fluoroscopy)
Spine and pelvis
Lower extremities (si joint)
Other procedures
4. Medicine
Physical medicine & Rehab
Psychiatry
Source: Laxmaiah Manchikanti, MD
355. Answer: A (1,2, & 3)
356. Answer: A (1,2, & 3)
Explanation:
Page xiii of the CPT Manual affirms that, “It is important
ASIPP
100
to recognize that the listing of a service or procedure and
its code number in a specific section of this book does not
restrict its use to a specific specialty group. Any procedure
or service in any section of this book may be used to
designate the services rendered by any qualified physician
or other qualified health care professional”.
Providers of medical service should consider the risk of
reporting services for which they are not fully trained and
licensed to perform. For example, when a Pain Specialist
advises a patient that a hip arthrogram is being performed
and charges the insurance carrier for a hip arthrogram, the
expectation is that a diagnostic radiological study has been
performed. The doctor would be expected to identify
whether or not there is any bone disease or arthritic
condition of the hip. If the doctor fails to identify a
condition that causes the patient future disability which
early treatment could have prevented, a malpractice suit
could result.
The “take home message” on Page xiii of the CPT Manual
is “...by any qualified physician or other qualified health
care professional.”
Source: CPT Coding Manual, Professional Version 2005
Source: Joanne Mehmert, CPC
357. Answer: B (1 & 3)
Explanation:
Sequential Coding:
* Line 1
Surgery with greatest relative value – 100%
* Lines 2-5 - 50%
Source: Laxmaiah Manchikanti, MD
358. Answer: E (All)
Explanation:
* Reasons for denial
- Misinterpretation of the coding
- Arbitrary denial
- Repeated incorrect coding leads to auditing
Source: Laxmaiah Manchikanti, MD
359. Answer: B (1 & 3)
Explanation:
Consultation vs. Referral Visit
1. Problem
Consultation
Suspected
Referral visit Known
“Patient is referred for treatment or management of
his/her condition.”
3. Request
Consultation
Written request for opinion or advice received from
attending physician, including the specific reason the
consultation is requested.
Referral visit
Patient appointment made for the purpose of providing
treatment or management or other diagnostic or
therapeutic services.
4. Report language
Consultation
“I was asked to see Mr. Jones in consultation by Dr.
Johnson.”
Referral visit
“Mr. Jones was seen following a referral from Dr.
Johnson.””
5. Patient care
Consultation
Only opinion or advice sought. Subsequent to the
opinion, treatment may be initiated in the same encounter
Referral visit
Transfer of total patient care for management of the
specified condition.
6. Treatment
Consultation
Undetermined course
Referral visit
Prescribed and known course
7. Correspondence
Consultation
Written opinion returned to attending physician.
Referral visit
No further communication (or limited contact) with
referring physician is required.
8. Diagnosis
Consultation
Final diagnosis is probably unknown.
Referral visit
Final diagnosis is typically known at the time of referral.
2. Request language
Consultation
“Please examine patient and provide me with your
opinion and recommendation on his/her condition.”
9. Follow-up
Consultation
Patient advised to follow up with attending physician.
Referral visit
Referral visit
ASIPP
101
Patient advised to return for additional discussion, testing,
treatment, or continuation of treatment and management.
10. Further follow-up
Consultation
Confirmatory or follow-up consultation or established
patient based on specific situation.
Referral visit
Always established patient for three years.
Source: Laxmaiah Manchikanti, MD
360. Answer: B (1 & 3)
Source: Laxmaiah Manchikanti, MD
361. Answer: E (All)
Source: Laxmaiah Manchikanti, MD
362. Answer: A (1,2, & 3)
Explanation:
Borderline personality characteristics and the borderline
personality in general are widely referenced by the
American Psychiatric Association. Borderline personality
disorder is a consistent pattern of instability in
relationships image, and patients tend to be very
impulsive. Bipolar personality is a very common example.
Self-mutilation, suicidal behavior, and substance abuse
disorder is also a common association experienced with
borderline characteristics, and particularly of interest to
the pain management physician is the high incidence of
chaotic lifestyle and impulsivity. Controlled substances
should be given with caution to these individuals.
Source: Hans C. Hansen, MD
363. Answer: A (1,2, & 3)
Explanation:
Although the typical bipolar patient may exhibit exuberant
euphoria from time to time, usually the borderline
personality, with either bipolar overlay or other comorbid
psychiatric disease, leads a chaotic lifestyle associated with
impulsivity, hostility, and depression. Anxiety is a
common feature. These individuals tend to be needy and
dependent, and catastrophize.
Source: Hans C. Hansen, MD
364. Answer: B (1 & 3)
Explanation:
Many times language, cultural, and financial barriers to
treatment exist, and if not asked, may not be readily
evident. When patients come to a pain management
physician and appear noncompliant, a more global
understanding is best assessed. The patient returns in
follow-up, but did not fill his prescriptions as written.
There are a number of reasons this could occur, and not
just unwillingness follow directions to avoid
misunderstandings decaying into frank complaints, it is in
the physicians best interest to ensure that the patient
understands the diagnosis, treatment course, and overall
directed care.
Source: Hans C. Hansen, MD
365. Answer: B (1 & 3)
Explanation:
Interventional Pain Management -09 designation
Profiling
Practice Expense
CAC Membership
Source: Laxmaiah Manchikanti, MD
366. Answer: E (All)
Explanation:
Local Medical Review Policy or Local Coverage
Determination
LMRPs or LCDs are those policies used to make coverage
and coding decisions in the absence of:
Specific statute
Regulations
National coverage policy
National coding policy
As an adjunct to a national coverage policy.
Development of LMRP - Identification of Need
* A validated widespread problem
Identified or potentially high dollar and/or high volume
services
* To assure beneficiary access to care
* LMRP development across its multiple jurisdictions by a
single carrier
* Frequent denials are issued or anticipated
LMRP’s reduce utilization and Save money
Source: Laxmaiah Manchikanti, MD
367. Answer: B (1 & 3)
Explanation:
Reference: Manchikanti L (ed). Principles of
Documentation, Billing, Coding & Practice Management
for the Interventional Pain Professional, ASIPP
Publishing, Paducah KY 2004.
Source: Laxmaiah Manchikanti, MD
368. Answer: D (4 Only)
Explanation:
The total treatment time was 37 minutes which supports
only two units to be billed with the “8 Minute Rule”. The 8
minute rule applies to all timed PT CPT codes that
require direct, one to one contact by the PT provider. It
states that for any single, timed CPT code, providers bill a
single 15’ unit for treatment greater than or equal to eight
minutes and less than 23 minutes. Two units would be
billed for treatment 23 minutes to less than 38 minutes. If
more than one CPT code is billed during a calendar day,
then the total number of units that can be billed is
constrained by the total treatment time. Ultrasound was
performed for only four (4) minutes and therefore should
not be billed.
Source: WPS Comminque May 2005, PHYSMED-009
Source: Marsha Thiel, RN, MA, Sep 2005
ASIPP
102
369. Answer: A (1,2, & 3)
Explanation:
The eight minute rule applies to all timed PT CPT codes
that require direct, one to one contact by the PT provider.
It states that for any single, timed CPT code, providers bill
a single 15’unit for treatment greater than or equal to eight
minutes and less than 23 minutes. Two units would be
billed for treatment 23 minutes to less than 38 minutes. If
more than one CPT code is billed during a calendar day,
then the total number of units that can be billed is
constrained by the total treatment time. Time is defined as
actual treatment time.
Source- WPS Communique May 2005, PHYSMED-009
Source: Marsha Thiel, RN, MA, Sep 2005
370. Answer: D (4 Only)
Explanation:
Physical therapist assistants do not have provider
numbers. Services provided by a physical therapist
assistant may be billed by the supervising physical
therapist if the physical therapist is in the clinic. The visit
cannot be billed by the supervising PT if the PT is not
present in the clinic. Medicare does not allow PTA’s to bill
work that they do incident to a physician who may be
present. In this case therefore, there are no options for
billing for the visit and it would be a no charge visit.
Source: Medlearn Matters #SE0533
Source: Marsha Thiel, RN, MA, Sep 2005
371. Answer: A (1,2, & 3)
Explanation:
Clinical Psychologists will be reimbursed for providing
direct services to patients, interpreting psychometric
testing and time it takes to write the report. CP generally
do not bill for coordination of care or other types of case
management services, and would not generally be
expecting to get reimbursed for these services if they did
bill for them.
CPT 2005 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY.
Source: Marsha Thiel, RN, MA, Sep 2005
372. Answer: D (4 Only)
Explanation:
1) This response is incorrect as it is generally used for the
assessment of mental health disorders.
2) This response is incorrect, as it is generally used to
designate individual services of a psychologist whose
treatment is designed to ameliorate a mental health
problem.
ASIPP
3) This response is incorrect, as it is generally used for a
psychosocial assessment of a medical problem.
4) This response is correct. Individual behavioral health
intervention is the code to use when the focus of a
psychologist’s services is the amelioration of an
individual’s medical problem.
CPT 2005 Manual
Principles of Documentation, Billing, Coding, and
Practice Management for the Interventional Pain
Professional (ed by) Laxmaiah Manchikanti, ASIPP
Publishing: Paducah, KY. p. 163
Source: Marsha Thiel, RN, MA, Sep 2005
373. Answer: E (All)
Source: www.cms.gov. ; Manchikanti L, Principles and
Practice of Documentation, Billing, Coding, and Practice
Management 2005.
374. Answer: D (4 Only)
Explanation:
Per Medicare “There must have been a direct, personal
professional service furnished by the physician to initiate
the course of treatment of which the service being
performed by the non-physician is an incidental part”
Source: Marsha Thiel, RN, MA, Sep 2005
375. Answer: B (1 & 3)
Explanation:
The definition of incorrect coding encompasses items #1
and #3. Items #2 and #4 reflect correct coding principles.
Source: James A. Mirazita, MD, Sep 2005
376. Answer: D (4 Only)
Explanation:
CMS has developed general policies that define the coding
principles and edits that apply to procedure and service
codes. Item #4 best describes the essential idea of these
policies. The remaining items represent coding practices
that should be avoided.
Source: James A. Mirazita, MD, Sep 2005
377. Answer: A (1,2, & 3)
Explanation:
Items 1, 2, and 3 are all considered generic services
integral to standard procedures. Referral to a different
physician may occur outside the provision of a procedure,
but is not integral to it.
Source: James A. Mirazita, MD, Sep 2005
378. Answer: A (1,2, & 3)
Explanation:
1. Improvement of quality of data
2. Improvement of knowledge
3. Creation of efficient medical practice
4. Improved relations between staff
5. Improved and correct reimbursement
6. Protection against fraud and abuse
103
7. Availability of proper data for evaluation purposes
8. Improved quality management and improvement with
enhanced availability of data.
9. Improved relations with public and payors
10. Peace of mind and comfort with enhanced medical
practice.
Source: Laxmaiah Manchikanti, MD
379. Answer: D (4 Only)
Explanation:
The service may not be reported as an “incident to” service
since the physician is not in the office. When the doctor’s
PIN is on a claim sent to Medicare, it represents that the
service was provided by the physician or incident to a
physician service, the nurse’s name on the form will not
mitigate having the doctor’s PIN listed. Code 96530 has
not been used for morphine pump refills for pain control
since 2003, when code 95990 was added to CPT.
No charge may be reported to Medicare for the nurse’s
service in this circumstance.
Source: Centers for Medicare and Medicaid,
www.cms.gov, Incident to reporting guidelines.
Source: Joanne Mehmert, CPC, Sep 2005
380. Answer: C (2 & 4)
Explanation:
Medicare’s payment rules relative to payment for group
practices are available on the CMS web site and providers
are expected know the payment rules. When in a group
practice, all physicians, in the same specialty, that reassign
payment to the group, are paid as a single physician. It
would be a deliberate intent to be paid for services that the
group is not entitled to be paid for if a different provider
performed post op care because the Medicare carrier did
not have its claim edits in place. When a provider knows
or should have known that money has been paid in error,
regardless of payer error, the provider is required to
return the money.
Sources: Source: Medicare Claims Processing Manual,
100-04 Chapter 12 Physicians/Nonphysician Practitioners
and OIG Compliance Program Guidance for individual
and Small Group Physician Practices (65 FR59434;
October 5, 2000)
Source: Joanne Mehmert, CPC
381. Answer: A (1,2, & 3)
Explanation:
Lysis of Adhesions
* 62263: 2 or more days
* 62264: 1 day
* Services which are bundled:
- Contrast injection (62311/19)
- Fluoro/epidurography (77003/03/72275)
- Transforaminal epidural (64483)
- Peripheral nerve blocks (64450)
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
382. Answer: A (1,2, & 3)
Explanation:
Add-on Codes
* Primary code has a code
* Second level has a separate code
* Examples:
- Facets, therapeutic and RF
- Transforaminal epidurals
- Vertebroplasty
* Do not use a 51 modifier; pays differently
* Add-on codes are modifier 51 exempt
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
Meeting
383. Answer: A (1,2, & 3)
Explanation:
1) The CMS region covering Kansas, Nebraska and
Northwest Missouri specifically states on its website that
billing Medicare for “no shows” is an indicator of fraud
and abuse.
2) Duplicate bills are often submitted to third party payors
under the mistaken belief that the original claim has been
lost or misplaced. Although double billing can occur due
to simple error, systematic double billing may indicate a
reckless disregard of the problem and give rise to false
claim liability.
3) Upcoding can lead to false claim allegations and should
not be tolerated within the physician practice.
4) Clustering can lead to false claim allegations and
should not be tolerated within the physician practice.
Source:
See Medicare: Fraud and Abuse
(www.nebraskamedicare.com/policy/fraud.htm); see also
65 Fed. Reg. at 59439.
Source: Erin Brisbay McMahon, JD, Sep 2005
384. Answer: E (All)
Explanation:
4 Coding Methodologies for Injections Affecting Multiple
Levels
* Add-on code methodology
* 51 Modifier methodology
* Mutually exclusive code methodology
* Single code methodology
Source: David M. Vaughn, Esq., CPC - ASIPP 7th Annual
ASIPP
104
Meeting
385. Answer: B (1 & 3)
Explanation:
Discharging a patient requires a careful process of
documentation, and there is disagreement among risk
managers and attorneys whether the patient should be told
of specifics why they are being discharged. Noncompliance
in particular should follow a pattern and documentation
and may include that consideration that it is injurious for
the patient to not follow treatment recommendations. A
policy should be in place to assist in orderly transfer to
another provider, following the required process of
discharge. These vary state to state, but usually consist of
requiring a 30 day follow-up for emergencies, and
assisting the patient with other resources in the
community.
Source: Hans C. Hansen, MD
386. Answer: A (1,2, & 3)
Explanation:
Currently Medicare does not require an NDC number; the
“J” code is all that is required. There are some nonMedicare carriers that do require the NDC number. The
billing staff should watch the EOB’s carefully to be sure
that the drugs are paid appropriately.
There is much confusion in the industry relative to the
appropriate method to bill for compounded medications.
The basic coding principle that applies to procedures and
other services pertains to coding for compounded drugs.
When the code doesn’t describe the item or service, use an
unlisted code and tell the insurer what it is. The “J” codes
do not represent compounded, specially mixed, drugs.
Source: Correct Coding Conventions; various Medicare
Carrier Policies
Source: Correct Coding Conventions; various Medicare
Carrier Policies
387. Answer: C
Explanation:
Training
* No cost to employee
* During work hours
* At time of initial assignment
* Within 90 days after effective date of standard
* Within 1 year of previous training
* Shift in occupational exposure
Source: Laxmaiah Manchikanti, MD
388. Answer: E
Explanation:
The ad discriminates on the basis of age and the
requirement to speak without accent discriminates against
race and national origin. The words front office
appearance have been held to discriminate against those
with visible disabilities. The ad also promises job
security, allowing a terminated employee to have a claim
ASIPP
against the clinic for breach of implied contract of
continued employment. Employers are at a decided
disadvantage
Source: Judith Holmes
389. Answer: E
Explanation:
Physician employers are required to comply with many
state and federal safety and employment-related laws.
Effective compliance requires adequate staff training.
Failure to do so, in the words of one court, is an
extraordinary mistake. In fact, the U.S. Supreme Court has
recently held that failure to conduct staff training on
harassment and discrimination may expose the employer
to punitive damages in addition to compensatorydamages.
Because training is so important, it is also important to be
able to produce evidence that your training programs are
adequate and that your staff members have actually
attended the training sessions
Source: Judith Holmes
390. Answer: E
Explanation:
This is a classic example of economic harassment. Dr
West is the office manager’s supervisor. She reduced the
office manager’s pay and demoted him as a result of his
refusal to continue a personal relationship. It only takes
one incident to create liability and it the clinic is strictly
liable even if there is a policy in place and even if the clinic
owner does not know it has occurred. It does not matter
that the supervisor is a female
Source: Judith Holmes
391. Answer: E
Explanation:
When a patient becomes noncompliant, care must be
exercised to avoid abandonment. At no time should the
patient feel that care will be withdrawn inappropriately or
that they are going to have an inadequate period of time to
find another treating physician, typically 30-days. It might
be wise to use a third party, such as a business manager to
sit in a non-confrontational environment with the patient
discussing more than one option, avoiding
embarrassment. Another strategy might be to give the
patient time to contemplate options and availability of
other treatment physicians. It might be that you are the
best choice, which would suggest payment compliance is a
better option than no treatment whatsoever.
Finally, when controlled substances are involved, abrupt
discontinuation in an age group that could benconsidered
at risk for adverse event or poor outcome should be
avoided.
Consider the appearances to referral sources or the
community of an older or elderly individual, refused
access to medications, which resulted in an adverse event.
Perceptions are sometimes far more costly than a few
dollars on a bill, particularly if this bill can be negotiated.
The caveat would of course be a managed care plan, or a
compliance violation when lack of collection could come
105
back with frequent write-offs, or lack of collection
resulting in a professional sanction. If good will is the
theme of the day, this is unlikely.
Source: Hans C. Hansen, MD
392. Answer: B
Explanation:
Anti-Kickback Statute
* A crime to offer, solicit, pay, or receive remuneration, in
cash or in kind, directly or indirectly, for referrals under a
federally-funded health care program
- Felony - 5 years imprisonment
- Civil Penalties - $50,000 per violation
- “One Purpose” Rule
- Safe Harbors
Source: Laxmaiah Manchikanti, MD
393. Answer: B
Source: Hans C. Hansen, MD
394. Answer: B
Explanation:
State Laws
* Medical records confidentiality laws
* Medical records access laws
* HIV/AIDs
* Mental health
* Genetic testing/anti-discrimination
395. Answer: B
Explanation:
Needlestick Safety & Prevention Act 0f 2001- Nov. 6, 2000
* Four areas of change
* Two terms added to definitions
* Why
- Total > 600, 000 Needle sticks a year
- 2/3 rd Hospital
- Risk of contracting disease
- Adverse side effects of treatments
- Psychological stress
Modification of Definitions - Area 3
* Solicitation of Employee Input
- Non-managerial employees who are responsible for
direct patient care and potentially exposed to injury
- Identification, evaluation, selection of effective
engineering and work practice controls
- Document employee solicitation in Exposure Control
Plan
Modification of Definitions - Area 4
* Record Keeping
- Sharps Injury Log
Type and brand of device involved
Department or work area of exposure incident
Explanation of how the incident occurred
Source: Laxmaiah Manchikanti, MD
396. Answer: A
Explanation:
Treating Mary differently or putting her on leave can lead
to a claim of retaliation. Terminating Bob before a
thorough investigation is conducted can lead to a claim of
wrongful termination.
Source: Judith H. Holmes, JD
397. Answer: B
Explanation:
Unless a limited exception applies, a health care provider
must give a patient access to his or her records that are
maintained in a designated record set.
A patient is entitled to inspect and copy records that are
maintained in a designated record set. A designated
record set includes medical records maintained by or for
the health care provider and includes any item, collection
used or disseminated by or for a covered entity. There is
no exception for records maintained by the provider but
generated by others,and thus a provider is not permitted
to withhold records held by the provider that have been
created by another provider.
Source: Laxmaiah Manchikanti, MD
Modification of Definitions - Area 1
* Relating to Engineering Controls
- Definition: Includes all control measures that isolate
or remove a hazard from the workplace.
- Examples: blunt suture needles, plastic or mylar
wrapped capillary tubes, sharps disposal containers, and
bio-safety cabinets
Modification of Definitions - Area 2
* Revision and Updating of the Exposure Control Plan
- Review no less than annually
- Reflect a new or modified task/ procedure
- Revised employee positions
- Reflect changes in technology
- Document consideration and/or implementation of
medical devices
398. Answer: D
Source: Judith H. Holmes, JD
399. Answer: D
Explanation:
The Privacy Rule permits a provider who is a covered
entity to disclose a complete medical record including
portions that were created by another provider. No
justification for releasing the entire record is needed in
those instances where the minimum necessary standard
does not apply, such as disclosures to or requests by a
health care provider for treatment purposes or disclosures
to the individual who is the subject of the protected health
information.
ASIPP
106
Source:
http://healthprivacy.answers.hhs.gov/
Source: Erin Brisbay McMahon, JD, Sep 2005
400. Answer: E
Explanation:
A.is true only if reasonably inferred under the
circumstances and should be confirmed by asking the
patient
B.is true only if the patient is incapacitated
C.is true only if supported by a court order or
investigation of a crime on the premises of the practice or
facility
D.is true only if patient consents or in emergency or
incapacitated patient
E.is true because patient must agree to disclosure in order
to file a worker compensation claim
Source: William Allen, JD
401. Answer: A
Explanation:
A covered entity must comply with the HIPAA Security
Rule with respect to electronic health information only.
Source: 64 CFR 164.302.
Source: Erin Brisbay McMahon, JD, Sep 2005
402. Answer: E
Explanation:
The OIG Compliance Program for Individual and Small
Group Physician Practices recommends that employee
training be conducted as needed, but at least annually.
Source: Vicki Myckowiak, Esq.
403. Answer: E
Explanation:
Answer E. Dr. Smith should contact qualified legal
counsel to direct the investigation. Although the
attorney/client privilege is not an absolute protection of
documents and discussions, having an attorney direct the
investigation makes it more likely that Dr. Smith will be
able to protect investigative documents and discussions.
Moreover, a qualified attorney will have experience in the
most effective investigative methods, the rules and
regulations surrounding the reported issue, and the
requirements for repayment of misbillings if necessary.
A.Dr. Smith should try to keep the identity of thereporting
individual confidential if he can. Therefore, it is better to
debrief the reporting individual on a one-to-one basis
than to subject them to questioning by the rest of the
office.
B.It is inappropriate to retaliate against an employee for
making a report. Firing the employee might lead the
employee to file a wrongful termination lawsuit.
Moreover, if Dr. Smith engages in any retaliation against
an employee for making a report he will discourage all
other employees from reporting concerns and he will
ensure that he does not have an effective compliance
program.
C.Dr. Smith should not promise the employee that he will
ASIPP
keep her identity confidential because it is not always
possible to conduct a thorough investigation without other
employees learning the identity of the reportingemployee.
Dr. Smith should only promise that he will attempt to
keep her identity confidential; but that, in fact, he may not
be able to keep her identity strictly confidentialthroughout
the course of the investigation.
D.An effective compliance program requires an
investigation of any reports of noncompliance that may
have merit. Therefore, Dr. Smith should not ignore the
report. In fact, if Dr. Smith ignores the report and the
Government ends up conducting an investigation on the
same matter, the pain practice might face criminal charges
and/or increased penalties.
Source: Vicki Myckowiak, Esq.
404. Answer: D
Explanation:
Answer: D. Dr. Smith should ask the FBI agents and
police officers to wait until he can get his attorney on the
premises so that the attorney can ensure that the
Government agents comply with the search warrant and
the law. However, Dr. Smith should understand that the
government agents do not have to agree to the request and
can immediately begin to execute the search warrant.
Source: Vicki Myckowiak, Esq.
405. Answer: E
Explanation:
A covered entity’s responsibility to implement security
standards extends to the members of its workforce,
whether they work at home or on-site. Because a covered
entity is responsible for ensuring the security of the
information in its care, the covered entity must include ‘‘at
home’’ functions in its security process.
Source: 68 Fed. Reg. 8339
Source: Erin Brisbay McMahon, JD, Sep 2005
406. Answer: A
Explanation:
Labeling requires fluorescent orange and red warning
labels are attached to waste, or other containers that may
contain potentially infectious materials and includes
blood,blood products, tissue, serum, or body fluids.
Universal/standard precautions implies that all blood is
infected with HIV or HBV and requires proper labeling.
Labels are not required when,
Blood components are labeled with their contents, and
specified for transfusion
Blood or infectious materials are placed in a labeled
container for transport and disposal.
When biohazard bags are used. The bags should not leak,
and they are free of sharps and the bag is sealed.
Placing materials of an infectious nature in a facility or
disposal container, such as a dumpster, without labeling
should not be done.
Source: Hans C. Hansen, MD
107
407. Answer: B
Explanation:
Based on the AMA study, only 8 states are considered to be
stable; California, Idaho, Colorado, New Mexico, Texas,
Louisiana, Wisconsin, Indiana
Source: Joel M. Blau, CFP
408. Answer: E
Explanation:
Based on current asset protection laws, only an IRA is
considered to be protected asset from creditors, in all
states.
Source: Joel M. Blau, CFP
409. Answer: B
Explanation:
CPT
1. Systematic listing and coding of procedures and
services performed by physicians
2. Procedure or service is accurately defined with
simplified reporting
3. Each procedure or service is identified with a five-digit
code
ICD-9
International Classification of Diseases
Source: 42 CFR 411.351.
Source: Erin Brisbay McMahon, JD, Sep 2005
413. Answer: D
Explanation:
Source: 29 CFR 1910.1030(d)(4)
Source: Erin Brisbay McMahon, JD
414. Answer: E
Source: Erin Brisbay McMahon, JD
415. Answer: C
Explanation:
Labels shall be fluorescent orange or orange-red or
predominately so, with lettering and symbols in
contrasting color.
Source: 29 CFR 1910.1030(g).
Source: Erin Brisbay McMahon, JD, Sep 2005
416. Answer: B
Explanation:
Source: 45 CFR 164.530.
Source: Erin Brisbay McMahon, JD
417. Answer: B
Explanation:
Source: 71 Fed. Reg. 52,720 (9/6/2006).
Source: Erin Brisbay McMahon, JD
418. Answer: D
Source: Erin Brisbay McMahon, JD
Organization
Disease classification: Alphabetic index to diseases
Tabular list of diseases
Source: Laxmaiah Manchikanti, MD
410. Answer: D
Explanation:
The estate tax exemption will be increased to $3.5 million
in 2009, but is reduced to $1 million in 2011.
Source: Joel M. Blau, CFP
411. Answer: A
Explanation:
Based on the impact of inflation and rate of return chart
for determining the amount of money required to reach a
retirement goal, $2,195,700 is the correct answer.
Source: Joel M. Blau, CFP
412. Answer: E
Explanation:
A referral is defined as the request by a physician for, or
ordering of,or the certifying or recertifying of the need for,
any designated health service for which payment may be
made under Medicare Part B, including a request for a
consultation with another physician.
419. Answer: D
Explanation:
A. The Stark rules permit organizations to give physicians,
the physician’s family members or office staff compliance
training – without the training being counted as an illegal
fringe benefit or perk if:
* The training takes place in the provider’s services area;
* The training is not for continuing medical education.
B. To qualify for the in-office ancillary service Exception,
services must be furnished in one of the following three
locations:
1. The same building if one of the following conditions
apply:
* The physician or practice has an office that is
normally open at least 35 hours a week and offers services,
including at least some non-DHS, at least 30 hours per
week; or;
* The patient usually receives services from the
referring physician or group at that office. The physician
or group’s office must normally be open at least eight
hours a week and the referring physician must personally
offer service, including some non-DHS, at least six hours a
week; or;
* The referring physician or practice member is
present and orders or provides DHS at that site during a
patient visit. In addition, the physician or group must own
ASIPP
108
or rent an office in the building that is open at lest eight
hours a week and offer services at least six hours a week.
2. One or more centralized buildings used by the group
practice to deliver at least some of its clinical lab services.
A centralized building may include a mobile vehicle if it’s
used exclusively by the practice and leased for at least six
months, 24 hours/day, 7 days/week
3. One or more centralized buildings used by the group
practice to deliver at least some of its designated health
services other than clinical lab services.
C & E. Providers may charge Medicare patients extra for
items and services that are not covered by Medicare, but
the providers should think carefully when they offer a
contract for boutique or concierge care to their Medicare
beneficiaries.
D. Health care providers that violate fraud and abuse laws
risk more than administrative sanctions and civil
penalties. OIG, working alone or with other law
enforcement agencies and state Medicaid Fraud Control
Units, may file criminal cases against individuals who
initiate or participate in illegal activities.
Source: Laxmaiah Manchikanti, MD
420. Answer: D
Explanation:
A physician’s “immediate family member” means the
physician’s husband or wife, birth or adoptive parent,
child, or sibling; stepparent, stepchild, stepbrother, or
stepsister; father-in-law, mother-in-law, son-in-law,
daughter-in-law, grandparent or grandchild; and spouse of
a grandparent or grandchild.
Source: Erin Brisbay McMahon, JD, Sep 2005
421. Answer: D
Explanation:
The possibility of a future inheritance should not be
considered in determining retirement income feasibility
since it is an unknown, uncontrollable, variable (waiting
for a parent or parents to die).
Source: Joel M. Blau, CFP
422. Answer: E
Explanation:
If a financial relationship exists between the DHS entity
and the referring physician, it must fit within an exception.
Exceptions are broken down into three broad categories:
ownership and compensation exceptions, ownership
exceptions, and compensation exceptions. An ownership
or investment interest requires an ownership exception. A
compensation arrangement requires a compensation
exception.
Source: 42 CFR 411.354.
Source: Erin Brisbay McMahon, JD, Sep 2005
423. Answer: C
ASIPP
Explanation:
Source:Proposed 21 CFR 1306.12
Source: Erin Brisbay McMahon, JD
424. Answer: B
Source: Laxmaiah Manchikanti, MD
425. Answer: A
Explanation:
Global Fee Policy
Packaged or certain services are included in allowance for
a surgical procedure.
Bundling: Combining multiple services into a single
charge.
Global Package
Includes:
Pre-operative
Procedure
Post-operative
Does Not Include:
Initial evaluation
Unrelated visits
Diagnostic test(s)
Return trips to OR
Staged procedures
Global Period
Major day prior, day of, and 90 days after
Minor day of or day of and ten days after
Source: Laxmaiah Manchikanti, MD
426. Answer: E
Explanation:
Source: ASIPP Model Compliance Program for Physician
Practices, May 2005 ed.
Source: Erin Brisbay McMahon, JD
427. Answer: D
Explanation:
Such ancillary services cannot be billed separately.
Source: 42 CFR 1001.952®
Source: Erin Brisbay McMahon, JD
428. Answer: C
Explanation:
Source: 2007 OIG Work plan,
http://oig.hhs.gov/publications/docs/workplan/2007/Wor
k%20Plan%202007.pdf
Source: Erin Brisbay McMahon, JD
429. Answer: E
Explanation:
Stark is a strict liability statute. No intent to defraud is
109
required to violate it.
Source: Furrow B et al. Health Law: Cases, Materials, and
Problems 2004 at 1034.
Source: Erin Brisbay McMahon, JD, Sep 2005
430. Answer: E
Explanation:
A. Gifts offered to patients or potential patients that may
affect the patient’s choice of provider or the treatment
decision are suspect under the Anti-Kickback Statute.
B. Compensation arrangements with physicians or other
practitioners that are based upon the volume or value of
referrals for services within the practice are suspect under
the Anti-Kickback Statute.
C. Giving a patient free medications with the intention of
inducing the patient to choose a specific provider is
suspect under the Anti-Kickback Statute.
D. The sale of pharmaceutical samples to beneficiaries is
suspect under the Anti-Kickback Statute.
E. Payments relating to the purchase and sale of physician
practices are considered one of the exceptions, commonly
known as a safe harbor, under the Anti-Kickback Statute.
Source:
e) 42 CFR 1001.952(e) (1991).
Source: Erin Brisbay McMahon, JD, Sep 2005
431. Answer: A
432. Answer: D
Explanation:
A. Standing orders are allowed when they’re part of an
extended course of treatment,but OIG says that in the
past, too often they have led to abusive practices. Standing
orders by themselves aren’t usually acceptable
documentation that tests are reasonable and necessary.
B. The False Claims Act has been violated when a provider
does any of the following:
Knowingly presents a false claim for payment or
approval to an officer or employee of the U.S. government
or armed forces.
Conspires to defraud the government by having a false
claim allowed or paid.
A claim, submitted prior to receipt of the results,could not
be based on qualified clinical lab services because the
independent lab would not have been able to determine
whether the test was performed meaningfully,for example,
whether the specimen was adequate or the results were
valid. This would be a direct violation of the False Claims
Act.
C. Clinical lab services are one of the 10 health care
services specifically designated by Stark for which
physicians cannot make referrals to entities with which
they or family members have a relationship. In fact, clinical
lab services were the first health care service designated by
Stark in 1989.
D. The Centers for Medicare & Medicaid Services (CMS)
allows laboratories to submit claims in limited instances
when the lab thinks the test may be denied. Such instances
include but aren’t limited to the following:
When a beneficiary has signed an Advance Beneficiary
Notice (ABN); or
When the beneficiary requests the provider submit the
claim.
When ABNs are used, the lab should include modifier GA
on the claim, which indicates that the beneficiary has
signed an ABN.
When a patient asks the provider to submit the claim, the
lab should note on the claim its belief that the service is
non-covered and that it is being submitted at the
beneficiary’s insistence.
E. Lab compliance policies should make sure that all
claims for testing services submitted to Medicare or other
federally funded health care programs are accurately and
correctly identify the services ordered by the physician or
authorized person and performed by the lab.
Source: Laxmaiah Manchikanti, MD
433. Answer: B
Explanation:
A. A supplier cannot offer to perform tests at a discounted
rate or for free in order to induce the ordering of Medicare
tests.
Penalties include a felony conviction, up to a $25,000
fine and/or five years in prison, plus possible exclusion
from Medicare, Medicaid or other federal health care
programs.
In addition, as added by the Balanced Budget Act of
1997, a convicted provider also could be hit with a civil
money penalty of up to $50,000 for each act, plus damages
of three times the amount of the kickback, whether or not
a portion of the kickback was legal.
B. Equipment rental is a key concept under both the AntiKickback Statue and the stark II regulations, in one case
because appropriate rentals may be protected under a safe
Harbor and in the other because they may be protected
ASIPP
110
under an exception.
According to Stark, physicians should use supplies
provided at no cost by a lab for that lab only and not
accept more supplies than they will use.
For example, if a physician’s office tends to send about
400 blood tests a year to a particular lab, the number of
items or supplies accepted from the lab should be
commensurate with the expected volume of tests.
If not, the receipt of these items or supplies could create
a financial relationship within the meaning of the stark
law.
Items provided must be used solely to collect, store,
process or transport specimens in order to avoid stark
violations.
Specialized equipment such as disposable or reusable
aspiration or injection needles and snares are not solely
collection or storage devices.
Computers and fax machines, although also used to
store data, are not viewed as solely collection or storage
devices.
The Anti-kickback Statute takes a different stance on
free equipment.
Whenever a lab offers or gives a referral source
anything of value that’s not paid for at fair market value,
OIG draws the inference that the thing of value is offeredto
induce the referral of business. by fair market value, OIG
means value for general commercial purposes.
However, in the health care context, fair market value
also must reflect an arms-length transaction unadjusted to
include the additional value that one or both parties might
attribute to the referral of business between them.
Under the anti-kickback law, an arrangement that
would normally violate the law is protected if it fits into a
safe harbor. The Equipment Rental Safe Harbor is
designed to give providers guidance on how to comply
with the law when renting equipment from entities to
which physicians refer. Arrangements must meet the
following 6 standards:
Leases must be in writing and signed by the parties.
The lease covers all equipment leased between the
parties and specifies the equipment it covers.
If the lease gives the renter access to the equipment for
only periodic intervals rather than full-time use, the lease
must specify exactly the schedule of the intervals and their
length,
The lease must be for a term of at least one year.
ASIPP
The aggregate rent for the lease must be set in advance,
must be at fair market value, and can’t be linked to
referrals or other business generated between the parties.
The amount of equipment rented is not greater than is
reasonable for the commercial purpose of the rental.
C. Managed care plans might require a physician or other
provider to use only the lab with which the plan has
negotiated a fee schedule. In these situations, the plan
usually will refuse to pay claims submitted by other labs.
The provider, however, may use a different lab and may
wish to continue to use that lab for non-managed care
patients. In order to keep the provider as a client, the lab
that doesn’t have the managed care contract may agree to
do the managed care work free of charge.
The legality of these types of agreements under the
Anti-Kick back Statue depends in part on the kind of
contractual relationship between the managed care plan
and its providers.
Under the terms of many managed care contracts, a
provider will get a bonus or other payment.
For proper utilization managed care plans threaten
financial penalties if the provider’s utilization of services
exceeds present levels.
When a lab agrees to write off charges for a physician’s
managed care work, the physician may receive a financial
benefit from the managed care plan because of the
appearance the utilization of tests has been reduced.
In cases in which providing services for free results in a
benefit to the provider, the Anti Kick-back Statue is
involved.
If free services are offered or accepted in return for the
referral of Medicare, Medicaid or other state health care
program business, both the lab and the physician may be
violating the statute.
There is no exception in the law or safe harbor
regulation that gives immunity to any party involved in
this kind of activity because the Medicare or Medicaid
programs don’t get the benefit of these free services.
D. While OIG recognizes that labs don’t treat patients or
make medical necessity determinations and that physicians
may order any of a wide range of tests they feel are
appropriate for their patients, it nonetheless says that there
are steps labs can and should take to make sure that they
bill only for tests that meet government reimbursement
rules. One such step is communicating to physicians that
the claim will be paid only for services that are covered,
reasonable and medically necessary.
On request,a lab should also be able to give documentation
supporting the medical necessity of a service billed to a
111
government program, such as requisition forms that have
diagnosis codes. Alternatively, the lab must be able to get
this supporting documentation from the physician who
ordered the test, an authorized person on the physician’s
staff or another person authorized by law to order tests.
specimen collection does not eliminate the concern over
possible abuse, particularly if it’s a situation where the
phlebotomist is not closely monitored by his or her
employer or where the contractual prohibition is not
rigorously enforced.
Source: Laxmaiah Manchikanti, MD
OIG states that labs are in a unique position to give
referring physicians information on Medicare rules
governing medical necessity, especially on which specific
tests (such as screening tests) don’t meet Medicare rules.
In OIG’s opinion, labs can and should give physicians such
advice.
E. A clinical lab may not alter a physician’s order without
consent.
434. Answer: B
Explanation:
Don’t accept anything from a clinical lab that you didn’t
pay fair market value for.
OIG indicated it was aware of a number of deals between
clinical labs and providers that could implicate the antikickback statute. When a lab offers or gives a referral
source anything of value without receiving fair market
value it can be viewed as an inducement to refer. It’s also
true when a potential referral source receives anything of
value from the lab.
When permitted by state law, a lab can make available to a
physician’s office a phlebotomist who collects specimens
from patients for testing by the outside lab. Although the
simple placement of a lab employee in the physician’soffice
isn’t by itself necessarily an inducement forbidden by the
Anti Kickback Statute, the statute does come into play
when the phlebotomist performs additional tasks that are
normally the responsibility of the physician’s office staff.
These tasks can include taking vital signs or other nursing
functions, testing for the physician’s office lab, or
performing clerical services.
When the phlebotomist performs clerical or medical
functions that aren’t directly related to the collection or
processing of lab specimens,OIG makes the deduction that
the phlebotomist is providing a benefit in return for the
physician’s referrals to the lab. In this case, the physician,
the phlebotomist and the lab may have exposure under the
Anti-kickback Statute. This analysis also applies to the
placement of phlebotomists in other health care settings,
including nursing homes, clinics and hospitals.
OIG also points out that the mere existence of a contract
between a lab and a health care provider that prohibits the
phlebotomist from performing services unrelated to
435. Answer: E
Explanation:
According to the final stark II regulations, fair market
value is the price that an asset would bring by bona fide
bargaining between well-informed buyers and sellers who
are not in a position to generate business for the other
party in an arms-length transaction, consistent with the
price the asset would bring on the general market. Fair
market price is the price paid in a particular market for
assets of like type, quality and quantity at the time of the
acquisition.
For rentals and leases, fair market value is the value of
rental property without taking into account the property’s
intended use. This means the space’s general market value,
unadjusted for the additional value of the space’s
convenience or proximity to the renter if the landlord is a
potential source of referrals to the renter
436. Answer: C
Explanation:
The OIG’s mandatory exclusionary authority does not
extend to misdemeanors relating to controlled substances
crimes.
Source: 42 U.S.C. § 1320a-7(a).
Source: Erin Brisbay McMahon, JD
437. Answer: D
Explanation:
If a compliance officer, compliance committee or other
management official discovers credible evidence of
misconduct from any source and, after a reasonable
inquiry, has reason to believe that the misconduct may
violate criminal, civil or administrative law, the provider
promptly should report the existence of misconduct to the
appropriate federal or state authorities within a reasonable
period, but not more than 60 days after determining that
there is credible evidence of violation to appropriate
federal and state authorities.
A. OIG states that some violations may be serious that they
warrant immediate notification to government authorities
prior to, or simultaneous with, commencing an internal
investigation. Examples include the following:
¨A clear violation of criminal law.
¨Has a significant adverse effect on the quality of care
provided to program beneficiaries (in addition to any
other legal obligations regarding quality of care).
ASIPP
112
¨Indicates evidence of a systemic failure to comply with
applicable laws, rules or program instructions or an
existing corporate integrity agreement regardless of the
financial impact on federal health care programs.
OIG states that all providers, regardless of size, should
ensure that they are reporting the results of any
overpayments or violations to the appropriate entity.
B. Violations need to be reported in 60 days.
C. Violations need to be reported in 60 days.
D. Violations need to be reported in 60 days.
regular auditing and monitoring, (2) written practice
standards that include a code or standard of conduct, (3)
designation of compliance officer, compliance committee
or compliance contacts, (4) education and training for all
personnel in the practice, (5) existence of response
mechanism and corrective action plan, (6) open lines of
communication, and (7) an enforced and well-publicized
disciplinary process.
Answer (c) is not correct because an effective
communication process is encouraged in a compliance
program and, to achieve this, the practice must establish a
procedure for communicating questions or complaints to
designated compliance personnel without raising concerns
about retaliation.
E. Violations need to be reported in 60 days.
438. Answer: C
Explanation:
WHAT’S ACCEPTABLE
- Free stethoscope
- Free meal, if it is “modest by local standards,” and
accompanied by educational or scientific exchange
- Lunch for staff, if provided during an information
presentation
- Free medical books, provided the cost is not substantial
- Modest buffet meal accompanying scientific or
educational meeting
WHAT’S NOT
- Golf balls and sports bag
- Free meal, if it’s of more than modest value and is not
accompanied by exchange of information
- Lunch for staff, if not connected to an information
presentation
- Gift certificate from a bookstore
- Scientific or educational meeting held before an athletic
event or entertainment performance
- Reimbursement for gasoline expenses
439. Answer: D
Explanation:
The DHS covered by the Stark Law include the following
eleven categories: clinical laboratory services, physical
therapy services, occupational therapy and speechlanguage
pathology services, radiology services, radiation therapy
services and supplies, durable medical equipment and
supplies, parenteral and enteral nutrients, equipment and
supplies, prosthetics, orthotics, and prosthetic devices,
home health services, outpatient prescription drugs, and
inpatient and outpatient hospital services.
Reference: 69 Fed. Reg. 16054 (2004).
Source: Erin Brisbay McMahon, JD, Sep 2005
440. Answer: C
Explanation:
Although the scope of a compliance program will vary
according to a practice’s resources, an effective compliance
program should reflect the following seven elements: (1)
ASIPP
Source: 65 Fed. Reg. 59434.
Source: Erin Brisbay McMahon, JD, Sep 2005
441. Answer: E
Explanation:
Answer (e) is false because the OIG does not consider
improper inducements, kickbacks and self-referrals as the
only major risk area for physician practices. The OIG has
identified four major risk areas for physician practices: 1)
coding and billing; 2) reasonable and necessary services; 3)
documentation; and 4) improper inducements, kickbacks
and self-referrals.
Source: 65 Fed. Reg. at 59438
Source: Erin Brisbay McMahon, JD, Sep 2005
442. Answer: C
Explanation:
Explanation: Answer (C) should be limited to the United
States.
Reference: The Department of Health and Human
Services and The Department of Justice Health Care Fraud
and Abuse Control Program Annual Report for FY 2003
(December 2004).
Source: Erin Brisbay McMahon, JD, Sep 2005
443. Answer: D
Explanation:
Chief Compliance Officer
*Access to the top
*Oversee and monitor the compliance plan
*Generally a compliance committee to assist
444. Answer: B
Explanation:
Examples of Abuse are:
Collecting more from the patient than you should
Routinely submitting duplicate claims
Upcoding
Unbundling
Wrong modifiers
113
Modifier 59
445. Answer: B
Explanation:
Regular and Effective Training
Who?
All employees and vendors
What?
Initial training
Regular ongoing training
In response to identified problem
446. Answer: C
Explanation:
RISKS OF NON-COMPLIANCE:
Criminal and civil penalties
The cost of an investigation and audit
Exclusion from government health care programs
including Medicare, Medicaid, and Tricare
Possible termination of private managed care and
insurance contracts
447. Answer: A
Explanation:
Although the physician is permitted to deny the request at
issue in the above scenario, the privacy rule does not
require denials to be put in writing. The privacy rule does,
however, permit the provider to require patients to put
their amendment requests in writing. A provider should
inform patients of this requirement in its Notice of Privacy
Practices.
According to the rule, if the provider denies a request, the
provider must provide the patient with a timely, written
denial. The denial letter must use plain language and
contain: the basis for the denial; a statement that the
patient can submit a written statement disagreeing with
the denial; a statement that, if the patient does not submit
a statement of disagreement, the patient may request that
the provider provide the amendment request and the
denial with any future disclosures related to the
information at issue; a description of how the patient can
complain to the provider or the government.
448. Answer: D
Explanation:
Explanation: Publishing is not an issue addressed in the
OIG compliance materials.
Source: 65 Fed. Reg. at 59,440-41.
Source: Erin Brisbay McMahon, JD
449. Answer: B
Explanation:
Source:42 USC § 1395y(a)(1)(A).
Source: Erin Brisbay McMahon, JD
450. Answer: A
Explanation:
Sending a patient’s electronic record is not a covered
transaction under the HIPAA Transaction and Codes Sets
Rule.
Source:45 CFR 162.1101-.1802
Source: Erin Brisbay McMahon, JD
451. Answer: B
Explanation:
a)Reporting violations to the Department of Health and
Human Services is not required.
b)Proof of proper training of employees regarding the
HIPAA Administrative Simplification Rules will
minimize the risk of liability for a physician practice if it
has not committed a HIPAA violation but an employee of
the practice has.
c)There is no time limit on responding to patient
complaints.
d)Amending the patient record upon the patient’s request
is not required.
e)Maintaining maintenance records for the practice’s
physical facility is an addressable safeguard under the
HIPAA Security Rule. Source:45 CFR 164.530(c).
Source: Erin Brisbay McMahon, JD
452. Answer: D
Explanation:
Source: 29 CFR 1910.1030(d)(2).
Source: Erin Brisbay McMahon, JD
453. Answer: D
Explanation:
Password management is an addressable administrative
safeguard under 45 CFR 164.308; all of the rest of these are
required administrative safeguards under that rule.
Source: 45 CFR 164.308
Source: Erin Brisbay McMahon, JD
454. Answer: C
Explanation:
Source:29 CFR 1910.1030.
Source: Erin Brisbay McMahon, JD
455. Answer: B
Explanation:
Source:42 USC §1395nn(h)(6)
Source: Erin Brisbay McMahon, JD
456. Answer: E
Explanation:
A hung jury does not result in a conviction under the
exclusionary statute; all of the other answers listed above
are considered a conviction under that statute.
Source:42 U.S.C. § 1320a-7(i).
Source: Erin Brisbay McMahon, JD
ASIPP
114
457. Answer: D
Explanation:
The OIG has discretionary or permissive authority to
exclude individuals and entities on the basis of all of the
answers above, except for (d).
Source: 42 U.S.C. § 1320a-7(b).
Source: Erin Brisbay McMahon, JD
458. Answer: B
Explanation:
A. The Criminal False Claims Act makes it a felony to
make or cause to be made any “false statement or
representation of material fact in any application for any
benefit or payment under a Federal health care program.
Returns directly proportional to capital invested
No separately billable ancillaries
Non-discriminatory treatment
Disclosure
Source: Ron Wiser, JD
460. Answer: C (2 & 4)
Explanation:
1) The regulations specifically provide that the hepatitis B
vaccine must be offered to all employees with occupational
exposures, but that the employee can decline to receive the
vaccine. In such an instance, the employee must sign a
Vaccine Declination form.
B. The Civil False Claims Act imposes liability if one
“knowingly” submits or causes to be submitted a false or
fraudulent claim for payment to the federal government. A
specific intent to defraud is not required.
2) The vaccine, vaccine series and post-exposure followup are to be made available to the employee at no cost.
C. Stark Law prohibits physicians from making referrals
for certain designated health services (DHS) to entities in
which the physician has a financial relationship and the
service is billed to Medicare or Medicaid.
3) The vaccine must be made available within 10 working
days of initial assignment to all employees who have
occupational exposure unless the employee has previously
received the complete hepatitis B vaccination series,
antibody testing has revealed that the employee isimmune,
or the vaccine is contraindicated for medical reasons.
D. The Drug Enforcement Agency monitors prescriptions
of controlled substances pursuant to authority under the
Controlled Substances Act, Title II of the Comprehensive
Drug Abuse Prevention and Control Act of 1970.
E. The Federal Anti-Kickback Law prohibits the offer or
receipt of anything of value which is intended to induce
the referral of a patient for an item of service that is
reimbursed under a federal health care program, including
Medicare and Medicaid.
Source:
A. 18 U.S.C. § 287, 1001; and 42 U.S.C. § 1320a-7b.
B. 31 U.S.C. § 3729.
C. 42 U.S.C. § 1395nn.
D. 21 U.S.C. § 801 et seq.
E. 42 U.S.C. § 1320a-7b(b).
Source: Erin Brisbay McMahon, JD, Sep 2005
459. Answer: E (All)
Explanation:
Safe Harbor Requirements - Common to all types of ASCs
Terms not related to previous or expected volume or value
of referrals
“One-third income” test
At least one-third of each physician’s practice income
from ASC procedures
No loans from ASC or other investors
ASIPP
4) See number 3) above.
Source: 29 CFR 1910.1030(f).
Source: Erin Brisbay McMahon, JD, Sep 2005
461. Answer: A (1,2, & 3)
Explanation:
Explanation: One of the elements of a sexual harassment
claim is that the alleged victim is personally offended.
That is not enough – the conduct or incidents must also be
offensive to a “reasonable person.” The lesson from this
situation is that the physician is getting a wake up call and
must rid the office of inappropriate conduct through
adopting appropriate policies, training and disciplinary
procedures.
Source: Judith Homes, Sep 2005
462. Answer: A (1,2, & 3)
Explanation:
An Exposure Control Plan must be in writing and contain
at least the following elements: (1) an exposure
determination, (2) the procedures for evaluating the
circumstances surrounding an exposure incident and (3) a
schedule of how and when other provisions of the
regulations will be implemented, including methods of
compliance, hepatitis B vaccination and post-exposure
follow-up, communication of hazards to employees, and
recordkeeping. The standard also requires employers to
solicit and document in the Exposure Control Plan input
of non-managerial employees who are responsible for
direct patient care and are potentially exposed to injuries
from contaminated sharps with regard to the
identification, evaluation and selection of effective
115
engineering and work practice controls. The telephone
number and address of OSHA’s office is not a required
element of the Exposure Control Plan,although it could be
included and may be required to be posted elsewhere
in the workplace.The Exposure Control Shall must be
reviewed and updated annually and whenever necessary to
reflect new or modified tasks and procedures which affect
occupational exposure and to reflect new or revised
employee positions with occupational exposure.
Source: 29 CFR 1910.1030(c).
Source: Erin Brisbay McMahon, JD, Sep 2005
463. Answer: C (2 & 4)
Explanation:
HIPAA is not specifically interested in the details of a
medical practice beyond elements of security and privacy.
The goal of HIPAA is not to either assist or impair billing
and collecting,but to hold accountable medical practices to
specific policy and procedures, and develop their own to
ensure medical record access, and accountability to audit,
security, and privacy. Security and privacy policies are
usually developed in conjunction with health law counsel.
The role of the EMR is to enhance compliance and
security.
Source: Hans C. Hansen, MD
464. Answer: A (1,2, & 3)
Explanation:
1.A review of random records is more likely to uncover
documentation, billing or payment irregularities.
Moreover, the Office of Inspector General recommends
random audits in its Compliance Guidance Program for
Individual and Small Group Practices.
2.An external auditor brings objectivity to the audit.
Asking the practice’s coder to audit his/her own coding is
less likely to uncover coding errors because the practice’s
coder will simply validate his/her own coding.
3.Providers are expected to identify Carrier overpayments
and then to return the money to the Carrier. Auditing the
Explanation of Benefits form will determine if the
practice’s protocol for identifying and returning
overpayments is effective.
4.The audit should always be either unannounced or
conducted on claims already billed. The point of the audit
is to uncover errors so Dr. Smith wants to audit a typical
day,not a day on which the staff reviews claims “with a fine
tooth comb.”
Source: Vicki Myckowiak, Esq.
465. Answer: E (All)
Explanation:
12 Elements of Training Program
* Accessible copy of regulatory text and explanation of its
contents
* General explanation of epidemiology and symptoms of
bloodborne diseases
* Explanation of modes of transmission of bloodborne
pathogens
* Explanation of Employer’s Exposure Control Plan and
how employee may obtain copy
* Explanation of appropriate methods for recognizing
tasks/activities involving exposure
* Explanation of methods to prevent or reduce exposure
* Information on decontamination and disposal of
personal protective equipment
* Appropriate actions and persons to contact in emergency
* Procedures to follow if exposure occurs
* Information post-exposure evaluation and follow-up
* Explanation of signs and labels and color-coding for biohazard
* Opportunity for interactive questions
466. Answer: E (All)
Explanation:
Health Care Fraud
Fines, up to 10 years in jail, or both
Theft or Embezzlement in connection with Health Care
Fines, up to 10 years in jail, or both
Obstruction of Criminal Investigations of Health Offenses
Fines, up to 5 years in jail, or both
False Statements and Relating to Health Care Matters
Fines, up to 5 years in jail, or both
Mail and Wire Fraud
Fines, up to 5 years in jail, or both
False Statements and kickbacks Involving Federal Health
Care Programs
Fines up to $25,000, up to 5 years in jail, or both
Exclusion from Participation in federal health care
programs
467. Answer: A (1,2, & 3)
Explanation:
WHY HAVE A COMPLIANCE PLAN?
Physicians and other practitioners often do not have the
financial means to employ a compliance specialist,
therefore may be more vulnerable to unintentional
violations.
Fewer errors, accurate reimbursement and less chance of a
CMS audit.
Now Medicaid, WC, MVA and private payors
Lends weight to billing procedures
Demonstrates “good faith efforts” to perform in
accordance with the laws.
WHY OIG COMPLIANCE PLAN?
The only thing worse than not having a compliance
ASIPP
116
program, is creating a plan without implementation
defraud is not required to be shown by the government in
a
The single most important step in practicing appropriately
To minimize the risk of a criminal prosecution and to
lower the risk of civil penalties
Creating an inference of good faith
468. Answer: E (All)
Explanation:
Explanation: Compliance personnel should participate in
developing the Practice Standards, developing a process to
communicate with and disseminate information to the
individuals in the practice, answering billing questions,
and conducting a baseline audit.
Reference: 65 Fed. Reg. at 59442.
Source: Erin Brisbay McMahon, JD, Sep 2005
469. Answer: A (1, 2 & 3)
Explanation:
A group practice that recruits a physician with an income
guarantee from a hospital cannot require the physician to
sign a covenant not to compete.
Source: 42 USC §1395nn(e)
Source: Erin Brisbay McMahon, JD
470. Answer: A (1,2, & 3)
Explanation:
Explanation: Voluntary implementation of a compliance
program can benefit a physician practice in many ways;
however, there is no cap on damages the government can
recover.
Source: OIG Supplemental Compliance Program
Guidance for Hospitals, 70 Fed. Reg. 4858 (January 31,
2005).
Source: Erin Brisbay McMahon, JD, Sep 2005
471. Answer: E (All)
Explanation:
Pentalties under False Claims Act:
Three times the amount of damages suffered by the
government
A mandatory civil penalty of at least $5,500 and no more
than $11,000 per claim.
civil false claims act case.
Source: 18 USC § 287, 1001; 42 USC § 1320-7b; 31 USC
§§ 3729, 3731
Source: Erin Brisbay McMahon, JD
473. Answer: A (1,2, & 3)
Explanation:
Explanation: Violations of the Self-Referral Laws are
punishable with civil money penalties of up to $15,000 per
claim, $100,000 per scheme, and exclusion from federallyfunded health care programs such as Medicare and
Medicaid.
Source: 42 U.S.C. 1395nn.
Source: Erin Brisbay McMahon, JD, Sep 2005
474. Answer: E (All)
Explanation:
The initial step in developing an effective compliance
program is the performance of a comprehensive baseline
audit of the practice’s operations. The purpose is to
ascertain whether the practice’s current practices and
procedures conform to all pertinent legal requirements.
The steps of an audit include: (1) review the key
documents, (2) review coding and billing practices, (3)
perform a physician practice walk-through, (4) interview
staff, and (5) review medical charts.
Source: 65 Fed. Reg. 59434.
Source: Erin Brisbay McMahon, JD, Sep 2005
475. Answer: C (2 & 4)
Explanation:
Disciplinary Guidelines
* Written policies - nondiscriminatory
* Scope of sanctions
* Range of responsibility
* Publication of standards and guidelines
* Background investigations for new employees
476. Answer: C (2 & 4)
Explanation:
Reasonable and Necessary
Service must be:
Safe and effective
Not experimental or investigational
Submit 50 false claims for $50 each
- Liability between $282,500 and $557,500 in damages.
Appropriate, including the duration and frequency that is
Program Exclusion
Source: Laxmaiah Manchikanti, MD
considered appropriate for the service, in terms of
whether it is:
472. Answer: A (1,2, & 3)
Explanation:
Intent to defraud is a required element of proof for the
government in a criminal false claims act case; intent to
ASIPP
• Furnished in accordance with accepted standards of
medical
practice for the diagnosis or treatment of the patient’s
condition or to improve the function
117
• Furnished in a setting appropriate to the patient’s
medical
needs and condition
• Ordered and/or furnished by qualified personnel
• One that meets, but does not exceed, the patient’s
medical need.
Documenting Medical Necessity
The physician practice should be able to provide
documentation such as a patient’s medical records and
physician’s orders, to support the appropriateness of a
service that the physician has provided
Only bill those services that meet the Medicare standard
of being reasonable and necessary for
the diagnosis and treatment of a patient
Source: Laxmaiah Manchikanti, MD
477. Answer: B (1 & 3)
Explanation:
Fraud
- Intentional deception or misrepresentation that the
individual knows to be false or
- Does not believe to be true, and the individual makes
knowing that the deception
could result in some unauthorized benefit to
himself/herself or some other person.
Abuse
- Billing Medicare for services that are not covered or
- Coding incorrectly.
Explanation:
1. Fair market value is a key term under the Stark
regulations on physician self-referral and is tied into a
number of its prohibitions and exceptions.
2. As defined by Stark, fair market value means the price
that an asset would bring by bona fide bargaining between
well-informed buyers and sellers in an arms-length
transaction consistent with the price the asset would bring
on the general market. Fair market price is the price paid
in a particular market for assets of like type, quality and
quantity at the time of the acquisition.
3. For service agreements, fair market value is the value of
rental property without taking into account the property’s
intended use. This means the space’s general market value
unadjusted for the additional value of the space’s
convenience or proximity to the renter if the landlord is a
potential source of referrals to the renter.
4. Fair Market Value Exception. This is one of the
exemptions under the Stark regulations on physical selfreferral. Specifically, this Exception allows compensation
resulting from an arrangement between a company and a
physician, immediate family member or group of
physicians (regardless of whether the group meets the
definition of group practice) if the arrangement meets the
following five conditions.
The agreement is in writing, signed by the parties, and
covers only identifiable items or services.
Fraud = Felony
- Knowingly, willfully, and intentionally
- Deliberate miscoding
- False documentation
- Billing for services
- not provided
Abuse
- Unknowing and unintentional
The agreement must specify the time frame for the deal.
The agreement specifies the compensation.
The arrangement must involve a transaction that is
commercially reasonable.
The arrangement must not be in violation of the AntiKickback Statute.
Fraud as per HIPAA
. . . the term should know means that a person . .
(A) acts in deliberate ignorance of the truth or falsity of
the information;
or
(B) acts in reckless disregard of the truth or falsity of the
information, and no proof of specific intent to defraud is
required.
Abuse
- Most errors do not represent fraud
- Most errors are not knowing, willful, and intentional.
Fraud
- High error rate
- Repeated submission of claims with errors
- Failure to follow plan of correction
478. Answer: B (1 & 3)
479. Answer: B (1 & 3)
Explanation:
Enforcement Weapons
Anti-Kickback Statute
HIPAA
Stark Law
False Claims Act
Administrative Sanctions
QUITAM (Whistle blower Act).
State Law(s)
480. Answer: A (1,2, & 3)
Explanation:
1)Civil money penalties may be imposed for knowingly
filing claims for services that were not provided as
ASIPP
118
claimed. See 42 U.S.C. § 1328a-7a(a)(1).
2) Billing a service as “incident to”a physician’s service if
the physician falsely represented to the patient that he/she
was certified by a medical specialty board may result in the
imposition of civil money penalties. See 42 U.S.C. §
1328a-7a(a)(1).
3)Routinely waiving co-payments for Medicare recipients
may result in a civil money penalty under 42 U.S.C. §
1320a-7a(i)(6)(A).
4)Being convicted of a misdemeanor relating to the
prescription of controlled substances can lead to exclusion
from federal health care programs, but is not a basis for
imposing a civil money penalty.
claim
Claim for payment
Any portion of which will be paid by the government
Claimant knows or should know that the claim was false
It is a felony
485. Answer: A (1,2, & 3)
Explanation:
Three steps to compliance
Source: Health Care Fraud and Abuse: Practical
Perspectives, Linda A. Baumann ed. (American Bar
Association 2002).
Source: Erin Brisbay McMahon, JD
The new rule on the security of electronic patient records
boils down to three sets of standards that practices will
need to implement step-by-step.
481. Answer: E (All)
Explanation:
The federal government lists all of the above as problems
that can result from referrals for remuneration.
1. Administrative safeguards
Assess computer systems
Train staff on procedures
Prepare for aftermath of hackers or catastrophic events
Develop contracts for business associates
Source:65 Fed. Reg. at 59940.
Source: Erin Brisbay McMahon, JD
482. Answer: B (1 & 3)
Explanation:
Eligible Investors
Physicians in position to use facility
Group practices composed exclusively of such physicians
Others who are not –
Employed by the facility or any investor
In position to provide services to facility
In position to make or influence referrals
Source: Ron Wiser, JD
483. Answer: B (1 & 3)
Explanation:
Federal Health Care Offense Under HIPAA
* Offense of “health care fraud” added to criminal statute
* Any health care program - public or private, affecting
commerce
* Fines ($10,000), forfeiture, 10 years imprisonment
484. Answer: B (1 & 3)
Explanation:
FALSE CLAIM:
“Knowingly”
Failure to make inquiry regarding the accuracy of the
ASIPP
2. Physical safeguard
Set procedures for workstation use and security
Set procedures for electronic media reuse and disposal
3. Technical Safeguard
Control staff computer log-in and log-off.
Monitor access of patient information
Set up computers to authenticate users.
4. There is no financial viability safeguard
Source: Laxmaiah Manchikanti, MD
486. Answer: C (2 & 4)
Explanation:
HIPAA COMPLIANCE - Administrative Simplification
1. Reduces costs associated with administrative and claims
related transactions
- Over $30 billion in savings over 10 years
2. Establishes a national uniform standards for 8 electronic
transactions, and claims attachments
3. Established unique provider identifiers
4. Establishes protections for the privacy and security of
individual health information
Implementation costs
- Over $500 billion over 10 years
Source: Laxmaiah Manchikanti, MD
487. Answer: A (1,2, & 3)
Explanation:
ASC Safe Harbors
Immunity from anti-kickback prosecution
119
4 Categories: Surgeon-Owned, Single Specialty, MultiSpecialty and Hospital/Physician
Protection limited to physician investors who either –
Use facility on regular basis, or
Practice in same specialty (so cross referrals less likely)
Must meet all requirements to qualify
Voluntary
Non-compliance does not mean illegal
Source: Ron Wisor, JD
488. Answer: D (4 Only)
Explanation:
1. Stark Law prohibits a physician from making referrals
for certain designated health services to entities where (a)
the physician has a direct or indirect financial relationship
and (b) the service is billed to Medicare or Medicaid.
2. Physicians who personally perform the DHS which they
order for their patients are covered by an exception to
Stark Law.
3. Investments in publicly traded companies and mutual
funds are protected as an exception to Stark Law.
4. Stark referral rules do not prohibit physician referrals
to hospitals.
Sources:
42 U.S.C. 1395nn; 42 CFR 411.355, .357.
Source: Erin Brisbay McMahon, JD, Sep 2005
489. Answer: E (All)
Explanation:
RISK AREAS
* Billing for items or services not actually rendered
* Providing medically unnecessary Services
* Upcoding
* DRG Creep
* Unbundling
* Double Billing
* Duplicate Billing
* Teaching physicians and residents
* Hospital Incentives
* Joint Ventures
* Physician Self-referrals
POLICIES AND PROCEDURES
* Documentation
- For claims and billing proper and timely
documentation of services
- Claims submitted only when documentation is
maintained and available for audit
- Legible
- Appropriately organized
- Diagnosis and procedures be based on documentation
which is available to the coding staff
* Compensation
- No incentive to upcode claims
490. Answer: B (1 & 3)
Explanation:
Modifiers
Means to indicate that an encounter or procedure has been
altered by some specific circumstance, but not changed in
its basic definition or code.
Common Modifiers
-21 prolonged E & M services
-22 unusual procedure services
-24 unrelated E & M by same physician in post-op period
-25 separate E & M on same day of procedure
-50 bilateral procedure
-51 multiple procedure
-52 reduced services
-53 discontinued procedure
-59 distinct procedural service
-76 repeat procedure by same physician
Source: Laxmaiah Manchikanti, MD
491. Answer: A (1,2, & 3)
Explanation:
Permitted Disclosures - Without the Individual’s
Permission
* Uses and Disclosures Required by Law
* Public Health Activities
* Violence or Elder Abuse
* Health Oversight Activities and Government Benefit
* Judicial and Administrative Proceedings
* Law Enforcement
* Disclosure to Coroners and Medical Examiners
* Organ procurement organizations
* Research purposes if IRB makes certain determinations
* Specialized government functions (military)
* Workers’ compensation
- Only to extent required by state law
492. Answer: D (4 Only)
Explanation:
1. It is illegal for a hospital to knowingly make payments
directly or indirectly to a physician as an inducement to
reduce or limit services provided to Medicare or Medicaid
beneficiaries who are under the physician’s direct care.
Hospitals that make (and physicians who receive) such
payments are liable for CMPs of up to $2,000 per patient
covered by the payments.
2. Some clinical-trial risk areas to avoid are as follows:
Institutions billing Medicare for services that are already
paid by the sponsor of a clinical trial are committing fraud
by double billing. Trial patients should be separated from
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the regular patient mix.
Medicare does not pay for most procedures using
experimental drugs or devices.
The physicians who run these studies or principal
investigator must supervise the work being done.
Falsifying results has clear quality-of-care implications for
patients. Prosecutors also might argue that providers
must return payments for procedures performed using
devices that were approved due to falsified trial results.
3. Both the Stark and anti-kickback laws sometimes allow
hospitals in health care professional shortage areas to,
under certain circumstances, persuade doctors to their
service areas by offering inducements that might normally
be viewed as illegal.
Under Stark, hospitals may persuade a physician to move
to the hospital’s area if certain specific conditions are met.
The Anti-Kickback Statute also has a corresponding
physician recruitment exception with many detailed
requirements that must be satisfied.
4. Patient enrollment fees: These might be paid to doctors
for enrolling patients in bona fide clinical trials. If such
fees are not fully disclosed, they could be prosecuted as
fraud.
493. Answer: A (1,2, & 3)
Explanation:
Social/Economic Climate
- Fraud and Abuse Headlines
- Runaway Healthcare Costs
- Failed Healthcare Reform
- Aging Baby Boomers
- Balanced Budget
Operation Restore Trust
- In 1995 the DHHS OIG, DOJ and others began a
demonstration project in 5 states to fight fraud and abuse.
- Result - for every $1 spent - $23 recovered
Laws - Old and New
- Enforcement Weapons
Source: Alan Reider, JD
494. Answer: E (All)
Explanation:
Source: 45 CFR 164.308.
Source: Erin Brisbay McMahon, JD
495. Answer: A (1,2, & 3)
Explanation:
1) The medical records required by the regulation are
required to be maintained by the employer for at least the
duration of employment plus 30 years.
2) Employers are required to keep records for each
employee with occupational exposure that must include
their name, social security number, hepatitis B vaccination
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status, post-exposure examination, testing and follow-up
procedures and healthcare opinions required by the
regulation and such records shall be kept for the duration
of the employee’s employment plus 3 years.
3) The training records required by the regulation are
required to be maintained by the employer for 3 years f
rom the date on which the training occurred.
4) The training required by the regulations require that
records include the dates of training, contents/summary of
the training sessions, name & qualification of instructors,
and name & title of attendees and such records shall be
keptfor 30 years from the date on which the training
occurred.
Source: 29 CFR 1910.1030(h).
Source: Erin Brisbay McMahon, JD, Sep 2005
496. Answer: C (2 & 4)
Explanation:
1. Carriers and fiscal intermediaries are supposed to refer
cases immediately to OIG’s Office of Investigations when
they receive fraud or abuse allegations.
Carriers look for the following “signs” or fraud and abuse:
- Indications of contractor employee fraud.
- Cases involving an informant who is an employee or
former employee of the suspect provider.
- Involvement of providers with prior convictions for
defrauding Medicare or who are currently the subject of
an OIG fraud investigation.
- Situations involving the subjects of current program
investigations.
- Multiple carriers (intermediaries) involved with any
one provider.
- Cases with or likely to get widespread publicity or
involving sensitive issues.
- Allegations or kickbacks or bribes or a crime by a
federal employee.
- Indications that organized crime may be involved.
- Indications of fraud by a third-party insurer that is
primary to Medicare.
2. Carriers and fiscal intermediaries are required under
Medicare regulations to give advance notice to a provider
about proposed suspension, the effective date, items or
services affected by the suspension, the duration of the
suspension and the carrier’s rationale for taking the action.
However, there is an exception to the notice rule. Carriers
and intermediaries can suspend payment without first
giving notice if they have reliable evidence of fraud, but
they still have to tell the provider what action they took
and why, and give the provider the chance to submit a
statement as to why suspension is not warranted.
Medicare regulations authorize carriers and
intermediaries to suspend Medicare payments when they
find reliable evidence of fraud or willful
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misrepresentation.
3. Carriers and fiscal intermediaries do not have the
authority to exclude providers. Instead, carriers and fiscal
intermediaries recommend sanctions to the HHS Office of
Inspector General. Carrier and fiscal intermediary fraud
units must review and evaluate abuse cases to see if they
warrant exclusion action.
- When OIG receives a sanction recommendation from a
carrier, it is reviewed by OIG medical and legal staff to
decide whether the sanction is supportable.
Then, OIG develops a proposal and sends it to the
provider, advising it of the recommended sanction period,
the basis for the finding that excessive or poor quality care
was provided and the provider’s appeal rights.
- The provider is also given a copy of all the material used
to make a decision.
- The provider has 30 days from the date on the proposal
letter to submit:
- Documentary evidence and written argument against
the proposed action, or
- A written request to present evidence or argument
orally to an OIG official.
497. Answer: A (1,2, & 3)
Explanation:
1. OIG can exclude individuals or companies if they have
been convicted of the following violations:
A misdemeanor for fraud, theft embezzlement, breach of
fiduciary responsibility or other financial misconduct
related to either:
Health care items or services
Act or omissions under any health care program financed
by federal, state or local governments other than Medicare
or Medicaid (which are covered under mandatory
exclusions).
The acts had a significant adverse physical or mental
impact on patients or others.
The court sentence included prison time.
The convicted individual had a prior record of criminal,
civil or administrative actions.
Mitigating Factors:
The individual or company was convicted of three or fewer
misdemeanors, and the loss to Medicare or Medicaid was
less than $1,500.
The court found that the individual had a mental, physical
or emotional condition that reduced his or her culpability.
Cooperation by the individual or company with federal or
state officials resulted in others being convicted or
excluded from Medicare, Medicaid or any other federal
health care program or the imposition of a civil money
penalty or assessment against anyone.
Alternative sources of the type of health care items or
services provided by the individual or company aren’t
available.
2. OIG can exclude individuals or companies if they are
convicted of a criminal offense related to the unlawful
manufacture, distribution, prescription or dispensing of a
controlled substance.
Length of exclusion: Three years, unless there are
aggravating or mitigating factors, in which case the
exclusion period may be increased or decreased.
Aggravating factors:
The acts were committed over a period of one year or
more.
The acts had a significant adverse physical or mental
impact on patients or others.
The court sentence included prison time.
The convicted individual had a prior record of criminal,
civil or administrative actions.
Mitigating factors:
A criminal offense for fraud, theft, embezzlement, breach
of fiduciary responsibility or other financial misconduct
related to an act or omission in any non-health care
program financed by federal, state or local governments.
Length of exclusion: Three years, unless there are
aggravating or mitigating factors, in which case the
exclusion period may be increased or decreased.
Aggravating Factors:
The acts caused a loss of $1,500 or more to the
government or other entities, or had a “significant
financial impact” to patients or others.
The acts were committed over a period of one year or
more.
Cooperation by the individual or company with federal or
state officials resulted in others being convicted or
excluded from Medicare, Medicaid or any other federal
health care program or the imposition of a civil money
penalty or assessment against anyone.
Alternative sources of the type of health care items or
services provided by the individual or company aren’t
available.
3. OIG can exclude any individual or company that fails to
supply Medicare or Medicaid with payment information
necessary to determine whether the payments were due, or
that refuses to permit examination or duplication or
records needed to verify payments.
Length of exclusion: OIG must consider the following
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factors in determining the exclusion period:
Number of times information was provided
Circumstances under which the information was provided
Amount of payment at issue
Individual or company’s prior record of criminal, civil or
administrative sanction (the lack of a record is considered
neutral).
Availability of alternative sources of the type of health care
items or services provided by the individual or company.
4. Civil actions for false claims or whistleblower lawsuits
– private citizens filing lawsuits on behalf of the
government and receiving a portion of any money
collected are authorized by the False Claims Act.
Whistleblower lawsuits are more formally known as qui
tam suits, the Latin name derived from an expression
meaning “who as well for the king as for himself sues in
this matters.
Whistleblower suits can be filed by virtually anyone. The
whistleblower doesn’t even have to be an employee, but
could literally be “the guy on the street. While
whistleblowers can file suits by themselves, most go
through attorneys, given the various forms and procedures
that must be followed. The suits are filed with the U.S.
District Court in whatever region they are located.
Whistleblower suits in themselves are not a cause for
exclusion.
498. Answer: A (1,2, & 3)
Explanation:
1. A local nursing home, hires a consulting firm to put
together a defense in an elder abuse case. Yes, an attorney
engaged for this purpose would be considered a business
associate and an agreement is required.
2. Ambulatory Surgery Centers, Inc. discloses PHI to a
health plan for payment purposes. No, this disclosure is
for the benefit of the health plan, not the covered entity,
and therefore a business associate agreement is not
required.
3. A medical malpractice insurer is given PHI by an
insured to provide a malpractice risk assessment of a case.
Yes, an attorney engaged for this purpose would be
considered a business associate and an agreement is
required.
4. Entities described in 1 & 3 are considered business
associates.
Source: Laxmaiah Manchikanti, MD
499. Answer: A (1,2, & 3)
Explanation:
An exception to the Stark Law permits certain time-based
or unit-of-service-based payments, even when the
physician receiving the payment has generated the
payment through a designated health service (DHS)
referral, as long as the individual payment for each unit
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reflects FMV and does not change during the course of the
agreement based on the level of referrals or other business
generated.
In order for an arrangement to satisfy the fair market value
compensation exception to the Stark Law, the following
conditions must be met:
The agreement must be in writing, signed by the parties
and cover only identifiable items or services. The items or
services must be specified, and the agreement must cover
all items and services to be provided by the physician or
family member to the entity, or refer to any other
agreement for items or services between the parties.
The agreement must specify the time frame for the
arrangement, which can be for any period and contain a
termination clause. The parties, however can enter into
only one arrangement for the same items or services
during the course of a year. An arrangement for more than
one year can be renewed any number of times if the terms
and compensation for the same items or services don’t
change.The agreement must specify the compensation.
The compensation or method for determining it must be
set in advance, must be consistent with fair market value,
and not determined in a manner that takes into account
the volumeor value of referrals or other business
generated by the referring physician.
The agreement must involve a transaction that is
commercially reasonable and furthers the legitimate
business purposes of the parties.
The agreement must not violate the Anti-Kickback statute
or any federal or state law or regulation Governing billing
or claims submission
The services to be performed under the arrangement must
not involve the counselling or promotion of a business
arrangement or other activity that violates a state or
federal law.
500. Answer: E (All)
Explanation:
Providers may use or disclose a patient’s PHI without the
patient’s authorization to treat the patient even though the
patient is not having an emergency, to get payment from
the patient’s insurance; or to perform certain
administrative, financial, legal, and quality improvement
activities.
To avoid interfering with an individual’s access to quality
health care or the efficient payment for such health care,
thePrivacy Rule permits a covered entity to use and
disclose protected health information, with certain limits
and protections, for treatment, payment, and health care
operations activities.” Most administrative, financial,
legal, and quality improvement activities are considered to
be health care operations
Treatment’ generally means the provision, coordination, or
management of health care and related services among
health care providers or by a health care provider with a
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third party, consultation between health care providers
regarding a patient, or the referral of a patient from one
health care provider to another.
Health care operations’ including administrative, financial,
legal, and quality improvement activities of a covered
entity that are necessary to run its business and to support
the core functions of treatment and payment
Covered Entities may use or disclose PHI without patient
authorization if the covered entity has first obtained
waiver from an IRB as long as the waiver complies with the
specifications contained in the Privacy Rule
501. Answer: C (2 & 4)
Explanation:
1. Stark applies only to physician referrals, not to referrals
by hospitals.
2. Assuming that Designated Health Services (DHS)
patients will be referred, the “lease” exception would need
to be met. This exception requires payments not to vary
based upon referrals. However, under this example,
payments would vary based on referrals.
3. It might implicate the kickback law, but it would not
violate Stark so long as the requirements of the personal
services exception are met Payments are FMV Not based
on referrals
Written contract is for at least one year Bonafide services a
re provided
4. The exceptions to the Stark Law specifically require that
payments not vary based upon referrals.
502. Answer: E (All)
Source: Erin Brisbay McMahon, JD
503. Answer: B (1 & 3)
Explanation:
There is an exception tothe Stark Law for compensation in
the form of items or services (not including cash or cash
equivalents) from a hospital to a member of its medical
staff when the item or service is used on the hospital’s
campus, and all of the following conditions are met.
The compensation is provided to all members of the
medical staff practicing in the same specialty without
regard to the volume or value of referrals or other
business generated between the parties.
Except with respect to identification of medical staff on a
hospital Web site or in hospital advertising, the
compensation is provided only during periods when the
medical staff members are making rounds or performing
other duties that benefit the hospital or its patients.
The compensation is provided by the hospital and used by
the medical staff members only on the hospital’s
campus.The compensation is reasonably related to the
provision of, or designated to facilitate directly or
indirectly the delivery of, medical services at the hospital.
The compensation is of low value (that is, less than $25)
with respect to each occurrence of the benefit (for
example,each meal given to a physician while he or she
is serving patients who are hospitalized must be of low
value).
The compensation is not determined in any matter that
takes into account the volume or value of referrals or other
business generated between the parties.
The compensation arrangement does not violate the Antikickback Statute or any federal or state law or regulation
governing billing or claims submission.
504. Answer: A (1,2, & 3)
Explanation:
At a minimum, comprehensive compliance programs
should include the following seven elements:
¨Written standards of conduct, policies and procedures
that promote the company’s commitment to compliance
(for example, by including adherence to the compliance
program as an element in evaluating managers and
employees) and that address such specific areas of
potential fraud as the claims submission process, code
gaming and financial relationships with providers.
¨Designating a compliance officer and other appropriate
high-level corporate structures (for example, a corporate
compliance committee that operates and monitors the
compliance program and reports directly to the CEO and
the governing body. (Important: Structure the compliance
program so it accomplishes the key functions of a
corporate compliance officer and a corporate compliance
committee).
¨Compliance training and education program for all
affected employees. They should be detailed and
comprehensive, covering specific procedures, as well as
the general areas of compliance.
¨Communication. Maintaining a hotline to receive
complaints and the adoption of procedures to protect the
anonymity of complainants and protect callers from
retaliation.
¨Auditing and monitoring or other risk-evaluation
techniques to monitor compliance and assist in the
reduction of identified problem areas.
¨Disciplinary procedures and development of policies
addressing the non-employment of sanctioned individuals.
¨Corrective actions to enforce appropriate disciplinary
action against employees who violate laws, regulations,
guidelines or company policies.
The elements are a guide that can be tailored to fit the
needs and financial realities of a particular billing
company, large or small, regardless of the type of services
offered.
505. Answer: B (1 & 3)
Source: Laxmaiah Manchikanti, MD
506. Answer: C (2 & 4)
Explanation:
A GAO Audit reported that in the U.S. approximately 10%
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of every Health Care dollar is lost to fraud annually.
10% = $100 Billion of one Trillion or 100,000
Million
2004 - 10%= $179.3 Billion of 1.7934 of Trillion or
1,793.4 Million
2010 - 10%=$263.74 Billion of $2.6374 Trillion or
263,740 Million
Fraud and Abuse cases
Public 60%
Private 40%
Source: Laxmaiah Manchikanti, MD
507. Answer: A (1,2, & 3)
Explanation:
Bundling Or Disbundling
Combining multiple codes or charges into one
comprehensive charge, when separate codes or charges are
justifiable.
Vs
Lysis of adhesions
Facet radiofrequency
Neurolytic blocks
Source: Laxmaiah Manchikanti, MD
509. Answer: E (All)
Explanation:
1. Civil monetary, assessed and exclusion.
2. Refunds. If a provider collects on a bill for a service that
was in violation of Stark, the provider must refund the
money within 60 days.
3. The physician may be excluded from the Medicare and
Medicaid programs.
4. Any provider presenting a claim or bill for a service that
the provider knows or should know is a violation or for
which a refund has not been made can be hit with a civil
monetary penalty of up to $15,000 for each service
claimed.
Unbundling
Charging multiple CPT codes when one code generally
describes the service.
Charging multiple procedures with the primary service
that are generally included in primary service.
Source: Laxmaiah Manchikanti, MD
508. Answer: A (1,2, & 3)
Explanation:
Global Period
In addition, an assessment of up to three times the amount
of money may be required.
Other:
Violators of the Stark Law are subject to one or more of
the following sanctions:
Denial of payment. Medicare will deny payment for
services rendered in violation of Stark.
Civil monetary penalty and exclusion for circumvention
schemes.
Major day prior, day of, and 90 days after
Minor day of or day of and ten days after
Major Procedures
DISC Decompression
Nucleoplasty®
DekompressorTM
IDET®
Spinal endoscopy ??
Implantables
Minor Procedures
One-day global period
Spinal puncture
Epidurals
Facet blocks
Intercostal blocks
Discography
Sympathetic blocks
Ten-day global period
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This provision is intended to crack down on physicians
who enter into arrangements or schemes (such as crossreferral arrangements) that they know or should know are
designed to get around the Stark prohibition.
Civil monetary penalty for failure to report information.
Any provider who fails to report required information to
Medicare or Medicaid is liable under the Stark law for
civil monetary penalty of up to $10,000 for each day the
information goes unreported.
510. Answer: E (All)
Explanation:
The OIG lists all of the above as risk areas for physician
practices with respect to Medicare and Medicaid Fraud
and Abuse.
Source:65 Fed. Reg. at 59,438.
Source: Erin Brisbay McMahon, JD
511. Answer: E (All)
Explanation:
Many common business arrangements have the potential
to violate state or federal anti-kickback laws. Physician
125
practices should not have any arrangement with hospitals,
ambulatory surgery centers, durable medical equipment
suppliers, diagnostic imaging centers, clinical
laboratories, billing companies, or others that provide any
form of payment or remuneration for referrals of patients
for services that may be covered by a federally-funded
health care program, unless the arrangement falls squarely
and appropriately within one of the anti-kickback law safe
harbors.
Source: 42 CFR 1001.952 (1991).
Source: Erin Brisbay McMahon, JD, Sep 2005
512. Answer: D (4 Only)
Explanation:
If a provider has less than ten full time employees, it can
continue submitting claims on paper. However, all
physician practices that conduct any of the electronic
transactions covered by HIPAA (including filing claims
electronically with a third-party payor) must comply with
HIPAA Privacy Rule.
2)Disclosures for treatment, payment, and health care
operations are not required to be tracked for accounting of
disclosures purposes. 45 CFR 164.528.
3)Sanctions have to be imposed under both the Privacy
and the Security Rules if an employee is found to have
violated either rule, no matter how small the violation
Source: Erin Brisbay McMahon, JD
513. Answer: B (1 & 3)
Explanation:
Effective Compliance Program
Seven Minimum Elements
1. Standards of conduct and policies and procedures
2. Chief Compliance Officer
3. Regular effective education and training
4. Process to receive complaints and protect them
5. Disciplinary guidelines
6. Periodic Monitoring and auditing
7. Procedures to detect, respond to, and correct problems
514. Answer: B (1 & 3)
Explanation:
Bilateral Codes
Transforaminal
Facet Joint Blocks
Facet Neurolysis
SI Joint Injection
Not Bilateral:
Intercostal Nerve Blocks
Sympathetic Blocks
Occipital Nerve Blocks, etc
Source: Laxmaiah Manchikanti, MD
515. Answer: A (1,2, & 3)
Explanation:
Indications of Non-Compliance
1. Claim problems
- paid slowly
- frequent problems
- problem claims unresolved
- cash flow problems
2. Staff problems
- rapid turnover
- staff takes work home
- poor morale
- disgruntled staff
- staff not loyal
- staff disrespectful
- staff questioning about charges
3. Accounting issues
- cash flow
- keep borrowing
- no real accounting
4. 1% Error Rate is Acceptable
-You are under scrutiny
- by Medicare, Medicaid, Tricare
- by W/C and personal injury insurances
- by third party payer
- your own staff
- your partners or superiors
516. Answer: E (All)
Explanation:
All four of the above are requirements for the rental of
space or equipment exception under the Stark law.
Source: 42 USC §1395nn(e)
Source: Erin Brisbay McMahon, JD
517. Answer: E (All)
518. Answer: C (2 & 4)
Explanation:
1)Workstation use is a required physical safeguard under
45 CFR 164.310.
2)This is a true statement. See 45 CFR 164.310.
3)Audit controls are required technically safeguard under
the HIPAA Security Rule. See 45 CFR 164.312.
4)This is a true statement under 45 CFR 164.312.
Source: 45 CFR 164.310-.312
Source: Erin Brisbay McMahon, JD
519. Answer: E (All)
Source: James A. Mirazita, MD, Sep 2005
520. Answer: A (1, 2 & 3)
Explanation:
A sanction policy is necessary in order for employees to
take the compliance plan seriously.
Source: 65 Fed. Reg. at 59,444
Source: Erin Brisbay McMahon, JD
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