OST-249: CPC Exam Prep - Chapter 5
– Compliance Questions and Answers.
Patient arrived at the outpatient facility earlier in the morning and a localization wire was
placed by the radiologist under mammographic guidance in the x-ray suite. The surgeon
infiltrated around the wire and an incision was made between the left areola and the wire. A
generous excision was made at least 2 cm around the wire, removing the lesion in question in
toto. The margins were marked and specimen sent to pathology. The following codes were
coded/billed by the surgeon's office: 19125-LT, 19281-LT, and 76098. The surgeon's office
received notification from Medicare indicating they are under investigation for inappropriate
billing for the services. Determine what inappropriate billing practices have been coded/billed
by the surgeon's practice. - Answer Surgeon may not submit claims for radiological services
not performed.
(The surgeon did not perform the radiological services performed earlier in the day and
therefore may not code/bill for the radiological services.) WRONG
Common name for qui tam action is - Answer whistleblower
(Qui Tam legislation is frequently referred to as the whistleblower, named for the individual who
"blows the whistle" on the provider or reports them to federal authorities.)
Abuse is defined as - Answer the overuse or excessive use of medical and health services.
(The overuse or excessive use of medical and health services is one example of abuse. The
remaining choices are all examples of fraud.)
Modifier -RT should be assigned to denote - Answer right anatomical site.
(The modifier "RT" denotes the right anatomical site. The right thumb, right index finger, and
right toe are designated with specific modifiers "F5," "F6," and "T5," respectively.)
Which of the following is NOT part of a physician compliance plan? - Answer Develop practice
E/M guidelines
(While it is recommended the practices develop guidelines for E/M services, it is not part of the
requirements for a compliance program.)
When E/M services for unrelated services are billed within a global period, what modifier
should be appended? - Answer modifier -24
(Modifier -24 denotes an E/M service performed during a global period that is unrelated.
Modifier -57 denotes decision for surgery, while modifier -25 is assigned to indicate a
"significantly separately identifiable service." The modifier -59 is assigned to indicate separate
and distinct services. Therefore, modifier -24 is appropriate in this instance.)
, NCCI edits refer to - Answer edits that indicate whether procedures may be separately
reported in conjunction with other procedures coded.
(Edits that indicate whether procedures may be separately reported in conjunction with other
procedures coded.)
What modifier would be appended to CPT code 28505 open treatment of great toe fracture to
denote the right great toe? - Answer -T5
(T5 would be appropriate because it designates the great toe on the right foot per CPT.)
Which of the following most certainly would describe upcoding? - Answer billing for a
procedure that is more extensive or intensive than what was actually performed
(According to NCCI guidelines, a less extensive procedure performed in the same anatomical
area is considered bundled in the more extensive procedure.)
WRONG
What is one of the main reasons that providers are investigated for fraud and abuse? - Answer
Patient complaints
(Patient complaints are one of the main reasons providers are investigated for fraud and abuse.
The other main reasons providers are investigated are employee complaints and statistical
analysis of claims submissions.)
Filing claims for services deemed not medically necessary is an example of - Answer abuse
(Underbilling and overbilling are examples of billing excessively or billing fewer codes than are
appropriate.)
In a teaching setting, what documentation must be present for resident services to be
coded/billed for an initial hospital admission by the teaching physician? - Answer personal
notation entered by teaching/attending physician documenting their participation and presence
during the encounter
(In addition to the documentation of the resident, the teaching physician must document their
participation in the history, exam, and/or MDM components of the service. Documentation by
the resident is also required; however, without the documentation by the teaching physician,
the service may not be billed.) WRONG
A provider has set a standing office policy that states EKGs should be ordered and performed on
all patients over the age of 35 regardless of their medical condition or complaint. What would
be the common denial for this scenario? - Answer Lack of medical necessity
(Medical necessity must be met for all services performed. Standing orders will often result in
denials for services that are not considered medically necessary.)
– Compliance Questions and Answers.
Patient arrived at the outpatient facility earlier in the morning and a localization wire was
placed by the radiologist under mammographic guidance in the x-ray suite. The surgeon
infiltrated around the wire and an incision was made between the left areola and the wire. A
generous excision was made at least 2 cm around the wire, removing the lesion in question in
toto. The margins were marked and specimen sent to pathology. The following codes were
coded/billed by the surgeon's office: 19125-LT, 19281-LT, and 76098. The surgeon's office
received notification from Medicare indicating they are under investigation for inappropriate
billing for the services. Determine what inappropriate billing practices have been coded/billed
by the surgeon's practice. - Answer Surgeon may not submit claims for radiological services
not performed.
(The surgeon did not perform the radiological services performed earlier in the day and
therefore may not code/bill for the radiological services.) WRONG
Common name for qui tam action is - Answer whistleblower
(Qui Tam legislation is frequently referred to as the whistleblower, named for the individual who
"blows the whistle" on the provider or reports them to federal authorities.)
Abuse is defined as - Answer the overuse or excessive use of medical and health services.
(The overuse or excessive use of medical and health services is one example of abuse. The
remaining choices are all examples of fraud.)
Modifier -RT should be assigned to denote - Answer right anatomical site.
(The modifier "RT" denotes the right anatomical site. The right thumb, right index finger, and
right toe are designated with specific modifiers "F5," "F6," and "T5," respectively.)
Which of the following is NOT part of a physician compliance plan? - Answer Develop practice
E/M guidelines
(While it is recommended the practices develop guidelines for E/M services, it is not part of the
requirements for a compliance program.)
When E/M services for unrelated services are billed within a global period, what modifier
should be appended? - Answer modifier -24
(Modifier -24 denotes an E/M service performed during a global period that is unrelated.
Modifier -57 denotes decision for surgery, while modifier -25 is assigned to indicate a
"significantly separately identifiable service." The modifier -59 is assigned to indicate separate
and distinct services. Therefore, modifier -24 is appropriate in this instance.)
, NCCI edits refer to - Answer edits that indicate whether procedures may be separately
reported in conjunction with other procedures coded.
(Edits that indicate whether procedures may be separately reported in conjunction with other
procedures coded.)
What modifier would be appended to CPT code 28505 open treatment of great toe fracture to
denote the right great toe? - Answer -T5
(T5 would be appropriate because it designates the great toe on the right foot per CPT.)
Which of the following most certainly would describe upcoding? - Answer billing for a
procedure that is more extensive or intensive than what was actually performed
(According to NCCI guidelines, a less extensive procedure performed in the same anatomical
area is considered bundled in the more extensive procedure.)
WRONG
What is one of the main reasons that providers are investigated for fraud and abuse? - Answer
Patient complaints
(Patient complaints are one of the main reasons providers are investigated for fraud and abuse.
The other main reasons providers are investigated are employee complaints and statistical
analysis of claims submissions.)
Filing claims for services deemed not medically necessary is an example of - Answer abuse
(Underbilling and overbilling are examples of billing excessively or billing fewer codes than are
appropriate.)
In a teaching setting, what documentation must be present for resident services to be
coded/billed for an initial hospital admission by the teaching physician? - Answer personal
notation entered by teaching/attending physician documenting their participation and presence
during the encounter
(In addition to the documentation of the resident, the teaching physician must document their
participation in the history, exam, and/or MDM components of the service. Documentation by
the resident is also required; however, without the documentation by the teaching physician,
the service may not be billed.) WRONG
A provider has set a standing office policy that states EKGs should be ordered and performed on
all patients over the age of 35 regardless of their medical condition or complaint. What would
be the common denial for this scenario? - Answer Lack of medical necessity
(Medical necessity must be met for all services performed. Standing orders will often result in
denials for services that are not considered medically necessary.)
