CPC Compliance and Regulatory Rules 5 — Questions and Answers
Question 1: A coder bills an established patient office visit and a separate E/M code for a preventive medicine service performed on the same day by the same physician. Which modifier allows separate billing of both services?
- Modifier 25 (Correct answer)
- Modifier 59
- Modifier 57
- Modifier 95
Correct answer: Modifier 25
Modifier 25 is appended to a significant, separately identifiable E/M service performed on the same day as a preventive medicine service.
Question 2: The Deficit Reduction Act of 2005 requires states to enact false claims laws in order to receive an enhanced Medicaid reimbursement. What percentage increase does a state receive?
- 5%
- 10% (Correct answer)
- 15%
- 20%
Correct answer: 10%
States that enact qualifying false claims laws receive a 10% increase in their share of any Medicaid fraud recoveries.
Question 3: Which Medicare administrative contractor (MAC) function involves reviewing claims before payment is made to determine if coverage criteria are met?
- Post-payment audit
- Prepayment review (Correct answer)
- Retrospective review
- Probe and educate
Correct answer: Prepayment review
Prepayment review allows MACs to examine claims before issuing payment to ensure all coverage criteria are met.
Question 4: A physician documents a 30-minute E/M visit but the coder bills a 60-minute code based on typical visit length for that diagnosis. This is an example of:
- Appropriate estimation
- Upcoding based on diagnosis (Correct answer)
- Medical necessity documentation
- Correct time-based billing
Correct answer: Upcoding based on diagnosis
Billing a higher-level code based on assumptions rather than actual documented time or medical decision-making constitutes upcoding.
Question 5: Which of the following actions would be appropriate when a compliance audit reveals a pattern of overcoding E/M services?
- Continue current practices while planning future training
- Conduct education, perform a corrective action plan, and consider a voluntary repayment (Correct answer)
- Immediately fire all coders involved
- Ignore findings if the error rate is below 10%
Correct answer: Conduct education, perform a corrective action plan, and consider a voluntary repayment
Appropriate responses to audit findings include education, corrective action plans, and voluntary repayment of identified overpayments.
Question 6: The Physician Payments Sunshine Act (Open Payments Program) requires manufacturers to report payments and transfers of value to physicians. Which agency collects and publishes this data?
- OIG of HHS
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- Department of Justice
- State medical boards
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the Open Payments Program and publicly posts the data reported by applicable manufacturers and group purchasing organizations.
Question 7: When a provider submits a claim to Medicare for services rendered to a patient who has other primary insurance, without billing that primary payer first, this is called:
- Coordination of benefits violation (Correct answer)
- Third-party liability error
- Secondary payer fraud
- Cost-sharing avoidance
Correct answer: Coordination of benefits violation
Failing to bill the primary payer first when Medicare is secondary violates Medicare Secondary Payer (MSP) rules and coordination of benefits requirements.
CPC Compliance and Regulatory Rules 5
A coder bills an established patient office visit and a separate E/M code for a preventive medicine service performed on the same day by the same physician.
Which modifier allows separate billing of both services?