Practice Enhancement – Post Test

Which statement is false regarding a DRG? A DRG …

a. Is a system which classifies hospital cases according to certain “groups” or diagnoses
b. Can be modified by noting comorbid conditions and comorbidities
c. Is a payment category that is used for the purpose of reimbursing hospitals for a fixed fee regardless of the actual costs incurred for a patient’s care
d. Is applied on inpatient and outpatient services

2. The Medicare Part B program

a. Covers physician payment and other ambulatory services
b. Is free to persons who paid enough in payroll taxes over time
c. Is the program where Medicare Advantage is defined
d. Has an out-of-pocket maximum Medicare patients will pay

3. Prescription drug cost is covered under which Medicare program?

a. Part A and B
b. Part C
c. Part D
d. Drugs are not covered by any Medicare plan

4. To have success in the business of hospital-based medicine, one must

a. Manage the DRG with the right diagnoses, right severity of illness
b. Manage the LOS, striving for clinically correct management and a safe discharge
c. Manage the cost of care ordering the right test at the right time for the right situation
d. All the above

5. Time is now one mode of billing a patient for care. The following tasks can be counted for the total time performed by the billing provider EXCEPT:

a. Reviewing old notes and labs in preparation for the visit
b. Dictation of the note done on the date of the encounter
c. Calling the son at the patient’s request to update them on his care
d. The time it takes to finish the note from yesterday after labs came back this morning

6. Which of the following does not qualify for drug therapy requiring intensive monitoring for toxicity?

a. Ordering a basic metabolic panel for a hypertensive patient on an ACE/HCTZ combination medication at the next follow-up visit in three months
b. Checking a PT/INR on a patient with epistaxis and bruising who is on Warfarin and has not been seen in 5 weeks
c. Drawing levels of phenytoin in a 69-year-old with new mental status changes
d. Drawing a basic metabolic panel on a patient with stage II renal disease 2 weeks after starting an ACE/diuretic to manage his elevated BP

7. A patient comes in for a blood pressure follow-up. Your nurse notes that the patient has seen a cardiologist since the last encounter with you and she takes it upon herself to reach out and get records. This process takes her 16 minutes in additional work to get the patient ready. You can

a. Count these 16 minutes in the time calculation for your visit today
b. Add this amount of prolonged service time to your 99213 bill with the add-on code G2212
c. Add the G2211 add-on code for “cardiology records reviewed” being documented by the nurse in the history for this added complexity to the visit
d. Bill nothing extra for the nurses work to prep you for this visit

8. A 76-year-old Medicare Advantage patient is seen for diabetes and HTN. Care is delivered and the patient is told to keep taking medications and to follow-up in 6 months for a repeat encounter. No labs were ordered or analyzed today. What level of MDM based on the 2021 guidelines?

a. Straightforward, 99212
b. Low, 99213
c. Moderate, 99214
d. High, 99215

9. Regarding the 2021 E&M ambulatory billing rules, regarding the DATA component of Medical Decision Making (MDM), true statements about the categories used to delineate the “moderate” and “high” MDM. ALL of the following are correct EXCEPT:

a. There are three total described to be used for MDM
b. Must have all elements met in each category to “count”
c. One category must be met for Moderate MDM
d. Two of the three categories must be met for High MDM

10. You spend 10 minutes today in review of the record, notes from the GI provider, and checking lab results. You spend 20 minutes FTF with the NEW patient and then 12 minutes to do the note. The appropriate billing code for this patient, if we used TIME, would be

a. 99202
b. 99203
c. 99204
d. 99205

11. A longstanding 77 yo former smoker-COPD patient presents to see you due to SOB and worsening cough with purulent sputum production of six days duration. Saturations on RA are 89% with ambulation, 92% at rest (96% baseline). CXR is negative, but given the presentation, you recommend a short stay in the hospital to get “tuned up”. He refuses, but agrees to follow-up with you in the AM or call tonight if things worsen. You agree with the plan and prescribe appropriate medications. Based on the MDM, this would be billed

a. 99213
b. 99214
c. 99215
d. 99215 + G2212 (15 min added time due to complexity)

12. A 63-year-old male new patient comes in for evaluation. Today his BP is 159/99 with a recheck BP of 161/101 after your visit is completed. He states that his entire family has hypertension. His father died after a CVA at the age of 61 and “my three brothers are on pressure pills”. He was told his BP was elevated 3 years ago, the last time he saw a “plant doctor at work” for a yearly check-up. He has had his BP checked at a local pharmacy twice in the last 3 months, both times the “top and bottom numbers were over 100”. His only complaint is rare, occasional dizziness. You feel that he needs medication management and labs to be drawn for this condition. The billing for this encounter would be

a. 99213
b. 99214
c. 99203
d. 99204

13. The Interval Detailed History

a. Is required in the ED setting for all subsequent visits
b. Has been stricken from use by the 2019 CMS Coding Primer Update
c. Requires 1 element of the past, family, and social history to be compliant
d. Can be used in follow-up hospital rounds, and is devoid of the past, family, and social history element

14. Which one of the following is TRUE?

a. There are multiple examination “bullets” available for credit without even touching the patient
b. The 1995 E/M rules are set up with “bullet points” to allow more ease in capturing discrete elements
c. The 1995 exam components are much more strict and harder to meet than the 1997 exam guidelines
d. The 2014 CMS Examination Primer has become the coders “Bible” for auditing physicians

15. Regarding the 99222 and 99223 (Initial Inpatient Care) admission codes…

a. One well documented organ system and another organ system addressed would meet the criteria for the exam for these encounters
b. They have identical requirements with respect to the exam documentation
c. The 99223 has more exam requirements than the 99222
d. The 99221 has the same exam requirements as the 99222 and 99922

16. Correct statements for the “Two Midnight Rule” include (choose ALL that are correct):

a. It is mandated by CMS that this “rule” be followed for Medicare patients
b. Two Midnights of active clinical management are needed to be documented to show the medical necessity of the condition and “inpatient” care needed
c. Weekends and holidays are not counted in the time-based calculation
d. There are no exclusions for the “Two Midnight Rule”

17. Procedure A is one you do routinely, and it is on the “inpatient only list”. A patient comes in today at 0600 and then goes to the OR where you perform Procedure A. The patient does extremely well and asks to go home at 515 pm. You agree and therefore discharge the patient to home. You would bill this patient for the Procedure A how….?

a. Inpatient procedure
b. Outpatient procedure
c. Observation since we did not stay over 2 MN
d. Outpatient level 5, 99215

18. A Medicare patient is placed in the hospital with observation services for heart failure. What is needed on day two for her care? (Choose all that are correct)

a. A safe discharge to home if able
b. Documentation of a clinical need for continued care and a change to inpatient status if unable to be discharged to home
c. Change to inpatient if she cannot go home today for social reasons
d. Leave observation until the patient can be discharged to home

19. Documentation on day two to merit inpatient admission includes (Choose all that are correct)

a. Continued oxygen need over baseline requirements
b. Creatinine climbing from 0.9 baseline to 1.3 on day one, then 1.9 on day two
c. New orthostatic hypotension and weakness on ambulation on day two
d. None of the above merit inpatient admission

20. All the following are FALSE about the Medicare Wellness Visits available to beneficiaries EXCEPT:

a. First year of eligibility for the IPPE is when patients become Medicare eligible, usually age 65
b. Nurses can perform either of the three exams as long as under the supervision of a physician
c. Doctors of Pharmacy are allowed to perform the AWVs and IPPE independent of having physician supervision
d. Co-payments are not waived for the SUBSEQUENT Annual Wellness Visit

21. Medicare Wellness Visits (choose the best option)

a. Are covered as no co-pay and no deductible as stand-alone visits
b. Allows a chance for PCPs to focus on medication list and diagnosis clean-up
c. Is an ideal time to do quality gap closure to optimize prevention and chronic disease management
d. Are a part of some Health Plans quality bonus structure
e. All of the above

22. Things NOT recommended to be covered at the stand-alone Medicare Wellness Visit

a. End of life counseling, as in Advance Care Planning, etc.
b. A full 8 organ system examination with stool testing for blood
c. Depression screening with a PHQ9 or related tool
d. Dementia screening with the Sweet 16 Dementia Screen or related tool

23. A 65 yo patient receives the IPPE in 02/2017. They return 13 months later and have not had a Medicare Wellness Exam since 02/2017. They should

a. get a Subsequent AWV
b. get another IPPE since it is 13 months later
c. get an Initial AWV since it is 13 months later
d. Have the problem E/M billed (and not a MWV) since it has been 13 month

24. To bill a Transitional Care Management visit, which of the following must occur (choose the best answer)?

a. Interactive communication (call or FTF) within two business days post discharge
b. Face-to-face within 14 calendar days post discharge
c. The discharge summary is available, reviewed, and referenced in the TCM note
d. All of the above

25. TCM services are appropriate after discharge from all these scenarios, except:

a. Observation care for 1-day hospital stay, discharged to home
b. Inpatient admission for 3 days, discharged back to assisted living facility
c. Emergency department visit, sent back to home after 10 hours
d. Inpatient Rehab patient discharged to home

26. CPT 99495 requires what amount of medical decision making?

a. Self-limited
b. Low
c. Moderate
d. High

27. TCM documentation requires:

a. Date of discharge and date of dialogue to assess patient and confirm appointment
b. Content to address hospital course (disease status, medication compliance, follow-up plan)
c. Medication reconciliation
d. All the above

28. The number of providers allowed to bill for TCM services is

a. One provider per lifetime
b. One provider per month
c. Multiple providers per month if the specialties are different
d. Multiple providers per month as long as the diseases managed are different

29. All of the following needs to be performed/documented with the Advance Care Plan (ACP) note for appropriate billing of the code EXCEPT (choose the best answer)……

a. A review of the conditions that led to the need for an ACP discussion
b. The patient’s signature on the ACP Plan Document with respect to the ACP discussion
c. The time spent in discussion that day with the patient and family related to ACP
d. Notation of the patient’s wishes and wants regarding Advance Directives
e. ALL are correct

30. Which of the following is FALSE with respect to Advance Care Planning?

a. There are no frequency limits
b. Form completion time counts, if done the same day
c. Critical care billing and ACP are allowed on same day ONLY
d. It is OK to

31. Which of the following is TRUE with respect to Advance Care Planning if documentation supports?

a. If performed in context of the Initial Preventive Physical Exam (the IPPE, or “Welcome to Medicare” visit) then the co-pay and deductible is waived (so, “free”) regardless of the time spent in ACP discussion with the patient
b. If performed in context of the Medicare Annual Wellness Visit (initial/subsequent) or IPPE, the co-pay and deductible is waived when a modifier -33 is attached to the ACP code
c. Use a -33 modifier to allow the ACP codes to be billed correctly with 99214 and 99215 visits to waive co-insurance
d. It can only be billed once a total time of 31 minutes is spent in discussion with the patient since it is a 30-minute time-based code

32. You do a 99213 encounter and spend an additional 11 minutes discussing end of life issues with the patient. She wishes to go home and call you to make sure her daughter is on board with her wishes. That call with you occurs over lunch today for an additional 14 minutes. You can optimally bill (assuming documentation supports)

a. 99214 due to E/M plus time
b. 99497 because it was under 30 minutes
c. 99498 because if was above the 16 minute threshold of 99497
d. 99213 + 99497 because we spent more than 16 (of the required 30) minutes dealing with ACP-specific issues

33. Which statement is false regarding a DRG? A DRG …

a. Is a measure to show the “degree of sickness” of a condition with hospitalized patients
b. Can be modified by noting comorbid conditions and comorbidities
c. Is a payment category that is used for the purpose of reimbursing hospitals for a fixed fee regardless of the actual costs incurred for a patient’s care
d. Is applied on inpatient and outpatient services

35. Which of the following is a Major Comorbid Condition (MCC)?

a. Dual Chamber Heart failure, unspecified
b. Acute systolic heart failure
c. Left heart failure
d. Diastolic Dysfunction

34. A 65 year old female developed a nodule on the left thyroid gland and it was removed surgically after FNA showed malignancy. It was completely excised and lymph nodes were removed and all negative. She was released from ENT back to her PCP for long term management. This occurred last year and you are seeing her for the first time this year and you diagnose her with a “History of Papillary Thyroid Cancer”. Which of the following is correct?

a. This should not be listed “history of” because it has not been seven years post thyroidectomy
b. “History of” in HCC means only 50% of the risk score will be applied
c. “History of” is correct and the risk score still is applied at 100%
d. “History of” is correct and the risk score for this condition will be 0

36. True comments related to the “risk score” in clinical documentation include all EXCEPT:

a. Higher scores indicate a higher clinical “risk” and usually higher “cost” of care
b. It is captured when a diagnosis is added to the claim billed for an office visit
c. The risk score for diabetes is the same as diabetes with nephropathy
d. Lower risk score capture may negatively impact revenues allotted to the health plan to be used in patient care delivery

37. The Maslach Burnout Inventory (MBI) is divided up in dimensions or domains. Which of the following is NOT one of the domains?

a. Emotional exhaustion – “exhaustion”
b. Depersonalization – “cynicism”
c. Personal accomplishment – “ineffectiveness”
d. Intentionalization – “obsessive focus”

38. Which is a true statement regarding anxiety and depression levels in the US because of the pandemic?

a. Prevalence of symptoms of an anxiety or depressive disorder were 25% more year over year in Q2 2020
b. Prevalence of symptoms of an anxiety or depressive disorder were 3-4x higher year over year in Q2 2020
c. Prevalence of symptoms of an anxiety or depressive disorder were unchanged year over year in Q2 2020
d. Prevalence of symptoms of an anxiety or depressive disorder are less year over year in Q2 2020 showing no negative effects from the pandemic

39. One strategy recommended in the session to help patients cope with the pandemic was noted to have an “apparently protective role”. Having patients engage in this strategy was noted in some studies to allow patients to develop an “inner peace in times of trial”. The modality referenced was

a. Employee Assistance Programs
b. In-office counseling with their PCP
c. Faith-based support systems
d. Psychiatric consultation and cognitive behavioral therapy

40. Acute MI is when a troponin is elevated in a clinical scenario. True statements about the troponin include (choose ALL that apply):

a. A cardiac troponin I values (cTn I) with at least one value above the 99th percentile upper reference limit (URL) and an associated rise/fall of the value
b. Cardiac troponin values (cTn I) with an increase of 10% over baseline in the context of chest pain
c. Cardiac troponin values have no value unless there are EKG changes consistent with ischemia
d. The patient’s vital signs (ie, blood pressure) are used in the assessment of the cTN I calculation for acute injury

41. Documentation to show an inpatient medical necessity for a stroke includes which of the following (choose all that pertain)?

a. A new ischemic infarct on a CT scan associated with persisted left upper extremity weakness on the morning of day 2 of the hospital stay
b. A subacute infarct noted on CT scan associated with neurologic deficits that persist on the morning of hospital day three
c. A subacute infarct noted on CT scan associated with mental status changes and persistent mild cognitive deficits noted on the morning of hospital day three
d. A subacute infarct noted on CT scan associated with resolution of right upper extremity weakness that was noted on presentation by the end of the second hospital day

42. On day two of a hospital stay where the patient was admitted as inpatient, what would help secure this as inpatient on day two?

a. Occasional PACs on overnight monitor
b. Noting an increased work of breathing on ambulation to the toilet (no accessory muscle use and RR 13) and RA saturation 96%
c. Continued shortness of breath (sat 95% off supplemental O2) at rest. RR12
d. Shortness of breath on ambulation with O2 saturation 85% in a patient not on home O2

43. Which of the following COPD scenarios would most likely merit INPATIENT hospitalization from initial presentation?

a. COPD patient with mild confusion exacerbation on day one
b. COPD exacerbation with RR 15, cough w/ thick increased phlegm, sat 96% on RA
c. COPD with chronic use of 2 liters home O2, presents with sat 81% and bumped to 4 liters. CXR with new LLL pneumonia. On 4 liters saturation is 91%
d. COPD patient who still smokes AMA, has 3d of wheezing and has used MDI 2x/day for 3d without relief

44. The Medical Decision Making that is a base minimum for critical care is indicative of some vital organ system failure (CNS, cardiometabolic, pulmonary, etc.). The medical decision making that is to be documented in the record to support such is

a. Minimal
b. Low
c. Moderate
d. High

45. The 99291 code time is billable

a. After 15 minutes of critical care is delivered
b. After 30 minutes of critical care is delivered
c. Is added every time an hour of care is exceeded
d. Used only for the first day of care

46. The NPP sees a patient at 0645 and delivers 22 minutes of critical care. You (the Attending Physician) see the patient at 1130 and deliver care of 19 minutes that you also feel merits critical care. On evening rounds, you deliver critical care for 10 minutes. The amount of critical care billable for today is billed under the

a. Physician, as there was >50% of time spent by her on the critical care delivery
b. The provider who documents the most in the note for the care delivered
c. The NPP since he started the critical care billing at 0645
d. Each provider as they both bill 50% of the charge

47. The following visits CAN be shared with a physician and NPP in 2022 (select each correct answer):

a. Hospital inpatient admissions (day one)
b. Hospital inpatient day two rounding encounters
c. Procedures
d. Critical Care

48. The standards of clinical care set forth by CMS

a. Are higher for physicians than NPPs
b. Are a different scope for physicians than NPPs
c. Were cancelled during the pandemic and will be re-instituted after the PHE
d. Are the same for physicians and NPPs

49. The reimbursement that a Physician Assistant gets from a Medicare patient is

a. The same as an NP and is 85% of the Medicare Physician Fee rate
b. The same as a physician only with subsequent Nursing Center patients
c. Less than a NP
d. 90% of the physician rate

50. The billing of split/shared services in 2022 can be determined by (select all that apply)

a. The provider who spends >50% of the time in care delivery in a calendar day
b. The physician’s total time in care delivery over a 3-day period
c. The provider who documents and performs the substantive part of the key component that drives the bill for the encounter
d. The physician’s documentation based on the AMA 1992 E&M office guidelines

Practice Enhancement – Post Test

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