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21 multiple-choice questions and 20 flashcards on Coding Guidelines, Compliance, and Reimbursement, about 12% of the Medical Coder bank. Every one carries a written rationale.
Coding Guidelines, Compliance, and Reimbursement is one of 6 chapters in CoStudy's Medical Coder (CPC/AAPC) bank, and it holds 21 of the bank's 173 multiple-choice questions — roughly 12% of the total. That proportion is not arbitrary: chapters follow the certifying body's published exam outline, and the number of questions in each is set by that domain's published weight, so the share of your practice time this chapter takes matches the share of the real exam it accounts for.
Studying by chapter is worth doing once you have a diagnostic score. A single overall percentage tells you whether you are close; it does not tell you which domain is dragging. Working a weak chapter in isolation, and re-testing it in isolation, is the fastest way to move a score that has stalled — and it is why the mock exams in CoStudy report by domain rather than as one number.
10 questions drawn from this chapter, with the full rationale shown — the controlling principle behind the right answer, and why each wrong option tempts and fails.
When a provider expects Medicare may deny a service as not medically necessary and has the patient sign an Advance Beneficiary Notice (ABN) agreeing to be financially responsible, the claim is submitted with modifier:
Answer: B — -GA
A) -GY indicates the item/service is statutorily excluded (no ABN required, never covered). B) Correct — -GA signals a signed ABN is on file for an expected denial, shifting liability to the patient. C) -GZ means an ABN was NOT obtained even though denial was expected — provider absorbs the cost. D) -KX indicates required documentation/criteria for medical necessity have been met, unrelated to ABN status.
Stark Law applies to:
Answer: A — Self-referral of designated health services to entities with financial relationship — federally-funded
Stark Law = physician self-referral prohibition for designated health services (DHS) when the physician/family has a financial relationship. Federal program-specific (Medicare/Medicaid).
Add-on codes:
Answer: D — Reported in addition to a primary procedure code
A/C/D) Wrong. B) Correct — marked with '+' in CPT.
Anti-Kickback Statute is a:
Answer: B — Criminal statute (with civil penalties also possible)
Anti-Kickback Statute (42 USC §1320a-7b) is CRIMINAL. Up to 10 years prison + fines. Stark, in contrast, is purely civil (strict liability).
A physician elects to stop a service after starting, before completion, due to the patient's condition, in a non-facility setting. The appropriate modifier is:
Answer: A — -53
A) Correct — -53 is discontinued procedure, used by the physician when a procedure is terminated after being started due to patient risk. B) -52 is for a service reduced by physician choice, not stopped for safety. C/D) -73/-74 are facility (ASC/hospital outpatient) discontinued-procedure modifiers, appended by the facility, not the physician's professional claim.
False Claims Act penalties may include:
Answer: A — Treble damages + per-claim civil penalties
FCA = treble (3x) damages plus civil penalties per false claim. Whistleblower (qui tam) provisions allow private parties to sue on behalf of government.
Medicare Part B covers:
Answer: D — Outpatient + physician services
A) Part A. B) Correct. C) Part D. D) Not Medicare.
An NCCI PTP edit indicates:
Answer: B — Two codes cannot generally be reported together; one is bundled into the other
PTP (Procedure-to-Procedure) edit = column 1/column 2 pair where col-2 code is normally bundled. May be unbundled with modifier when clinically appropriate.
A surgeon performs a procedure that is significantly more complex and time-consuming than usual due to extensive scarring from prior surgery. Which modifier reflects this?
Answer: A — -22 (increased procedural services)
A) Correct — -22 indicates the work required substantially exceeded the typical effort; documentation of the extra work/time is required. B) -52 is the opposite (service reduced, not increased). C) -78 applies to an unplanned second trip to the OR during the global period, not extra effort in the same session. D) -59 separates distinct procedures, unrelated to added complexity of one procedure.
CMS-1500 form is used for:
Answer: B — Professional/outpatient claims by physicians
A) UB-04. B) Correct. C/D) Wrong.
4 cards from the 20 in this chapter.
NCCI?
National Correct Coding Initiative. CMS edits preventing improper code pairs. Two types: PTP (Procedure-to-Procedure) + MUE (Medically Unlikely Edits).
OIG Work Plan?
Annual list of HHS OIG audit + investigation priorities. Coders should review to anticipate audit risk areas.
CMS-1500 vs. UB-04?
CMS-1500: professional/outpatient claims (physicians). UB-04: institutional/hospital claims. Different layouts, similar content.
CPC role?
Reviews medical documentation + assigns standardized codes (CPT, ICD-10-CM, HCPCS) for outpatient services. Used for insurance claims, billing, statistics, compliance.
These are a sample. The full Coding Guidelines, Compliance, and Reimbursement chapter runs 41 items with per-chapter progress tracking, on the web and in the iOS app.
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