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CRIP Set 2
| Question | Answer |
|---|---|
| What does ms- drg stand for? | Medicareseverity diagnosis related group |
| What is the 72-hour period or MS-DRG Payment Window. | When related outpatient services are provided within 72 hours prior to an inpatient admission the charges are bundled with the inpatient charge. |
| What three things must be considered when determining if an outpatient service is subject to be bundled with an inpatient admission? | The date the outpatient service was rendered, the relationship of the outpatient and inpatient provider, whether the services are diagnostic or non-diagnostic |
| Should the diagnosises/ procedure codes on the outpatient claim be included in the inpatient claim? | Yes, because it is possible that the additional charges can contribute to an outlier payment if the inpatient or outpatient charges are expensive. |
| When should outpatient services join the 3-day window be build separately from the inpatient claim ? | If the inpatient claim is deemed not medically necessary |
| What can violations of the ms- drg payment window result in? | Rework, payment delays, and monetary sanctions. |
| What does mue stand for? | Medically unlikely edit |
| What is an mue? | The maximum number of units for a specific CPT/hcpcs code that can be reported on a claim. |
| Why were mues established? | To reduce errors due to clerical entries in incorrect coding based on anatomic considerations |
| Can an ABN be used to charge the patient for a service with an mue edit? | No |
| What should be considered when reviewing an mue edit or denial? | Verify that the data service is correct for the procedure/service that is reported, check to ensure that there are no duplicate charges or codes for the same data service, validate the charges. Never add a modifier or split the charges on a separate line to bypass the edit without first validating that the charges are appropriate, a pending modifier only if the service is correctly reported and medically necessary |
| What is a modifier? | A two-digit numeric or alphabetic code that can be appended to a hcpcs or CPT code for another level of specificity |
| Can the use of modifiers impact reimbursement? | Yes. Some modifiers act as multipliers to increase or decrease reimbursement while other modifiers provide additional info that allows the claim to be processed |
| Do modifiers 25, 59, and 91 increase or decrease payment for a procedure ? | No |
| What do modifiers 25, 59, and 91 do? | Indicate that the services were medically necessary and distinct from other services that were provided on the same day and therefore allow payment to be received for the distinct service |
| Give some info about modifier 25 | Defined as significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other services. It's usually appended to an E&m code to indicate that on the same day a diagnostic or therapeutic procedure was performed. Good rule to follow is that modifier 25 is likely if the other services performed during the visit have a payment status indicator of t or s, such as x-rays or infusions |
| When should modifier 25 be appended to an E&m service | The service is beyond the usual pre-operative and post-operative Care associated with the procedure being performed, a separate history was taken. , separate medical decision making occurred and was documented in the patient medical record, the service is above the procedure being performed |
| What does modifier 50 mean? | It defines a bilateral procedure |
| Give some information about modifier 50 | Should be reported on a CPT code when the procedure performed bilaterally is not identified in the CPT code description. |
| What is the rule for applying modifier 50? | It should not be filled with the CPT code for the procedure and then an LT and an RT . It should be reported on one claim line with the modifier in one unit. Used only one paired organ and body parts. Used to report a procedure done bilaterally in the same session. Use when the same code identifies. The procedure is performed on both sides of the body |
| When should modifier 50 not be used? | When the code description for the procedure is non-specific, applies to different body parts, or includes the word bilateral or unilateral in the CPT code. Description. Wanted procedure where the organ is considered to be midline such as the esophagus, uterus, or bladder. To report the procedure with modifiers LT and RT on the same claim line |
| What does modifier 59 mean? | Distinct procedural services |
| What are appropriate uses for the modifier? 59 | Indicate that a procedure or service was distinct or independent from services performed on the same day. Representing a different procedure or surgery, different site or organ system, separate incision /excision, separate lesion, or separate injury |
| What are the four subsets of modifier of 59? | Xe- a service that is distinct because it occurred during a separate encounter Xs- a service that is distinct because it was performed on a separate organ or structure Xp- a service that is distinct because it was performed by different provider XU - A service that is distinct because it does not overlap usual components of the main service |
| Should modifier 59 be hard-coded into the system? | No |
| What modifier instead of 59 be it pended to E&m services? | 25 |
| How is modifier 73 defined? | Discontinued outpatient procedure prior to anesthesia Administration. Use the report procedures that require anesthesia but are terminated after the patient has been prepared for surgery and taken to the procedure room but before the induction of anesthesia |
| What are some other coding guidelines that should be followed when reporting modifier 73 with surgery and other diagnostic services? | Used only for procedures requiring anesthesia, common used to report discontinued procedures on an outpatient if the patient has been prepared for the procedure, patient taken to the procedure room, and before anesthesia |
| How is modifier 74 defined? | Discontinued outpatient procedure after anesthesia Administration. The modifier is used to report a procedure that is terminated after the patient has been taken to the procedure room and the induction of anesthesia has occurred |
| What are some coding guidelines for modifier 74? | It is used only for procedures requiring anesthesia and used to report a discontinued procedure on an outpatient. If the patient has been prepared for the procedure, the patient was taken to the procedure room, and after the induction of anesthesia. |
| If a patient is scheduled for more than one procedure and at least one or more of the procedures are completed. Should a modifier 73/74 be appended to the claim if some of the procedures were canceled? | No, report the completed procedures as usual. The other procedures planned but not started should not be reported. |
| How is modifier 76 defined? | Repeat procedure by same physician. Indicates that a procedure or service was requested in a separate session on the same day by the same physician. The first procedure should be listed once and then on a separate line the repeated procedure code is listed again with modifier 76 appended |
| How is modifier 77 defined? | Repeat procedure by another physician. Procedure performed and then repeated by different physician in a separate session on the same day. The first procedure is listed once and then on a separate line the repeated procedure code is listed again with modifier 77 |
| How is modifier 91 defined? | Repeat clinical diagnostic laboratory test. This is used when it is necessary to repeat the same lab test on the same day in order to receive multiple test results. It should not be used when tests are rerun to confirm initial results due to testing problems with specimens or equipment. |
| What is an ABN | Advanced beneficiary notice of non-coverage |
| When should an ABN be issued to the patient? | When it is expected that Medicare will deny payment for an item or service. Some reasons are services does not meet medical necessity criteria, frequency exceeds limits, services are experimental or investigational, services are not considered safe or effective for the care of the patient. |
| When should an ABN not be obtained from a Medicare patient? | In the ER if he or she is being seen for a medical emergency or under duress |
| What are the guidelines that state the issuance of an ABN is effective? | Issued and comprehended by the patient, provided on the approved CMS form with all blanks completed, advanced notice to allow sufficient time for the patient to consider options, explained in questions answered, signed indeed by the patient or representative |
| Can one be one airbn be used for an extended course of treatment? | Yes, it must list all items and services plus the duration of the length for the expected treatment. ABN cannot extend past one year. If longer than one year of treatment, a new ABN must be obtained. |
| Is an ABN an official denial coverage by Medicare? | No, The patient or the facility has the right to file on a pill for payment if the claim is submitted and denied |
| What are the triggering events for an ABN? | Initiation- this is at the beginning of treatment Reduction- occurs when the frequency or duration of care is decreased Termination- occurs when there is a discontinuation in the services being provided |
| How long must an ABN be retained for? | Must be retained for 5 years from discharge or the completion of the care provided that there are no other applicable requirements which fall under state-specific law. Retention is still required. If the patient refused the care, refuse signing ABN, or selecting an option. Electronic versions of the document are acceptable. |
| What does hinn stand for? | Hospital issued notice of non-coverage |
| What is an hinn? | Hospitals use this form to inform patients that all are part of their part. A inpatient hospital care may not be covered. Similar to the ABN. |
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