CHAPTER 21- Reimbursement for Nurse Practitioner Services

Question 1

It is important for the FNP to understand coding for all of the following reasons EXCEPT:

1. Maintain fiscal responsibility.
2. Calculate a raise.
3. Add revenue to a practice.
4. Decrease liability.

Answer 1

2. Calculate a raise.

Coding has nothing to do with a raise, which is part of the employment agreement.

Question 2

The CPT is known as which of the following?

1. Common Physician Terminology
2. Current Physical Terminology
3. Current Procedural Terminology
4. Common Procedural Terminology

Answer 2

3. Current Procedural Terminology

It is published by the American Medical Association.

Question 3

Who can bill using the CPT?

1. MD, PA, NP, RN
2. MD, NP, MA
3. MD, PA, NP, PT
4. MD, PA, NP

Answer 3

4. MD, PA, NP

Only medical doctors, physician assistants, and nurse practitioners can bill for their services and be reimbursed.

Question 4

What is NOT true of the CPT?

1. Updated monthly
2. Lists procedures and codes
3. Has an appendix of coding examples
4. Owned by the AMA

Answer 4

1. Updated monthly

The CPT is updated annually.

Question 5

In 1997, President Bill Clinton signed the _________, which allows FNPs to be reimbursed.

1. Balanced Bill Act
2. Balanced Budget Act
3. Balanced Budget Alliance
4. Balanced Bill Alliance

Answer 5

2. Balanced Budget Act

In 1997, President Clinton signed the Balanced Budget Act into law which allowed for reimbursement of nurse practitioner services.

Question 6

The signed legislation mentioned in the previous question allows NPs to be reimbursed at what percentage?

1. 65%
2. 75%
3. 85%
4. 100%

Answer 6

3. 85%

The BBA of 1997 allowed for nurse practitioners to be reimbursed at 85% of the physician reimbursement rate.

Question 7

The resource-based relative value scale replaced ______ as a method of reimbursement.

1. fee for service
2. cost balance
3. bartering
4. value-based

Answer 7

1. fee for service

The resource-based relative value scale replaced the fee for service method of reimbursement.

Question 8

ICD (International Classification of Diseases) was developed by which of the following?

1. HOW – Health Organization of the World
2. HHS – Health and Human Services
3. WOD – World Organization of Diseases
4. WHO – World Health Organization

Answer 8

4. WHO – World Health Organization

World Health Organization working with the United Nations. Started in 1860 when Florence Nightingale wanted to keep data on hospitals.

Question 9

ICD provides all of the following EXCEPT:

1. Morbidity data.
2. Public health data.
3. World drug data.
4. Mortality data.

Answer 9

3. World drug data.

Classified diseases, symptoms, and injuries.

Question 10

NPI stands for which of the following?

1. National Provider Number
2. National Provisionary Number
3. Numerical Provider Number
4. Numerical Physician Number

Answer 10

1. National Provider Number

Unique identifier recognized through passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996.

Question 11

An NPI costs how much?

1. $10
2. $50
3. $100
4. Free

Answer 11

4. Free

There is no cost to apply for an NPI number.

Question 12

The FNP must apply for a new NPI number if they change their practice to another state.

1. True
2. False

Answer 12

2. False

The NPI number is yours only and travels with you wherever you practice.

Question 13

CMS stands for which of the following?

1. Centers for Medicare and Medicaid Services
2. Committee for Medicare Services
3. Center for Medicine Services
4. Center for Medicare and Medicaid States

Answer 13

1. Centers for Medicare and Medicaid Services

See www.cms.gov.

Question 14

The medical record should do all of the following EXCEPT:

1. Be complete and legible.
2. Reflect what was done and why it was done.
3. Be signed by the provider.
4. Be co-signed by the MD of the FNP notes.

Answer 14

4. Be co-signed by the MD of the FNP notes.

Co-signature is not required by the MD for FNP documentation. The provider of record providing the service must sign the documentation.

Question 15

What form must you sign in order to be credentialed on an insurance panel?

1. Attestation form
2. Regulatory form
3. Affirmation form
4. Declaratory form

Answer 15

1. Attestation form

The nurse practitioner will be required to complete an attestation form to verify that the information to the credentialing organization is correct.

Question 16

An electronic health record should not _____________.

1. contain templates
2. contain macros
3. replace good documentation
4. use cut and paste for all visits

Answer 16

4. use cut and paste for all visits

The nurse practitioner must ensure that there is clear and accurate documentation at every visit.

Question 17

All of the following are key components of documentation EXCEPT:

1. Counseling.
2. History.
3. Medical decision making.
4. Physical exam.

Answer 17

1. Counseling.

Not a key component. Counseling is considered when coding by time.

Question 18

History includes which of the following?

1. History of present illness
2. Review of systems
3. Past, Family, Social
4. Financial

Answer 18

4. Financial

It may be required for payment but has nothing to do with coding a visit.

Question 19

Medications are part of the past history.

1. True
2. False

Answer 19

1. True

Medications are being taken by a patient already, so they are considered part of the past medical history.

Question 20

An established patient is one who is _____________.

1. seen by the FNP for the first time
2. seen by the FNP in follow-up
3. seen by the FNP for pre-op
4. seen by the MD for a first visit

Answer 20

2. seen by the FNP in follow-up

The FNP already has a relationship with the patient.

Question 21

Practice authority is governed by the states. The three types of practice authority include which of the following?

1. Full practice
2. Reduced practice
3. Limited practice
4. Restricted practice

Answer 21

3. Limited practice

The practice authority map is located at www.aanp.org and is based upon the FNP’s ability to diagnose, treat, and prescribe treatments under supervision (Restricted), collaboration (Reduced), or autonomously (Full).

Question 22

All of the following are true of Medicare EXCEPT:

1. It is state-regulated.
2. It is an entitlement for the elderly and disabled.
3. It is for everyone starting at age 65.
4. It is a federal program.

Answer 22

1. It is state-regulated.

Medicare is a federal program run by the federal government.

Question 23

A collaborative agreement is between an FNP and an MD.

1. True
2. False

Answer 23

2. False

Depending upon the practice authority, the collaborative agreement can be with an MD or FNP.

Question 24

An FNP forgot to chart information in the EMR when she saw the patient two days ago. She should _______________________.

1. know it cannot be added in after the fact
2. put today’s date on it and write that the omission was from the date of service and document it
3. have IT override it so she can document what she omitted in that day’s note
4. add it when she sees the patient the next time.

Answer 24

2. put today’s date on it and write that the omission was from the date of service and document it

This is the best way to handle an omission and the FNP should correct it as soon as it is known.

Question 25

There is a general multisystem examination and a single system examination form. 1. True 2. False

Answer 25

**1.** True ## Footnote Single-system exam forms are for musculoskeletal, psychiatry, and cardiology, for example. More information can be found at www.cms.gov/medlearn.

Question 26

Which is NOT a single system examination? 1. Cardiology 2. Gastroenterology 3. Musculoskeletal 4. Psychiatry

Answer 26

**2.** Gastroenterology ## Footnote Gastroenterology covers everything from the mouth to the anus, which is not a single system.

Question 27

Coding by time is used when greater than ___ of the visit is spent counseling or coordinating care. 1. 40% 2. 50% 3. 75% 4. 80%

Answer 27

**2.** 50% ## Footnote This is used when the FNP is basing the visit on time and not the level of history, physical exam, or medical decision making.

Question 28

Incident to billing is for Medicare patients. 1. True 2. False

Answer 28

**1.** True ## Footnote Though it may happen with other insurance carriers, "incident to" is rooted in Medicare regulations.

Question 29

Incident to billing is when the MD bills with the FNP provider number. 1. True 2. False

Answer 29

**2.** False ## Footnote "Incident to" billing is when the FNP bills with the MD NPI number.

Question 30

Incident to requires the MD to be in the office but not necessarily see the patient. 1. True 2. False

Answer 30

**1.** True ## Footnote The MD has to be available to the FNP for consultation or to answer questions.

Question 31

Incident to does not include which of the following? 1. MD formulates treatment plan. 2. MD signs FNP paycheck. 3. Practice gets 100% reimbursement. 4. Patient can have a new problem.

Answer 31

**4.** Patient can have a new problem. ## Footnote The patient cannot have a new problem. If there is a new problem, the visit must be billed under the FNP NPI number.

Question 32

Medicare fraud is a costly problem. In a study published in 2010, how much revenue was billed fraudulently? 1. Thousands 2. Millions 3. Billions 4. Trillions

Answer 32

**3.** Billions ## Footnote $6.2 billion dollars was fraudulently billed. This is why, as part of the Affordable Care Act, Recovery Audit Contractors are hired to investigate fraudulent billing practices.

Question 33

What can trigger an audit? 1. Billing all visits using one code 2. Collecting co-pays 3. Billing non-covered services as covered 4. Documentation does not support E&M billed

Answer 33

**2.** Collecting co-pays ## Footnote Co-pay is a monetary agreement between the insured and the insurance company.

Question 34

What is the most common established patient code billed? 1. 99212 2. 99213 3. 99214 4. 99215

Answer 34

**2.** 99213 ## Footnote This is based upon a study done by the Department of Health and Human Services and the Office of the Inspector General looking at claims from 2000–2010.

Question 35

What is the code for an initial office visit for a 13-year-old with comedopapular acne unresponsive to over-the-counter treatment? 1. 99214 2. 99211 3. 99202 4. 99204

Answer 35

**3.** 99202 ## Footnote A new patient requires weighing history, physical exam, and medical decision making equally. A dermatology patient will have lower levels of visit codes. OTC treatment is not as risky as a prescription.

Question 36

What is the code for an office visit for a 32-year-old female established patient with new onset right lower quadrant pain? 1. 99211 2. 99202 3. 99212 4. 99214

Answer 36

**4.** 99214 ## Footnote Abdominal pain requires a workup, and being female could be GYN, GI, or GU etiology.

Question 37

What is the code for an office visit for a 60-year-old established patient with chronic hypertension on a multiple drug regimen who has come in for a blood pressure check? 1. 99213 2. 99204 3. 99202 4. 99215

Answer 37

**1.** 99213 ## Footnote An established patient with no change in medication.

Question 38

What is the code for an initial evaluation of a 70-year-old patient with recent onset confusion? 1. 99202 2. 99203 3. 99204 4. 99205

Answer 38

**3.** 99204 ## Footnote The elderly require an extensive workup to determine etiology, because a change in mental status could be neuro, GU, or medication related.

Question 39

What is the code for an office visit for an 82-year-old female established patient for a monthly B12 injection with a documented vitamin B12 deficiency? 1. 99202 2. 99211 3. 99213 4. 99203

Answer 39

**2.** 99211 ## Footnote B12 injections are given by an RN, which can be billed as a 99211.

Question 40

What is the code for an office visit for a 50-year-old female established patient with insulin-dependent diabetes mellitus who has come in for monitoring? 1. 99211 2. 99212 3. 99213 4. 99214

Answer 40

**3.** 99213 ## Footnote An established patient with a stable condition and no treatment plan change.

Question 41

What is the code for an initial office visit for a 33-year-old male with painless gross hematuria without cystoscopy? 1. 99202 2. 99203 3. 99204 4. 99205

Answer 41

**2.** 99203 ## Footnote A new patient requiring history, physical exam, and medical decision making weighed equally. The physical exam will keep the visit at 99203.

Question 42

What is the code for an office visit for a 10-year-old female established patient who has been swimming in a lake and has a one-day history of left ear pain with purulent discharge? 1. 99211 2. 99212 3. 99213 4. 99214

Answer 42

**2.** 99212 ## Footnote An established patient with localized body area and a problem-focused examination.

Question 43

What is the code for an office visit for the evaluation of recent onset syncopal attacks in a 70-year-old female established patient? 1. 99212 2. 99213 3. 99214 4. 99215

Answer 43

**4.** 99215 ## Footnote Any mental status change will require workup. Etiology can be neuro, cardiac, GU, or medication.

Question 44

The FNP is responsible for what is billed. 1. True 2. False

Answer 44

**1.** True ## Footnote The provider of the service is responsible for what is documented and billed.