Unit 5: HCPCS Level II Coding

• Topic 01

  HCPCS Structure — Permanent, Temporary, and Miscellaneous Codes

  15 questions
• Topic 02

  Durable Medical Equipment (DME) Coding

  45 questions
• Topic 03

  Drug Coding — J Codes and Route-Based Billing

  15 questions
• Topic 04

  Ambulance Coding — A Codes and Base Rate vs Mileage

  31 questions
• Topic 05

  Dental Codes (D Codes) Overview

  39 questions
• Topic 06

  Medicare and Medicaid Billing Rules

  15 questions
• Topic 07

  HIPAA Privacy and Security in Billing

  16 questions
• Topic 08

  Fraud, Waste, and Abuse in Healthcare Billing

  18 questions
• Topic 09

  Compliance Programs and Coding Ethics

  35 questions
• Topic 10

  Appeals and Denial Management

  40 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A DMEPOS supplier is enrolling in Medicare for the first time. Which of the following is a required enrollment step beyond obtaining an NPI?

   • A
     Obtain accreditation from a CMS-approved accrediting organization and post a surety bond.
     Correct answer
   • B
     Apply for a Medicare Advantage contract through a state health insurance exchange.
   • C
     File a state Medicaid enrollment application before applying to Medicare.
   • D
     Complete a hospital credentialing application and join a physician group practice.
   Explanation

   DMEPOS supplier enrollment under 42 CFR §424.57 requires, among other things, accreditation by a CMS-approved organization and posting a surety bond (currently $50,000 per location). These additional hurdles were added to curb fraudulent billing by shell companies. A standard NPI is necessary but not sufficient for DMEPOS enrollment. Key takeaway: DMEPOS enrollment has special requirements — accreditation and surety bond — beyond those for physician practices.

2. A Medicare DME MAC uses a K code to identify a specific type of wheelchair seat cushion. A private commercial insurer does not recognize K codes. How should the billing specialist handle this for the commercial payer?

   • A
     Check whether a permanent HCPCS Level II E code describes the cushion; if one exists, use it for the commercial claim. If no permanent code exists, use the most appropriate miscellaneous HCPCS code and submit supporting documentation.
     Correct answer
   • B
     Use the K code for the commercial claim because all HCPCS Level II codes are recognized by all payers.
   • C
     Bill the commercial insurer using the same K code but append modifier GY to indicate the item is non-covered.
   • D
     Use a CPT unlisted code because commercial insurers do not accept HCPCS Level II codes.
   Explanation

   K codes are temporary HCPCS Level II codes established by DME MACs for use in the Medicare program. They are not universally recognized by commercial payers. When billing a commercial insurer, the specialist should first look for a permanent HCPCS E code that describes the same item. If no permanent code exists, a miscellaneous code (with supporting documentation) may be required. T codes are used exclusively by Medicaid state agencies, not commercial payers. Key takeaway: K codes are Medicare DME MAC-specific; commercial payers may require a permanent HCPCS code or a miscellaneous code instead.

3. A physician at a hospital orders an oral surgery consultation for a patient who is scheduled for cardiac valve replacement surgery. The cardiac surgeon requests tooth extractions of several infected teeth to reduce bacteremia risk during and after surgery. The hospital's billing department is unsure whether to bill Medicare. What is the correct billing determination?

   • A
     The extractions are covered only if the patient's dentist, not the oral surgeon, performs the procedure, because the dental exclusion only applies to independent dental offices
   • B
     The tooth extractions are likely covered under Medicare's integral-to-covered-service exception because they are directly related to the inpatient cardiac valve replacement surgery, which is a covered Medicare procedure; the billing department should document the clinical connection and submit the claim as part of the inpatient hospital bill
     Correct answer
   • C
     The hospital should bill the patient's dental plan for the extractions because the dental exclusion exception does not apply when the patient has active dental coverage
   • D
     The extractions are covered under Medicare Part D as a drug-related benefit because the post-extraction antibiotic prophylaxis is the primary reason for the procedure
   Explanation

   Medicare's coverage exception for dental procedures extends to procedures that are directly integral to a covered inpatient medical service. Tooth extractions performed to reduce bacteremia risk prior to cardiac valve surgery (a covered Medicare service) fall within this exception under CMS Medicare Benefit Policy Manual, Chapter 15, Section 150. The billing department should document the surgical connection in the medical record and include the extractions on the inpatient hospital claim. The key takeaway: dental extractions required as a clinical prerequisite to a covered Medicare inpatient procedure fall under the integral-to-covered-service exception and are billable on the inpatient hospital claim.