ICD-10-CM, CPT and HCPCS on the CCMA

Name the noun in each stem first, then ask whether it answers why, what, or with what.

1. Question 1

   The provider administers an injectable drug in the office. Which code set is used to report the drug itself (for example, a J-code)?

   • AICD-10-PCS
   • BHCPCS Level II
   • CICD-10-CM
   • DCPT (HCPCS Level I)
   Answer & explanation

   Answer: B. HCPCS Level II

   HCPCS Level II codes report supplies, DME and drugs, including J-codes for injectable medications. CPT (HCPCS Level I) reports the service performed, such as the injection administration, which is why candidates pick it. ICD-10-CM reports the diagnosis, and ICD-10-PCS is used only for inpatient hospital procedures.

   • ICD-10-PCS is used only for inpatient hospital procedures, not office drug supplies.
   • Correct: HCPCS Level II reports drugs, supplies, and DME; J-codes cover injectable drugs.
   • ICD-10-CM reports the diagnosis behind the injection, not the drug itself.
   • CPT reports the administration service, the act of injecting, which is why it tempts.

2. Question 2

   On a claim, which code set reports the patient's diagnosis to show why a service was medically necessary?

   • AHCPCS Level II
   • BICD-10-CM
   • CICD-10-PCS
   • DCPT
   Answer & explanation

   Answer: B. ICD-10-CM

   ICD-10-CM codes describe diagnoses and symptoms, the "why" that supports medical necessity. CPT describes the procedure or service performed, the "what," and is the code set most often reversed with ICD-10-CM. HCPCS Level II covers supplies, DME and drugs, and ICD-10-PCS is used only for inpatient hospital procedures.

   • HCPCS Level II reports supplies, DME, and drugs, not diagnoses.
   • Correct: ICD-10-CM reports the diagnosis, the why that justifies the service.
   • ICD-10-PCS is for inpatient hospital procedures, not diagnoses.
   • CPT reports the service performed, the what; it is the code set most often reversed with ICD-10-CM.

3. Question 3

   What is the main purpose of CPT codes in medical billing?

   • ATo classify the patient's various diseases and health conditions
   • BTo record patient demographic information
   • CTo report the procedures and services a provider performed
   • DTo track pharmacy prescriptions for each patient
   Answer & explanation

   Answer: C. To report the procedures and services a provider performed

   CPT codes report the procedures and services performed, giving payers a uniform description for reimbursement. Classifying diseases is the role of ICD-10-CM, while prescriptions and demographics are recorded elsewhere.

   • Classifying diseases and conditions is the job of ICD-10-CM, not CPT.
   • Demographics live in the registration record, not in any procedure code.
   • Correct: CPT gives payers a uniform description of the procedures and services performed.
   • Prescriptions are tracked through pharmacy systems and NDC numbers, not CPT.

4. Question 4

   The provider performs a 12-lead EKG in the office. Which code set is used to report the EKG service?

   • AICD-10-CM
   • BCPT
   • CHCPCS Level II
   • DDiagnosis-related group (DRG)
   Answer & explanation

   Answer: B. CPT

   CPT (HCPCS Level I) reports procedures and services performed by providers, such as an office EKG. ICD-10-CM reports the diagnosis that justifies the test, not the test itself, and is the most common reversal. HCPCS Level II covers supplies, drugs and DME, and DRGs group inpatient hospital stays for payment.

   • ICD-10-CM reports why the EKG was done, not the EKG itself.
   • Correct: CPT, also called HCPCS Level I, reports provider services such as an office EKG.
   • HCPCS Level II covers supplies, drugs, and DME, not the EKG service.
   • DRGs group inpatient hospital stays for payment; they do not apply to office services.

5. Question 5

   What are HCPCS Level II codes used to report?

   • ASurgical operating-room procedures exclusively
   • BSupplies, equipment, and services not covered by CPT
   • CPatient allergies and adverse drug reactions
   • DPsychiatric diagnoses and various mental-health conditions
   Answer & explanation

   Answer: B. Supplies, equipment, and services not covered by CPT

   HCPCS Level II codes bill items CPT does not cover, such as durable medical equipment, ambulance services, and certain drugs. They are not diagnosis codes, surgery-only codes, or allergy records.

   • Operating-room procedures are reported with CPT or, for inpatients, ICD-10-PCS.
   • Correct: Level II covers items CPT does not, such as DME, ambulance services, supplies, and certain drugs.
   • Allergies and adverse reactions are documented in the chart, not coded with HCPCS.
   • Mental-health diagnoses are ICD-10-CM codes, like every other diagnosis.

6. Question 6

   On the CMS-1500, which element links each service line to the diagnosis that justifies it?

   • AThe diagnosis pointer
   • BThe place-of-service code
   • CThe rendering provider's NPI
   • DThe procedure modifier
   Answer & explanation

   Answer: A. The diagnosis pointer

   The diagnosis pointer on each service line refers back to the ICD-10-CM codes listed on the claim, showing which diagnosis supports medical necessity for that service. A modifier changes the meaning of the procedure code but does not link it to a diagnosis, which is why it is tempting. The place-of-service code shows where care was given, and the NPI identifies the provider.

   • Correct: each service line's diagnosis pointer refers back to the ICD-10-CM codes listed in Item 21.
   • The place-of-service code shows where care was given, such as the office, not why.
   • The NPI identifies the provider who rendered the service, not the diagnosis behind it.
   • A modifier changes the meaning of the procedure code but does not link it to a diagnosis.

7. Question 7

   A claim is denied because the ICD-10-CM code billed does not support the need for the CPT service. What is the reason for this denial?

   • AMissing prior authorization
   • BLack of medical necessity
   • CMissed timely filing limit
   • DCoordination of benefits error
   Answer & explanation

   Answer: B. Lack of medical necessity

   Payers pay only for services justified by the reported diagnosis, so a diagnosis that does not support the procedure causes a medical-necessity denial. A missing prior authorization is also a common denial but concerns approval before the service, not the diagnosis-to-procedure link. Timely filing is about the submission date, and coordination of benefits concerns which payer is primary.

   • A missing prior authorization is about approval before the service, not the diagnosis-to-procedure link.
   • Correct: when the diagnosis does not justify the service, the payer denies it for medical necessity.
   • Timely filing concerns when the claim was sent, not what codes it contains.
   • Coordination of benefits concerns which payer is primary, not whether the service was justified.

8. Question 8

   A two-character code such as -25 is added to a CPT code to show that the service was altered or distinct. What is this code called?

   • AAn add-on code
   • BA modifier
   • CAn E/M level code
   • DA place-of-service code
   Answer & explanation

   Answer: B. A modifier

   A modifier is appended to a CPT or HCPCS code to show that a service was changed or performed under special circumstances, such as -25 for a separate E/M service on the same day. An add-on code is a separate code reported in addition to a primary procedure, which makes it the closest confusion. Place-of-service codes identify where care was given, and the E/M level describes the complexity of a visit.

   • An add-on code is a separate code reported with a primary procedure, not a two-character suffix.
   • Correct: a modifier, like -25, shows a service was altered or distinct without changing its code.
   • An E/M level describes visit complexity; it is a full code, not an appended suffix.
   • Place-of-service codes show where care was given and go in a separate claim field.

9. Question 9

   When looking up an ICD-10-CM diagnosis code, which two resources should you use first, and in what order?

   • AAlphabetic Index, then Tabular List
   • BTabular List, then Alphabetic Index
   • CAlphabetic Index, then codebook appendices
   • DTabular List, then modifier guidelines
   Answer & explanation

   Answer: A. Alphabetic Index, then Tabular List

   Use the Alphabetic Index first to locate a possible code, then verify the code and its instructions in the Tabular List. The Tabular List should be used after the Alphabetic Index to confirm details, such as required characters and instructional notes. Appendices and modifier guidelines provide additional information but are not the first resources used to locate an ICD-10-CM diagnosis code.

   • Correct: find a likely code in the Alphabetic Index, then confirm it and its notes in the Tabular List.
   • Starting in the Tabular List is backwards; it is where you verify, not where you search.
   • The Index first is right, but appendices are reference material, not the verification step.
   • Modifiers belong to CPT and HCPCS, not to ICD-10-CM diagnosis lookup.