Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 12

1. What type of code edit could be used for the following rule?
Medicare Part B covers a screening Pap smear for women for the early detection of cervical cancer but will not pay for an E/M service for the patient on the same day.
2. An OIG fraud project found that during one month in a single state, there were 23,000 billings for an E/M service with the modifier 25 reported with one of these CPT codes: 11055, 11056, 11057, and 11719, and with HCPCS code G0127 (trimming of dystrophic nails).
A. Look up the descriptors for the CPT codes. Do you think the procedures appear to be simple or complicated?
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B. Why do you think that this billing combination continues to be under scrutiny by CMS?
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