Dental Assisting National Board Certified Restorative Functions Dental Assistant (DANB CRFDA)

Correct: In the Ambulatory Surgery Center (ASC) setting, when a patient’s preference leads to a change in the surgical plan before the procedure begins, the coder must report the code that accurately describes the service actually performed. Since a unilateral knee arthroscopy was performed in its entirety, the unilateral code (29881) with the appropriate side modifier (RT) is the correct representation. Modifiers 73 and 74 are reserved for procedures discontinued due to unforeseen circumstances or medical necessity that threaten the patient’s well-being, not for elective changes in the surgical plan or patient preferences that result in a different, complete procedure being performed.

Incorrect: Option b is incorrect because modifier 73 is used for the cancellation of an entire planned procedure due to medical or safety reasons, not when a patient elects to perform a smaller, complete version of a planned bilateral surgery. Option c is incorrect because modifier 52 (Reduced Services) is used when a physician elects to reduce or eliminate a portion of a procedure, but it is not appropriate when a more specific unilateral code exists to describe the final service. Option d is incorrect because modifier 22 is used for increased procedural services involving unusual difficulty or time, and it is not used to compensate for administrative changes or reduced surgical scope.

Takeaway: When a patient’s elective preference changes a bilateral procedure to a unilateral one before it begins, the coder should report the specific unilateral code performed rather than using discontinued or reduced service modifiers.

Correct: Modifier 59 is used to identify procedures or services that are not normally reported together but are appropriate under the circumstances, such as a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. In this scenario, the cholecystectomy and the umbilical hernia repair are distinct procedures performed at different sites, making Modifier 59 (or the more specific X{EPSU} modifiers if required by the payer) the correct choice to bypass NCCI bundling edits.

Incorrect: Modifier 22 is used for increased procedural services that are significantly greater than typically required, not for reporting two distinct procedures. Reporting without modifiers would lead to the secondary procedure being bundled into the primary one by NCCI edits, resulting in underpayment. Using an unlisted HCPCS code for a procedure that has a specific CPT code is incorrect and violates coding conventions.

Takeaway: Modifier 59 is the standard mechanism to indicate that a procedure is a distinct and separate service from other procedures performed on the same day.

Correct: In ASC coding, distinguishing between planned and unplanned procedures within a global period is critical for compliance. Modifier -58 is used for staged or related procedures that were planned at the time of the original procedure, while modifier -78 is used for an unplanned return to the operating room for a related procedure. Reviewing the operative notes and anesthesia logs is the only way to accurately abstract the physician’s intent and the clinical necessity of the subsequent procedure, ensuring the correct modifier is applied and the reimbursement is accurate.

Incorrect: Applying modifier -79 to all procedures is incorrect because that modifier is reserved for unrelated procedures performed during a postoperative period. Prohibiting the reporting of multiple procedures within a 10-day window is not a standard ASC guideline, as multiple procedures are allowed if they are medically necessary and documented. Relying on scheduling software logs over the physician’s dictated operative report violates the principle that the clinical record is the primary source of truth for medical coding and auditing.

Takeaway: Accurate ASC coding for procedures on different timelines requires a thorough review of clinical documentation to correctly apply modifiers -58, -78, or -79 based on the relationship between the procedures.

Correct: According to AHIMA and AAPC coding compliance guidelines, when there is conflicting documentation within the medical record (misuncertainties), the coder must not choose one document over another. The appropriate action is to query the physician to resolve the discrepancy. This ensures that the final coded data is accurate and that the medical record is legally sound, especially when the operative report contradicts the consent and preoperative records.

Incorrect: Coding based solely on the operative report narrative ignores the significant compliance risk and potential for a dictation error when other parts of the record conflict. Coding for the osteotomy based on the consent form is also incorrect because it may result in reporting a procedure that was not actually performed. Using an unlisted code is inappropriate when specific codes exist for the procedures described; the issue is one of documentation consistency, not a lack of a specific CPT code.

Takeaway: When documentation within the medical record is inconsistent or contradictory, the coder must query the provider to ensure the record is reconciled before code assignment.

Correct: According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient is treated for an injury resulting from maltreatment or neglect, the injury code (such as a fracture or open wound) should be sequenced as the primary diagnosis. This is followed by the appropriate code from category T74.- (Adult or child abuse, neglect and other maltreatment, confirmed) or T76.- (Suspected maltreatment). Additionally, external cause codes should be used to identify the perpetrator and the location of the incident to provide a complete clinical and legal record.

Incorrect: Sequencing the maltreatment code as the primary diagnosis is incorrect because the acute physical injury that necessitated the surgical procedure takes precedence in the diagnostic hierarchy. Using only Z-codes is insufficient because Z-codes for social determinants do not capture the clinical severity or the specific ‘maltreatment syndrome’ defined by the T-codes. Omitting the codes entirely for liability or confidentiality reasons is a violation of coding compliance and HIPAA, as HIPAA governs the protection of data rather than the omission of clinically documented diagnostic information required for accurate billing.

Takeaway: In ASC coding for mistreatment, the physical injury is sequenced first, followed by the specific T-category maltreatment codes and external cause codes to ensure full regulatory compliance.

Correct: In an Ambulatory Surgery Center (ASC) facility setting, Modifier 74 is used to indicate that a procedure was terminated after the administration of anesthesia (which includes local, regional, or general anesthesia) or after the procedure was started. Since the patient had already received a regional nerve block, the facility is entitled to the full payment rate for the intended procedure, and Modifier 74 is the correct modifier to append to the CPT code for the facility fee.

Incorrect: Modifier 73 is incorrect because it is specifically reserved for procedures discontinued after the patient is prepared but before the administration of anesthesia. Modifier 53 is used by physicians to report discontinued professional services and is not recognized for ASC facility billing. Reporting only HCPCS Level II codes for supplies and drugs is inappropriate because it fails to capture the facility’s overhead, preparation, and clinical resources consumed prior to the cancellation, which are bundled into the CPT code with the appropriate modifier.

Takeaway: For ASC facility billing, the administration of anesthesia is the determining factor between using Modifier 73 (before anesthesia) and Modifier 74 (after anesthesia) for discontinued procedures.

Correct: Modifier 74 is specifically designed for Ambulatory Surgery Center (ASC) facility billing to indicate that a procedure was terminated after the administration of anesthesia or after the procedure had started (e.g., incision made, intubation). In the context of an audit or financial investigation, using this modifier correctly ensures that the facility is reimbursed at 100% of the ASC rate while accurately reflecting that the full procedure was not completed due to medical necessity or patient safety concerns.

Incorrect: Modifier 73 is incorrect because it is used for procedures discontinued before the administration of anesthesia, which results in a 50% payment reduction for the facility. Modifier 53 is incorrect because it is a professional fee modifier used by physicians to report discontinued procedures and is not recognized for ASC facility billing. Modifier 52 is incorrect because it refers to a partial reduction of a service that was intentionally limited by the physician, rather than a procedure that was terminated due to unexpected complications or safety risks.

Takeaway: ASC facility coding requires the use of Modifier 74 for procedures discontinued after the induction of anesthesia to ensure accurate reimbursement and compliance with reporting standards.

Correct: In the context of Ambulatory Surgery Center (ASC) facility billing, modifier -74 is used to indicate that a procedure was terminated after the administration of anesthesia (local, regional, or general) or after the procedure was started. Since the patient had already been intubated and received general anesthesia before the cardiac arrhythmia occurred, modifier -74 is the appropriate modifier to reflect that the procedure was discontinued after anesthesia induction.

Incorrect: Modifier -73 is incorrect because it is used for procedures discontinued prior to the administration of anesthesia. Modifier -53 is incorrect in this context because it is used by physicians to report discontinued procedures on professional claims, whereas ASC facility claims require -73 or -74. Reporting only supplies and drugs (Option D) is incorrect because ASC reimbursement for discontinued procedures is captured by reporting the procedure code with the appropriate modifier to trigger the correct percentage of the facility fee.

Takeaway: For ASC facility billing, the distinction between modifier -73 and -74 depends entirely on whether anesthesia has been administered before the procedure is discontinued.

Correct: In the ASC setting, ICD-10-CM guidelines for outpatient services require that coders report the highest degree of certainty. When a procedure is performed based on a clinical misdoubt or suspected condition, the coder must wait for definitive results, such as pathology or radiology reports, rather than coding the suspected condition as confirmed. A control that mandates the correlation of the operative report with these ancillary findings ensures that the final claim reflects the actual findings of the procedure, thereby reducing the risk of reporting unconfirmed diagnoses.

Incorrect: Using the preoperative diagnosis is incorrect because outpatient coding guidelines prioritize postoperative findings and definitive diagnoses over initial suspicions. Coding suspected or probable conditions as confirmed is a direct violation of ICD-10-CM outpatient coding conventions, which state that such conditions should not be coded as if they exist. Relying solely on the anesthesia record is an insufficient control because the anesthesiologist may not have access to the final surgical findings or pathology results, leading to a high risk of abstracting incomplete or inaccurate diagnostic data.

Takeaway: ASC coders must code to the highest level of clinical certainty by prioritizing definitive postoperative findings and pathology results over preoperative suspicions or suspected conditions.

Correct: According to CPT coding guidelines, Modifier 52 (Reduced Services) must be used when a procedure is partially reduced or eliminated at the physician’s discretion. If a surgeon documents that they performed less than the full description of a CPT code due to patient preferences or ‘mispreferences,’ the coder must append Modifier 52 to accurately reflect the work performed. Failing to do so results in the facility receiving the full reimbursement for a reduced service, which is considered upcoding and can lead to significant legal and financial penalties under the False Claims Act.

Incorrect: The suggestion that a Patient Preference Waiver is required for documentation is incorrect, as the operative report itself is the primary legal document for surgical details. The claim that patient-requested deviations automatically invalidate medical necessity is false; the necessity of the underlying condition remains, but the execution of the procedure is what changed. Updating the Charge Description Master with unique codes for patient modifications is not a requirement of HIPAA Transaction and Code Set standards, which rely on standardized CPT and HCPCS codes rather than facility-created variations.

Takeaway: Accurate coding in an ASC requires appending Modifier 52 when documented surgical deviations result in a reduced service, regardless of whether the change was driven by physician judgment or patient preference.