National Dental Specialty Examination (NDSE) – Oral and Maxillofacial Radiology

Correct: The global surgical package for a major procedure with a 90-day period is designed to include all necessary services normally furnished by a surgeon before, during, and after a procedure. This specifically includes the preoperative evaluation on the day before or the day of surgery, the surgery itself, and routine postoperative care, such as follow-up visits to monitor the patient’s recovery and the function of the nervous system pathways addressed, for the duration of the 90-day period.

Incorrect: The initial evaluation where the decision for surgery is made is not part of the global package and is billed separately, often with modifier 57. The global period for major surgery is 90 days, not 30, and it extends beyond the inpatient stay to include all routine outpatient follow-up. Global packages are time-bound and do not cover lifetime care for a chronic condition.

Takeaway: A 90-day global surgical package bundles the preoperative, intraoperative, and routine postoperative services into a single payment to ensure comprehensive care for the surgical recovery period.

Correct: Effective translation into action requires adherence to both CPT and ICD-10-CM guidelines. For major surgeries like penile revascularization or prosthesis implantation, a 90-day global period is standard. The coder must ensure that all related services within this window are bundled, while also following the coding convention of sequencing the underlying etiology (such as diabetes or vascular disease) before the manifestation (the sexual dysfunction). This ensures both clinical accuracy and regulatory compliance.

Incorrect: Using unlisted codes to bypass global package rules is a violation of coding standards and can lead to audits and penalties. Misrepresenting organic dysfunctions as psychogenic to avoid global periods constitutes fraudulent coding and ignores the anatomical and physiological basis of the condition. Arbitrarily changing the length of a global period from the CPT-defined 90 days to 10 days is a failure of internal controls and results in inaccurate billing and potential overpayment or underpayment issues.

Takeaway: Accurate coding for sexual dysfunction packages requires integrating the 90-day global surgical rules with precise etiology-manifestation sequencing for the reproductive and vascular systems.

Correct: The most effective way to address risks in global coding is to ensure that the clinical documentation fully supports the bundled service. This involves a multidisciplinary review to verify that all components—such as medical monitoring, nutritional therapy, and psychiatric care—were provided as defined by the global code’s requirements. This prevents unbundling and ensures that the level of care billed matches the level of care delivered.

Incorrect: Separately billing for components that are already included in a global package is considered unbundling, which is a significant compliance risk. Using a standardized template without clinical validation can lead to billing for services not rendered or misrepresenting the patient’s actual condition. Prioritizing individual codes over a required global bundle is a failure to follow coding guidelines and can result in claim denials or audits for fraudulent billing.

Takeaway: Regulatory compliance in global billing requires rigorous validation that clinical documentation supports every element included in the bundled service package.

Correct: In the context of neurocognitive disorders, coding guidelines require the identification of both the underlying condition (the etiology, such as Alzheimer’s) and the presence or absence of behavioral disturbances (the manifestation). This dual-coding approach is critical for global packages and risk-adjustment models because it captures the full clinical picture of the patient’s nervous system impairment and the resulting resource intensity required for management.

Incorrect: Focusing solely on anatomy while ignoring behavioral symptoms fails to meet the specificity required by ICD-10-CM for neurocognitive disorders. Prioritizing acute events like TIAs over the primary chronic neurodegenerative process misrepresents the patient’s long-term care needs within a global package. Using generic codes is incorrect because it ignores the specific physiological pathways and clinical manifestations that define the severity of the neurocognitive disorder.

Takeaway: Effective coding for global neurocognitive packages requires capturing both the underlying etiology and the associated behavioral manifestations to fully document the patient’s neurological status.

Correct: Evaluating the design and operational effectiveness of automated cross-checks is the most appropriate audit action because it directly addresses the control failure that allowed the unbundling of global packages. In a CIA context, the auditor must focus on the underlying controls that prevent or detect the manipulation of data (in this case, medical coding) used to circumvent compliance thresholds like gift policies.

Incorrect: Increasing the frequency of filings does not address the root cause of the miscoding or the circumvention of the threshold. Reviewing medical necessity documentation is a clinical audit function rather than a control-focused internal audit of the billing process. Implementing training on physiological differences, while educational, does not provide the auditor with evidence regarding the effectiveness of the controls governing the billing and reporting systems.

Takeaway: Internal auditors must prioritize the evaluation of automated controls and coding logic when investigating the circumvention of compliance thresholds through data manipulation or unbundling of services.

Correct: Unbundling is a significant compliance risk in medical coding. Global codes for sleep studies are specifically designed to include various physiological monitoring components such as EEG, EOG, and EMG. Billing these components separately violates the National Correct Coding Initiative (NCCI) edits and can lead to overpayment, audits, and legal penalties. Automated claim scrubs serve as an effective internal control to identify and prevent these errors before submission.

Incorrect: The risk of under-coding is a financial concern but does not address the compliance violation of unbundling described in the scenario. Using clinical shortcuts like BMI to assign codes is inaccurate and does not address the structural coding issue. Splitting dates of service for the technical and professional components is a form of fragmentation and is considered a fraudulent billing practice rather than a mitigation strategy.

Takeaway: Internal auditors must ensure that global coding packages for sleep-wake disorders are not unbundled into individual physiological components to prevent compliance violations and overpayment.

Correct: The correct action is to perform a comparative analysis of the documented services against CPT and payer-specific global package definitions. The global surgical package typically includes all routine preoperative, intraoperative, and postoperative care. A coder must verify if the subsequent services for the elimination disorder are truly part of the routine recovery or if they meet specific criteria (such as a new problem or a return to the operating room) that allow for separate reporting with appropriate modifiers.

Incorrect: Appending modifier 24 automatically is incorrect because that modifier is reserved for unrelated evaluation and management services, and its routine use without clinical justification is considered improper coding. Re-submitting encounters after the global period expires to bypass edits is a form of fraudulent billing and misrepresents the timing of the services. Unbundling a primary surgical code into component codes to avoid global period restrictions is a violation of National Correct Coding Initiative (NCCI) guidelines and constitutes upcoding.

Takeaway: Accurate coding within a global period requires a thorough comparison of documented postoperative care against the specific definitions of the surgical package to prevent improper unbundling or fraudulent reporting.

Correct: In the context of an internal audit, once a discrepancy is identified, the auditor must perform a root cause analysis to understand the failure in the control environment. By evaluating the internal controls and the data flow between clinical and billing systems, the auditor can determine if the documentation gap is due to a system error, a lack of training, or a process design flaw, which is essential for developing effective corrective actions.

Correct: Implementing a mandatory documentation template is a preventive control that ensures all clinical components of a global package—such as the physiological monitoring of the digestive system—are documented at the point of care. This ensures that the coding is supported by medical necessity and clinical evidence, which is essential for the integrity of global billing packages in medical coding.

Incorrect: Retrospective reviews are detective controls that identify errors after they occur rather than preventing them. Educational diagrams, while helpful for clinical knowledge, do not provide a control mechanism to ensure documentation compliance. Appending modifiers to indicate missing documentation is an improper coding practice and does not resolve the underlying compliance failure regarding the global package requirements.

Takeaway: Preventive controls, such as mandatory EHR templates, are the most effective way to ensure that all clinical components of a global coding package are documented and compliant with payer requirements.