National Dental Specialty Examination (NDSE) – Periodontics

Correct: Verifying the patient’s identity with a government-issued photo ID and the physical Social Security card is the most compliant method to resolve data discrepancies. This practice aligns with the Red Flags Rule, which requires healthcare providers to implement identity theft prevention programs to detect and respond to patterns or practices that indicate the possibility of identity theft.

Incorrect: Overriding the system alert without verification compromises data integrity and increases the risk of medical identity theft. Creating a duplicate patient profile leads to fragmented medical records, which can result in patient safety issues and billing errors. Relying solely on the insurance provider’s data is insufficient because the insurance company’s records may also be inaccurate or based on fraudulent information; the provider must verify the identity of the person standing before them.

Takeaway: Strict adherence to identity verification protocols during registration is essential for maintaining data integrity and complying with federal identity theft prevention regulations.

Correct: According to ICD-10-CM guidelines, the word ‘with’ in the Alphabetic Index (under Diabetes) assumes a causal relationship between the diabetes and the chronic kidney disease. Therefore, a combination code from category E11 (Type 2 diabetes mellitus) must be used to show the relationship. Additionally, an instructional note within the Tabular List for category E11 requires an additional code from category N18 to identify the specific stage of the chronic kidney disease.

Incorrect: Assigning separate codes without the combination link fails to follow the ‘with’ convention in the ICD-10-CM Index. Sequencing the CKD as primary is incorrect because the diabetes is the underlying etiology of the manifestation in this scenario. Using category E13 is inappropriate because the provider specifically documented Type 2 diabetes, and E11 codes are specifically designed to include various manifestations and complications, not just uncomplicated cases.

Takeaway: In ICD-10-CM, diabetes with chronic kidney disease requires a combination code from the diabetes category followed by a specific stage code from the N18 category.

Correct: Substantive testing of clinical documentation against coding sequences is the standard for verifying the accuracy of Medicaid claims. Ensuring the principal diagnosis aligns with the ‘condition established after study’ (the official definition for principal diagnosis) directly addresses the regulatory concern regarding improper sequencing and potential upcoding. This approach provides objective evidence that the codes submitted for reimbursement are supported by the medical record.

Incorrect: Focusing only on high-value claims or contractual rates is a financial audit approach that ignores the underlying clinical accuracy and sequencing risks identified by regulators. Recommending auto-sequencing based on Relative Value Units (RVUs) is a violation of coding ethics and constitutes a form of upcoding, which would exacerbate the regulatory issue. While a peer-review system is a useful internal control, using it as the sole metric for remediation without independent audit verification is insufficient to satisfy regulatory requirements for objective remediation.

Takeaway: Internal audit remediation for Medicaid coding must involve verifying that clinical documentation supports the sequencing of diagnoses according to official guidelines to prevent improper reimbursement.

Correct: The False Claims Act (FCA) defines “knowing” and “knowingly” to mean that a person has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required to establish liability.

Correct: In a Staff Model HMO, the organization owns the facilities and employs the physicians directly on a salary basis. This is the most restrictive form of HMO, and billing for services outside this closed system (except for emergencies) usually results in total denial of coverage, which is a critical distinction for reimbursement specialists to understand when managing claim denials and appeals.

Incorrect: Contracting with IPAs describes the Network or IPA model, not the Staff Model. Allowing members to seek care anywhere with varying reimbursement levels describes a PPO or Point of Service (POS) plan rather than a Staff Model HMO. While gatekeepers are common in many HMOs, the defining feature of the Staff Model is the employment relationship and facility ownership, not just the referral mechanism.

Takeaway: Understanding the structural differences between MCO models, such as the Staff Model HMO, is essential for accurately predicting reimbursement outcomes and managing claim denials in a medical billing environment.

Correct: The first step in addressing any performance deficiency in a value-based purchasing (VBP) model is to identify the root cause. By auditing clinical documentation and workflows, the facility can determine whether the clinical staff failed to provide the prophylaxis (a quality of care issue) or if the care was provided but not documented or coded correctly (a data integrity issue). This distinction is critical for developing an effective corrective action plan.

Incorrect: Increasing chargemaster rates is an inappropriate response to quality deficiencies and does not address the underlying performance issue. Prioritizing high-acuity codes solely to manipulate the case-mix index without clinical justification can be seen as upcoding or fraud. Requesting an exclusion of a metric due to staffing shortages is generally not a valid reason for non-compliance in standard VBP programs and does not solve the internal process failure.

Takeaway: Effective remediation of value-based purchasing deficiencies requires a systematic audit to differentiate between actual clinical performance gaps and administrative documentation errors.

Correct: According to NCCI Procedure-to-Procedure (PTP) edits and CPT guidelines, the implantation of mesh (CPT 49568) is an add-on code that is only permitted to be reported with specific base codes, such as those for incisional or ventral hernia repairs. It is not compatible with inguinal hernia repair codes (like 49505), as the work of mesh placement is already included in the relative value units (RVUs) of the inguinal repair. Therefore, billing them together is a violation of NCCI bundling rules.

Incorrect: Appending modifier 59 is inappropriate because the mesh placement is not a distinct or separate service in the context of an inguinal hernia repair; it is a standard part of the procedure. Modifier 51 is used for multiple procedures to adjust payment but does not override NCCI PTP edits. The distinction between initial and recurrent hernias does not change the fact that 49568 is restricted to specific hernia types (incisional/ventral) and cannot be used with inguinal repairs.

Takeaway: NCCI PTP edits prevent unbundling by identifying services that are integral to a primary procedure or restricted to specific clinical contexts.

Correct: In the medical reimbursement process, capturing external cause codes such as the Place of Occurrence (Y92) is critical for Coordination of Benefits (COB). This information allows the billing department to determine if another entity, such as a workers’ compensation carrier or a homeowner’s insurance policy, should be the primary payer before the health insurance is billed. Failure to collect this at registration delays the identification of the correct payer.

Incorrect: The National Correct Coding Initiative (NCCI) primarily focuses on CPT and HCPCS code combinations to prevent unbundling, rather than the relationship between primary and supplemental ICD-10 codes. Status codes (Y99) indicate the patient’s status (e.g., civilian, military) and are not the determining factor for the level of an Evaluation and Management (E/M) service. While incomplete documentation is a compliance risk, the omission of a supplemental code does not inherently constitute a False Claims Act violation without evidence of ‘knowing’ and ‘willful’ intent to defraud the government.

Takeaway: Thorough data collection during patient registration regarding the circumstances of an injury is essential for accurate payer sequencing and liability determination.

Correct: In medical billing and reimbursement, when an auditor identifies a discrepancy between clinical documentation and the assigned ICD-10-CM codes, the standard professional response is to query the provider. This process allows the provider to clarify the documentation, ensuring that the final code reflects the true clinical picture of the patient and adheres to the highest level of specificity required by coding guidelines.

Incorrect: Reassigning codes to a generic category without provider input can lead to inaccurate data and potential under-reimbursement. Assigning codes based solely on pharmacology or medications is a violation of coding principles, as a diagnosis must be explicitly documented by a provider. Marking claims as errors without allowing for a query process ignores the clinical documentation improvement (CDI) framework and may lead to inaccurate audit conclusions regarding the provider’s intent or the patient’s actual condition.

Takeaway: The provider query process is an essential component of billing audits to resolve documentation ambiguities and ensure ICD-10-CM coding accuracy and clinical validity.

Correct: Integrated episode-of-care tracking systems are essential because bundled payments involve multiple providers across different settings (e.g., acute care, rehab, home health). To manage the financial risk and ensure the total cost does not exceed the target price, the lead entity must have visibility into the total spend across the entire continuum of care. This allows for real-time monitoring and coordination to prevent cost overruns.

Incorrect: Manual verification of codes for separate claims is a fee-for-service mindset that does not address the holistic nature of a bundled payment episode. Delaying claim submission for 90 days would create severe cash flow problems and is not a recognized control for managing clinical costs during the episode. Capping specialist rates at the MPFS does not provide the necessary oversight of the total episode cost or the quality of care coordination required to make the bundle financially successful.

Takeaway: Managing bundled payments necessitates a centralized data aggregation system to monitor total episode spending and ensure alignment with financial targets across all providers.