What You Need.

You will need CPT, HCPCS, and ICD-10 coding books, or software.   The use of an encoder software program is allowed and encouraged.  The use of internet searches or any other tool you would have access to on the job is allowed and encouraged.  This assessment is not “theory” based and requires skills in the real world of coding and billing. The certification is a pre-employment coding evaluation that verifies a coder’s ability to work successfully in a professional fee coding job. Do not take this exam if you are not able to successfully research and apply payer-specific coding requirements including but not limited to Medi-Cal, all Medicare MACs, and the published rules of various private payers.  To bear this credential, you will be required to strictly follow the  Code of Ethics Agreement.

50 Questions – Test Time:  90 minutes

What’s Tested

The CEPFG exam tests a coder’s ability to accurately code the physician side of a patient encounter, including coding for all professional fees (Pro Fees) according to reimbursement and coverage rules.   While specialty experience is valuable,  each example is chosen based on coding conventions that are necessary in all medical specialties, including the ability to research a service and code it appropriately per payer regulations without an experienced precedent to follow. The coder must be able to identify all appropriate CPT®,  HCPCS, modifiers,  and ICD-10-CM codes and report them compliantly per Medicare,  and Medicaid (including Medi-Cal) rules.  Claim types tested with including E/M for multiple locations (i.e. office, ED, critical care, etc.), Surgery, Radiology, Pathology, and Medicine.

The successful examinee will be an proficient in interpreting rules including (but not limited to):

• 1995 and 1997 CMS Documentation Guidelines for Evaluation and Management Services  and Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30  6 – Evaluation and Management Service Codes – General (Codes99201 – 99499)
• AMA 2021 CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354  99355  99356  99XXX) Code and Guideline Changes and Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30  6 – Evaluation and Management Service Codes – General (Codes99201 – 99499)
• California NMP: DEPARTMENT OF HEALTH CARE SERVICES Provider Manuals Part 2-General Medicine Manual Non-Physician Medical Practitioners (NMP) (non ph) (Revision Date Feb 17 2021) and Non-Physician Medical Practitioners (NMP) Billing Example: CMS-1500 (non ph cms) (Revision Date Aug 14 2020)
• California Part 1 – Medi-Cal Program & Eligibility Manual and Part 2 – General Medicine Manual
• ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 – UPDATED January 1 2021
• INCIDENT TO: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  4 – Evaluation and Management (E/M) Services Furnished Incident to Physician’s Service by Nonphysician Practitioners
• INSUFFICIENT DOCUMENTATION: Medicare Program Integrity Manual Chapter 3 – Verifying Potential Errors and Taking (no documentation denies the claim as not reasonable and necessary)
• MEDICAL NECESSITY: Section 1862(a) (1) (A) of the Social Security Act directs the following: “No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member ”
• MODIFIER 24: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  6 – Payment for Evaluation and Management Services Provided During Global Period of Surgery
• MODIFIER 25: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  6 – Payment for Evaluation and Management Services Provided During Global Period of Surgery B   CPT Modifier “-25” – Significant Evaluation and Management Service by Same Physician on Date of Global Procedure:  If a significant separately identifiable evaluation and management service is performed  the appropriate E & M code should be reported utilizing modifier 25   For an evaluation and management service provided on the same day  a different diagnosis is not required
• MODIFIER 50 LT  RT- Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 40.7 – Claims for Bilateral Surgeries
• MODIFIER 51 – Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 40.6 – Claims for Multiple Surgeries
• MODIFIER 59 XE  XS  XP  XU – Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 40.6 – Claims for Multiple Surgeries
• MODIFIER: MODIFIER 25: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners
• NEW VS EST PT: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  7 – Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 – 99215) A   Definition of New Patient for Selection of E/M Visit Code
• PREVENTIVE WITH SICK: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  2 – Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service
• SAME GROUP: Medicare Claims and Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30 6  7 – Payment for Office or Other Outpatient Evaluation and management (E/M) Visits (Codes 99201 – 99215) A   Definition of New Patient for Selection of E/M Visit Code and 30  6  5 – Physicians in Group Practice
• SIGNATURE/DATE: CMS Medicare Program Integrity Manual Chapter 3  Section 3  3  2  4
• SURGERY ASSISTANT: Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 20.4.3 – Assistant-at Surgery-Services
• TEACHING PHYSICIANS: Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 100 Teaching Physician Services
• TIME G2212 HCPCS: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional with or without direct patient contact (List separately in addition to CPT® codes 99205  99215 for office or other outpatient evaluation and management services)