Association of Social Work Boards Advanced Generalist Examination (ASWB Advanced Generalist)

Correct: According to clinical guidelines and coding standards for Colony-Stimulating Factors (CSFs), G-CSF (such as filgrastim or pegfilgrastim) should not be administered in the period between 24 hours before and 24 hours after the administration of cytotoxic chemotherapy. This is because CSFs stimulate the proliferation of hematopoietic progenitor cells; if chemotherapy is given while these cells are rapidly dividing, they become more susceptible to the cytotoxic effects of the drugs, potentially worsening myelosuppression rather than mitigating it.

Incorrect: Administering CSF concurrently with chemotherapy is contraindicated because it increases the sensitivity of myeloid cells to the chemotherapy. Waiting for the ANC to reach a nadir before administration describes a reactive or therapeutic use rather than the prophylactic use indicated for high-risk dose-dense regimens. Administering CSF within 12 hours before chemotherapy is also incorrect, as the 24-hour window must be respected to ensure the stimulated cells are not destroyed by the upcoming treatment.

Takeaway: To ensure patient safety and therapeutic efficacy, colony-stimulating factors must be administered at least 24 hours after the completion of a chemotherapy dose.

Correct: CPT 38222 (Diagnostic bone marrow; aspiration and biopsy) and chemotherapy administration are subject to NCCI edits. To bypass these edits using modifier 59 (or the more specific X{EPSU} modifiers), the documentation must clearly support that the procedure was performed at a separate anatomic site, through a separate incision, or during a distinct session. An internal audit recommendation should focus on ensuring that the clinical documentation justifies the use of the modifier to prevent ‘unbundling’ and potential fraud or abuse charges.

Incorrect: The suggestion to automatically append modifier 51 is incorrect because modifier 51 is used for multiple procedures but does not bypass NCCI edits, and ‘automatic’ appending without clinical review is a significant compliance risk. Using modifier 25 is incorrect because that modifier is reserved for Evaluation and Management (E/M) services, not for procedural codes like chemotherapy administration. Suggesting that the services can never be reported together is incorrect because NCCI edits allow for both services to be billed if they are truly distinct and documented appropriately; a blanket policy of non-reporting leads to inaccurate data and lost legitimate revenue.

Takeaway: Accurate oncology coding requires clinical documentation that justifies the use of modifiers to bypass NCCI edits by demonstrating distinct procedural sites or purposes.

Correct: According to CPT guidelines and NCCI edits, when a central venous access device is removed and a new one is inserted through the same venous access site during the same session, the removal is not separately reportable. The work of removing the old device is considered an integral part of the replacement process. Reporting both CPT 36590 and 36561 in this context constitutes unbundling, leading to an overpayment risk.

Incorrect: The use of modifier 52 is incorrect because the removal is not a ‘reduced’ service but rather a bundled component of the replacement. While documenting medical necessity and using appropriate complication codes is important for clinical accuracy, the primary compliance risk in the scenario described is the billing of two codes that are bundled by NCCI edits. Using a ‘re-evaluation’ code is not a standard CPT convention for port replacements; the issue is specifically the bundling of the removal (36590) into the replacement/insertion code.

Takeaway: When replacing a Port-a-Cath through the same access site, the removal of the old device is bundled into the code for the insertion of the new device.

Correct: For non-emergency ambulance services, particularly for oncology patients, the primary compliance risk is medical necessity. Medicare and other payers require that the patient’s condition be such that any other form of transportation (like a wheelchair van or private car) would be medically contraindicated. A valid Physician Certification Statement (PCS) is a regulatory requirement for scheduled non-emergency transports, and clinical documentation must support the ‘bed-confined’ status or other medical reasons why an ambulance is the only safe option.

Incorrect: Matching modifiers and mileage is a basic billing check but does not address the underlying risk of whether the transport was medically necessary in the first place. Billing all patients with catheters as Specialty Care Transport (SCT) constitutes upcoding and potential fraud, as SCT is reserved for critically injured or ill patients requiring a level of care beyond the scope of a paramedic. Reviewing provider licensure is a standard administrative control but does not mitigate the specific risk of medical necessity denials or recoupment.

Takeaway: The most effective control for ambulance service risks is ensuring clinical documentation and physician certification explicitly justify the medical necessity of the transport mode.

Correct: In the context of oncology and hematology, the methodology of the biopsy is driven by the diagnostic requirement. Fine Needle Biopsy (FNB) needles are designed to obtain a core of tissue that preserves the histological architecture. This is particularly effective and often necessary for the accurate subtyping of lymphomas (such as distinguishing between various Non-Hodgkin subtypes) and the immunohistochemical staining required for many oncologic diagnoses, whereas Fine Needle Aspiration (FNA) primarily collects individual cells for cytological examination.

Incorrect: FNA is not the exclusive recommendation for lymphoma; in fact, the lack of architectural detail in FNA can often lead to inconclusive results for lymphoma subtyping. Brush cytology is a superficial sampling technique and is ineffective for submucosal lesions or deep tissue layers. Jumbo forceps actually provide a larger tissue volume than cold forceps and are often preferred when deeper or more substantial mucosal samples are needed, contrary to the claim that cold forceps allow for deeper penetration.

Takeaway: Fine Needle Biopsy (FNB) is superior to Fine Needle Aspiration (FNA) when preserved tissue architecture is required for complex oncologic diagnoses like lymphoma subtyping.

Correct: National Coverage Determinations (NCDs) are developed by CMS to describe the circumstances under which Medicare will pay for items or services nationwide. They are the highest level of authority. Local Coverage Determinations (LCDs) are developed by individual Medicare Administrative Contractors (MACs) to provide coverage guidance for their specific jurisdictions when no NCD exists or to supplement an NCD with additional details. An LCD can never be less restrictive than an NCD, nor can it contradict a national policy.

Incorrect: The claim that LCDs take precedence over NCDs is incorrect because national policy always overrides local policy. The suggestion that providers must wait for a CMS ruling in the absence of an NCD is false; MACs have the authority to create LCDs to address coverage in the absence of national guidance. Finally, NCDs and LCDs are not merely advisory; they are mandatory requirements that define medical necessity, and failure to adhere to the specified ICD-10-CM linkages or clinical thresholds (such as hemoglobin levels for ESAs) will result in claim denials.

Takeaway: National Coverage Determinations (NCDs) provide the baseline for nationwide coverage, while Local Coverage Determinations (LCDs) fill gaps for specific jurisdictions without contradicting national standards.

Correct: According to CMS and HCPCS Level II guidelines, when a drug is supplied in a single-dose vial and a portion is discarded, the JW modifier must be used to report the wasted amount on a separate line item. This ensures that the provider is reimbursed for the entire vial while maintaining an accurate record of the amount actually administered to the patient. The documentation in the medical record must support both the administered and the discarded amounts.

Incorrect: Using an unclassified drug code like J3490 is incorrect when a specific HCPCS code (like J9312 for Rituximab) exists. The JZ modifier is specifically used to certify that no drug was wasted, which would be inaccurate in this scenario where waste occurred. Consolidating waste from multiple patients into a single claim is a violation of billing standards, as drug administration and waste must be reported on a per-patient, per-encounter basis to maintain the integrity of the patient’s medical and billing record.

Takeaway: Proper HCPCS Level II reporting for oncology drugs requires the use of the JW modifier for discarded amounts from single-dose vials to ensure compliance and accurate reimbursement.

Correct: In oncology and hematology coding, a total resection (such as a total splenectomy) is defined by the complete anatomical removal of the organ. This is clinically and procedurally evidenced by the ligation of the primary vascular supply (the main artery and vein) and the removal of the entire structure. If any portion of the organ is left behind to maintain physiological function, it must be coded as a partial resection, regardless of the complexity of the case.

Incorrect: The weight of the tissue is a pathological measurement that varies by patient and disease state and does not define the surgical scope. The diagnosis (malignant vs. benign) may influence the medical necessity or the specific code set used, but it does not dictate whether a resection is classified as partial or total. Intraoperative time is a factor for using modifiers related to increased procedural services but does not change the fundamental definition of the resection type performed.

Takeaway: A total resection is defined by the complete anatomical removal of the organ and its primary vascular supply, whereas a partial resection involves leaving functional tissue behind.

Correct: According to CPT coding guidelines for endoscopic procedures, the biopsy code (e.g., 43239) is reported only once per session, even if multiple biopsies are performed on the same or different sites during that procedure. The code descriptor specifically accounts for ‘single or multiple’ biopsies, making it inappropriate to bill multiple units or separate codes for each specimen obtained during the same EGD.

Incorrect: Reporting separate codes for each anatomical site (stomach and duodenum) is incorrect because the EGD biopsy code covers all biopsies performed during that specific entry. Using modifier -51 is inappropriate for multiple biopsies within the same endoscopic code as it is not a separate procedure. Upcoding to a surgical excision based on pathology results is a violation of coding standards; the code must reflect the procedure actually performed (biopsy), not the diagnosis or the complexity of the findings.

Takeaway: In endoscopic coding for oncology staging, a single biopsy code covers all specimens obtained during the procedure, regardless of the number of sites sampled.