Billing Documentation & Compliance Flashcards
7 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Billing Documentation & Compliance flashcards as text
Which of the following describes 'unbundling' in medical billing?
Answer: Billing separately for component services that should be billed under a single comprehensive code
Unbundling is billing individual component codes separately when a comprehensive code (such as a surgical package) should encompass all of those services.
Under the CMS 60-day rule, a provider who identifies an overpayment must:
Answer: Report and return it within 60 days of identification
The 60-day rule requires Medicare and Medicaid providers to report and return identified overpayments within 60 days of identification or face FCA liability.
A Medicare Recovery Audit Contractor (RAC) is authorized to review claims and:
Answer: Identify and correct improper payments, including both overpayments and underpayments
RACs review claims for both overpayments (which must be returned) and underpayments (which can be corrected in the provider's favor).
Which documentation element is most critical to establish medical necessity for an ordered diagnostic test?
Answer: A diagnosis or sign/symptom that explains why the test was ordered
A diagnosis or sign/symptom that is consistent with Medicare's coverage criteria is the key element demonstrating medical necessity for a diagnostic test.
The Anti-Kickback Statute (AKS) prohibits offering, paying, soliciting, or receiving anything of value in exchange for:
Answer: Referring patients for services covered by federal health care programs
The AKS prohibits remuneration intended to induce or reward referrals of items or services reimbursable by federal health care programs.
A provider's compliance plan should include which of the following as one of its core elements?
Answer: Written standards of conduct and policies addressing compliance risks
The OIG's seven elements of an effective compliance program include written standards, policies, and procedures that address identified compliance risks.
When a claim is submitted with an incorrect billing provider NPI, the most likely outcome is:
Answer: The claim will be denied or rejected due to enrollment mismatch
If the billing NPI does not match the payer's enrollment records, the claim will typically be rejected or denied for provider identification errors.