AAPC Billing Documentation & Compliance 2 — Questions and Answers
Question 1: A physician documents a patient encounter but fails to sign the note. Under CMS guidelines, this claim is:
- Payable as long as the diagnosis is correct
- Considered incomplete documentation and may be denied (Correct answer)
- Acceptable if the NPI is on the claim
- Valid if the date of service is recorded
Correct answer: Considered incomplete documentation and may be denied
CMS requires that all documentation be authenticated (signed and dated) by the ordering/treating provider to support medical necessity.
Question 2: Which federal law primarily governs the privacy and security of patient health information used in billing?
- EMTALA
- HIPAA (Correct answer)
- Stark Law
- False Claims Act
Correct answer: HIPAA
HIPAA's Privacy and Security Rules regulate how protected health information (PHI) may be used and disclosed, including for billing purposes.
Question 3: A biller notices a claim was submitted with a date of service that predates the physician's licensure. This is an example of:
- Upcoding
- Unbundling
- Fraudulent billing (Correct answer)
- Duplicate billing
Correct answer: Fraudulent billing
Submitting a claim for services rendered before a provider was licensed to perform them constitutes fraudulent billing.
Question 4: The OIG Work Plan is most useful to billers because it:
- Lists all CPT codes for the current year
- Identifies areas the OIG intends to audit for compliance issues (Correct answer)
- Provides fee schedules for Medicare services
- Establishes E/M documentation guidelines
Correct answer: Identifies areas the OIG intends to audit for compliance issues
The OIG Work Plan outlines the OIG's planned audit and review activities, helping practices identify high-risk billing areas to monitor.
Question 5: Under the False Claims Act, qui tam provisions allow:
- Providers to appeal denied claims in federal court
- Private individuals to file lawsuits on behalf of the government and share in any recovery (Correct answer)
- Insurance companies to recoup overpayments without notice
- Billers to report coding errors anonymously to the OIG
Correct answer: Private individuals to file lawsuits on behalf of the government and share in any recovery
Qui tam provisions of the False Claims Act allow whistleblowers (relators) to sue on the government's behalf and receive a portion of recovered funds.
Question 6: When a payer requests medical records to support a claim, the biller should send:
- Only the superbill
- Only the UB-04 or CMS-1500 form
- Documentation that directly supports the billed services and diagnosis (Correct answer)
- The entire medical chart regardless of what was requested
Correct answer: Documentation that directly supports the billed services and diagnosis
Billers should submit only the relevant documentation that supports the specific services billed, as requested by the payer.
Question 7: A compliance program's internal audit function is designed to:
- Replace external audits by Medicare contractors
- Proactively identify and correct billing errors before they become systemic problems (Correct answer)
- Generate revenue by catching underpaid claims only
- Satisfy HIPAA security rule requirements
Correct answer: Proactively identify and correct billing errors before they become systemic problems
Internal audits allow an organization to identify patterns of billing errors and implement corrective action before government audits occur.
AAPC Billing Documentation & Compliance 2
A physician documents a patient encounter but fails to sign the note.
Under CMS guidelines, this claim is: