CAC Professional Ethics & Standards 3 — Questions and Answers
Question 1: Which of the following best describes 'medical necessity' in EMS transport coding?
- The transport was requested by a physician regardless of the patient's condition
- The patient's condition required ambulance transport and could not have been met by other means (Correct answer)
- The patient or family requested ambulance transport
- The distance to the hospital exceeded 10 miles
Correct answer: The patient's condition required ambulance transport and could not have been met by other means
Medical necessity for ambulance transport means the patient's condition required the level of care only an ambulance could provide and transport by other means would be contraindicated.
Question 2: An EMS billing coder receives a gift card from a vendor in exchange for recommending their billing software. This arrangement likely violates which law?
- The False Claims Act
- The Anti-Kickback Statute (Correct answer)
- The Emergency Medical Treatment and Labor Act (EMTALA)
- The Stark Law
Correct answer: The Anti-Kickback Statute
The Anti-Kickback Statute prohibits offering, soliciting, or receiving anything of value to induce referrals or recommendations involving federal health care programs.
Question 3: What is the purpose of a Compliance Plan in an EMS agency?
- To maximize revenue by identifying all billable services
- To establish policies that prevent, detect, and correct fraud, waste, and abuse (Correct answer)
- To eliminate the need for internal audits
- To satisfy state licensing requirements only
Correct answer: To establish policies that prevent, detect, and correct fraud, waste, and abuse
A compliance plan creates a framework for identifying and addressing billing and operational practices that could violate laws or regulations.
Question 4: Which of the following is an example of 'waste' in EMS billing, as opposed to 'fraud'?
- Intentionally billing for services not provided
- Consistently coding ALS transport without reviewing documentation due to time pressure (Correct answer)
- Altering patient records to support a higher level of care
- Knowingly submitting duplicate claims
Correct answer: Consistently coding ALS transport without reviewing documentation due to time pressure
Waste involves careless or inefficient practices that result in unnecessary costs, while fraud involves intentional deception.
Question 5: What is the significance of an ABN (Advance Beneficiary Notice) in EMS billing?
- It guarantees Medicare will pay for the transport
- It informs the Medicare beneficiary that the service may not be covered and they may be liable for payment (Correct answer)
- It is required for all ALS transports
- It replaces the physician certification statement
Correct answer: It informs the Medicare beneficiary that the service may not be covered and they may be liable for payment
An ABN notifies Medicare beneficiaries before a service is rendered that Medicare may not cover it, allowing them to decide whether to proceed and accept financial responsibility.
Question 6: A CAC coder finds conflicting information between the EMS run report and the hospital's triage notes regarding the patient's chief complaint. What is the best course of action?
- Use the hospital notes since they are more authoritative
- Code based on the EMS run report since EMS documented care rendered
- Query the EMS crew or supervisor for clarification before coding (Correct answer)
- Choose whichever documentation supports the higher reimbursement level
Correct answer: Query the EMS crew or supervisor for clarification before coding
When documentation conflicts, the coder should seek clarification from the appropriate clinical staff rather than guessing or selecting based on financial impact.
Question 7: Under the OIG's seven elements of an effective compliance program, which element involves training staff on compliance policies?
- Monitoring and auditing
- Open lines of communication
- Education and training (Correct answer)
- Responding to detected offenses
Correct answer: Education and training
Education and training is one of the OIG's seven elements and ensures all employees understand compliance requirements and their responsibilities.
CAC Professional Ethics & Standards 3
Which of the following best describes 'medical necessity' in EMS transport coding?