CCDS Healthcare Compliance Law for CDI (False Claims Act, Anti-Kickback, HIPAA) — Questions and Answers
Question 1: The False Claims Act (FCA) is most directly relevant to CDI professionals because:
- It prohibits hospitals from recruiting CDI specialists from competing facilities
- Submitting claims based on documentation that was manipulated or fabricated to increase reimbursement constitutes fraud subject to federal civil and criminal penalties (Correct answer)
- It requires that all physician queries be submitted in writing within 24 hours of admission
- It mandates that CDI specialists hold a federally issued license to review medical records
Correct answer: Submitting claims based on documentation that was manipulated or fabricated to increase reimbursement constitutes fraud subject to federal civil and criminal penalties
The FCA imposes liability on any person or entity that knowingly submits false claims to federal healthcare programs. When CDI activity results in diagnoses being documented without clinical support in order to increase DRG weight, the resulting claim can constitute a false claim — exposing the hospital and individuals to treble damages and exclusion from federal programs.
Question 2: Under the False Claims Act, an employee who reports their employer's fraudulent billing practices to the federal government is legally called a:
- Concurrent reviewer
- Qui tam relator (Correct answer)
- Compliance arbitrator
- Documentation auditor
Correct answer: Qui tam relator
The FCA's qui tam provision allows a private individual (the relator) to file a lawsuit on behalf of the government and receive a portion of any recovery. CDI specialists who witness improper documentation practices that lead to false claims may have whistleblower standing under this provision.
Question 3: The Anti-Kickback Statute (AKS) is most directly relevant to CDI practice when:
- A CDI specialist sends a compliant open-ended query to a physician about a missing secondary diagnosis
- A hospital offers financial incentives to physicians contingent on their documenting specific higher-weighted diagnoses (Correct answer)
- A coder assigns an incorrect principal diagnosis without physician query
- A patient disputes a hospital bill and requests an itemized statement
Correct answer: A hospital offers financial incentives to physicians contingent on their documenting specific higher-weighted diagnoses
The AKS prohibits offering, paying, soliciting, or receiving anything of value to induce referrals or services covered by federal healthcare programs. Paying physicians bonuses tied to documenting diagnoses that increase reimbursement can be construed as a remuneration scheme that violates the AKS.
Question 4: HIPAA is relevant to CDI practice primarily in that it:
- Sets minimum documentation standards for physician queries under the Privacy Rule
- Protects patient health information accessed during chart review and limits its use to permitted purposes such as treatment, payment, and healthcare operations (Correct answer)
- Prohibits CDI specialists from sending queries to physicians in paper form
- Mandates that electronic health records be used at all hospitals with CDI programs
Correct answer: Protects patient health information accessed during chart review and limits its use to permitted purposes such as treatment, payment, and healthcare operations
HIPAA's Privacy and Security Rules govern how protected health information (PHI) is accessed, used, and disclosed. CDI chart reviews involve access to PHI, and CDI specialists must ensure that information is used only for permitted purposes (e.g., improving documentation for coding and billing) and is not disclosed improperly.
Question 5: A CDI director is pressured by hospital administration to query physicians only when likely to result in a higher-weighted MS-DRG, regardless of whether clinical indicators support the query. This practice most directly violates:
- The Emergency Medical Treatment and Labor Act (EMTALA)
- The False Claims Act and the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (Correct answer)
- The Stark Law prohibiting physician self-referral
- The Joint Commission's documentation improvement standards
Correct answer: The False Claims Act and the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice
Sending queries designed to drive a particular documentation outcome — rather than to clarify genuine clinical ambiguity — is a hallmark of a non-compliant query program. It can lead to unsupported diagnoses on claims, constituting false claims under the FCA. The ACDIS/AHIMA Practice Brief explicitly prohibits leading or biased queries intended to influence reimbursement.
Question 6: According to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, which of the following best describes a compliant physician query?
- A query that suggests the diagnosis the hospital's CDI program needs to meet its case-mix index targets
- A query presenting clinical indicators from the record and asking the physician to clarify or confirm a diagnosis in an unbiased, open-ended or multiple-choice format (Correct answer)
- A verbal query documented only in the CDI specialist's personal notes, not in the medical record
- A query sent only retrospectively after final coding is complete to avoid influencing care decisions
Correct answer: A query presenting clinical indicators from the record and asking the physician to clarify or confirm a diagnosis in an unbiased, open-ended or multiple-choice format
A compliant query must be based on clinical indicators present in the record, be unbiased in format (not leading the physician toward a financially favorable answer), and be clearly documented as part of the medical record. Queries sent purely for reimbursement purposes or that suggest a specific answer violate the ACDIS/AHIMA Practice Brief and raise FCA risk.
CCDS Healthcare Compliance Law for CDI (False Claims Act, Anti-Kickback, HIPAA)
The False Claims Act (FCA) is most directly relevant to CDI professionals because: