Testing and Quality Assurance Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Testing and Quality Assurance flashcards as text
A recovery audit contractor (RAC) denies a claim stating the procedure was not medically necessary. The FIRST step the facility should take is:
Answer: Review the medical record documentation to determine whether it supports medical necessity, then decide whether to appeal
The facility should first review the documentation to assess whether it supports medical necessity before deciding whether to appeal the RAC denial.
Which metric is MOST useful for tracking the effectiveness of a CDI program over time?
Answer: Case mix index (CMI) trend compared to clinical complexity
Tracking the case mix index (CMI) trend against the facility's actual clinical complexity is the best measure of CDI program effectiveness in capturing the true severity of illness.
When a coding audit identifies systemic errors affecting multiple coders, the MOST appropriate organizational response is:
Answer: Implement a facility-wide education initiative and revise coding policies to address the root cause
Systemic errors affecting multiple coders indicate a process or education gap that requires facility-wide corrective action including education and policy revision.
A hospital's compliance plan requires that all voluntary self-disclosures to OIG be made promptly when overpayments are discovered. This is primarily driven by which regulation?
Answer: The 60-day overpayment rule under the ACA
The ACA's 60-day rule requires providers to report and return identified Medicare/Medicaid overpayments within 60 days of identification to avoid False Claims Act liability.
An inpatient coding audit finds a coder used an Excludes1 note incorrectly by assigning both the excluded codes together. What does an Excludes1 note indicate?
Answer: The two conditions cannot occur together and should never be coded simultaneously
An Excludes1 note means 'NOT CODED HERE' — the two conditions cannot occur together, and assigning both codes simultaneously is incorrect.
Which of the following is the BEST indicator of high-quality outpatient E/M coding accuracy?
Answer: E/M level assignments consistently supported by documented medical decision making or time
Per 2021 E/M guideline revisions, outpatient E/M level selection must be based on medical decision making (MDM) or total time, both of which must be documented to support the level billed.
A coder documents a query was sent to a physician who did not respond. The coder then codes based on the clinical indicators in the record. According to AHIMA query guidelines, what should happen?
Answer: Document the non-response and code only what is clearly documented; do not assume the queried diagnosis
If a physician does not respond to a query, coders must code based only on what is clearly documented in the medical record and document the unanswered query in the audit trail.