CCT Billing and Coding Compliance 2 — Questions and Answers
Question 1: What is the National Provider Identifier (NPI)?
- A state-issued license number assigned to healthcare providers
- A unique 10-digit identification number issued to healthcare providers by CMS under HIPAA (Correct answer)
- A billing code assigned by private insurance companies to contracted providers
- A Medicare beneficiary identification number used on insurance cards
Correct answer: A unique 10-digit identification number issued to healthcare providers by CMS under HIPAA
The NPI is a unique 10-digit identification number issued by CMS to HIPAA-covered healthcare providers, used to identify providers in all standard electronic transactions.
Question 2: What does 'incident to' billing allow under Medicare Part B?
- Billing for services rendered in a hospital emergency department under one facility fee
- Billing for services provided by non-physician practitioners under direct physician supervision at the physician's full reimbursement rate (Correct answer)
- Billing for preventive screenings without a supporting diagnosis code
- Combining charges from multiple dates of service onto a single claim
Correct answer: Billing for services provided by non-physician practitioners under direct physician supervision at the physician's full reimbursement rate
'Incident to' billing allows services by non-physician practitioners (e.g., nurses, medical assistants) provided under direct physician supervision to be billed under the supervising physician's NPI at 100% of the Medicare fee schedule.
Question 3: Under the False Claims Act, what is 'qui tam' litigation?
- A government audit of healthcare claims for potential overpayments
- A lawsuit filed by the DOJ directly against a healthcare provider
- A whistleblower lawsuit filed by a private individual on behalf of the government (Correct answer)
- An administrative appeal process for denied Medicare claims
Correct answer: A whistleblower lawsuit filed by a private individual on behalf of the government
Qui tam provisions of the False Claims Act allow private individuals (relators/whistleblowers) to file lawsuits on behalf of the government against those who defraud federal programs and share in any monetary recovery.
Question 4: What is a 'clean claim' in Medicare billing?
- A claim submitted with no diagnosis codes attached
- A claim submitted electronically rather than on paper
- A claim that contains all required information and can be processed without requesting additional data (Correct answer)
- A claim that has already been approved and paid by the payer
Correct answer: A claim that contains all required information and can be processed without requesting additional data
A clean claim contains no defects or improprieties and includes all required data elements, allowing the payer to adjudicate it without needing to request additional information.
Question 5: What is 'phantom billing' in the context of healthcare fraud?
- Billing for services at a higher complexity level than was actually provided
- Billing for services, procedures, or supplies that were never actually provided to the patient (Correct answer)
- Billing under another provider's NPI without their knowledge
- Submitting a claim after the timely filing deadline has passed
Correct answer: Billing for services, procedures, or supplies that were never actually provided to the patient
Phantom billing involves submitting claims for services or items that were never actually rendered to the patient, constituting outright fraud against Medicare, Medicaid, or other payers.
Question 6: What is an Advance Beneficiary Notice (ABN) primarily used for?
- To notify a patient before surgery of potential medical complications
- To inform a Medicare beneficiary that Medicare may not cover a service and the patient may be financially responsible (Correct answer)
- To obtain prior authorization from Medicare before providing an elective service
- To formally appeal a Medicare claim denial on behalf of a beneficiary
Correct answer: To inform a Medicare beneficiary that Medicare may not cover a service and the patient may be financially responsible
An ABN is given to Medicare beneficiaries before receiving potentially non-covered services so they can make an informed decision about receiving the service and assume financial responsibility if Medicare denies payment.
Question 7: What does 'coordination of benefits' (COB) mean in billing compliance?
- The process of combining multiple diagnosis codes onto a single claim form
- The process that determines the order in which multiple insurance plans pay when a patient has more than one coverage (Correct answer)
- The distribution of a single payment across multiple providers for the same service
- The process of verifying patient insurance eligibility prior to rendering services
Correct answer: The process that determines the order in which multiple insurance plans pay when a patient has more than one coverage
Coordination of benefits is the process used to determine which insurance plan is primary and which is secondary when a patient carries more than one health insurance policy, preventing duplicate payments.
CCT Billing and Coding Compliance 2
What is the National Provider Identifier (NPI)?