CDIP Healthcare Compliance and Ethics 2 — Questions and Answers
Question 1: Under the False Claims Act, what is the term for a private individual who files a lawsuit on behalf of the government alleging healthcare fraud?
- Relator (Correct answer)
- Arbitrator
- Ombudsman
- Mediator
Correct answer: Relator
A relator (also called a whistleblower) files a qui tam lawsuit under the False Claims Act on behalf of the government.
Question 2: Which federal statute prohibits healthcare providers from referring patients to entities in which they have a financial relationship, unless an exception applies?
- Stark Law (Correct answer)
- Anti-Kickback Statute
- False Claims Act
- HIPAA Privacy Rule
Correct answer: Stark Law
The Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare/Medicaid patients to entities where they or an immediate family member have a financial interest.
Question 3: A CDI specialist notices a physician consistently documents 'pneumonia' without specifying the type. What is the MOST appropriate first step?
- Submit a physician query requesting clarification of the pneumonia type (Correct answer)
- Code the case as unspecified pneumonia without querying
- Report the physician to the compliance officer immediately
- Change the documentation to bacterial pneumonia based on clinical indicators
Correct answer: Submit a physician query requesting clarification of the pneumonia type
A compliant physician query requesting clarification of the pneumonia type is the appropriate first step to improve documentation specificity.
Question 4: Which element is REQUIRED for a physician query to be considered compliant according to AHIMA guidelines?
- The query must be clear, concise, and not leading (Correct answer)
- The query must suggest the highest-severity diagnosis
- The query must be submitted only after discharge
- The query must be approved by the compliance officer first
Correct answer: The query must be clear, concise, and not leading
AHIMA guidelines require physician queries to be clear, concise, and non-leading to avoid influencing documentation inappropriately.
Question 5: What does the term 'upcoding' refer to in the context of healthcare billing compliance?
- Billing for a more complex or higher-reimbursement service than was actually provided (Correct answer)
- Assigning codes that are more specific than the documentation supports
- Adding modifier codes to increase reimbursement legitimately
- Updating outdated codes to current ICD versions
Correct answer: Billing for a more complex or higher-reimbursement service than was actually provided
Upcoding is a fraudulent practice of billing for a higher-level or more expensive service than was actually rendered.
Question 6: A hospital's compliance program identifies a pattern of incomplete surgical documentation. Under OIG guidelines, what is the recommended corrective action?
- Conduct physician education, implement monitoring, and document corrective steps taken (Correct answer)
- Immediately suspend the physicians involved from surgical privileges
- Report all affected cases to CMS for investigation
- Retroactively amend all operative reports
Correct answer: Conduct physician education, implement monitoring, and document corrective steps taken
OIG guidelines recommend education, monitoring, and documented corrective action as the appropriate response to identified compliance issues.
Question 7: Which principle of healthcare ethics requires clinicians and coders to act in the best interest of the patient?
- Beneficence (Correct answer)
- Autonomy
- Justice
- Nonmaleficence
Correct answer: Beneficence
Beneficence is the ethical principle of acting in the patient's best interest and providing positive benefit.
CDIP Healthcare Compliance and Ethics 2
Under the False Claims Act, what is the term for a private individual who files a lawsuit on behalf of the government alleging healthcare fraud?