Certified Coding Associate Exam Reimbursement and Compliance 2 — Questions and Answers
Question 1: What is the primary purpose of the Medicare Physician Fee Schedule (MPFS)?
- To assign DRGs for inpatient claims
- To set payment rates for physician services under Medicare Part B (Correct answer)
- To determine hospital outpatient payment rates
- To establish Medicaid reimbursement rates
Correct answer: To set payment rates for physician services under Medicare Part B
The MPFS establishes the payment rates for physician and other professional services billed under Medicare Part B.
Question 2: A compliance program in a healthcare organization is primarily designed to:
- Maximize reimbursement for all services
- Prevent, detect, and correct non-compliance with laws and regulations (Correct answer)
- Increase patient volume
- Reduce documentation requirements
Correct answer: Prevent, detect, and correct non-compliance with laws and regulations
A compliance program is designed to prevent, detect, and correct violations of healthcare laws, regulations, and standards.
Question 3: Which of the following best describes the concept of 'unbundling' in medical billing?
- Combining multiple services into one CPT code
- Reporting individual components of a procedure when a comprehensive code exists (Correct answer)
- Adding modifiers to bundled codes
- Using the correct E/M level for documentation
Correct answer: Reporting individual components of a procedure when a comprehensive code exists
Unbundling means billing individual components of a procedure separately when a single comprehensive CPT code already covers all components.
Question 4: What does 'clean claim' mean in medical billing?
- A claim submitted on paper instead of electronically
- A claim submitted without any errors that can be processed for payment (Correct answer)
- A claim that has been paid in full
- A claim for preventive services only
Correct answer: A claim submitted without any errors that can be processed for payment
A clean claim is one that is free of errors and contains all required information so it can be processed for payment without delay.
Question 5: The False Claims Act imposes liability for which of the following?
- Billing errors made in good faith
- Knowingly submitting fraudulent claims to government healthcare programs (Correct answer)
- Late submission of Medicare claims
- Using outdated CPT codes
Correct answer: Knowingly submitting fraudulent claims to government healthcare programs
The False Claims Act imposes civil liability on those who knowingly submit false or fraudulent claims to federal healthcare programs like Medicare.
Question 6: What is a Coordination of Benefits (COB) situation?
- When a patient has no insurance coverage
- When a patient has more than one insurance plan covering the same services (Correct answer)
- When Medicare is the sole payer
- When a provider does not accept insurance
Correct answer: When a patient has more than one insurance plan covering the same services
COB occurs when a patient is covered by more than one insurance plan, and the plans coordinate to avoid overpayment.
Certified Coding Associate Exam Reimbursement and Compliance 2
What is the primary purpose of the Medicare Physician Fee Schedule (MPFS)?