Certified Coding Associate Exam Reimbursement and Compliance 1 — Questions and Answers
Question 1: What does the acronym 'MS-DRG' stand for?
- Medical-Surgical Diagnostic Resource Group
- Medicare Severity Diagnosis Related Group (Correct answer)
- Multi-System Disease Reference Guide
- Medical Standard Documentation Review Group
Correct answer: Medicare Severity Diagnosis Related Group
MS-DRG stands for Medicare Severity Diagnosis Related Group, used by Medicare for inpatient hospital reimbursement.
Question 2: Which federal law primarily governs healthcare privacy and the security of patient health information?
- HITECH Act
- HIPAA (Correct answer)
- ACA
- COBRA
Correct answer: HIPAA
HIPAA (Health Insurance Portability and Accountability Act) governs the privacy and security of protected health information.
Question 3: What is a Remittance Advice (RA)?
- A physician's order for treatment
- A document sent by payers explaining payment or denial of claims (Correct answer)
- A patient's insurance card
- A document authorizing a procedure
Correct answer: A document sent by payers explaining payment or denial of claims
A Remittance Advice is sent by payers to explain how claims were processed, including payment amounts or denial reasons.
Question 4: The Outpatient Prospective Payment System (OPPS) uses which payment unit?
- DRG
- APC (Correct answer)
- RBRVS
- RUG
Correct answer: APC
OPPS uses Ambulatory Payment Classifications (APCs) to reimburse hospitals for outpatient services.
Question 5: Which of the following is an example of upcoding?
- Submitting a claim with a lower-level E/M code than documented
- Billing for a higher-level service than what was actually provided (Correct answer)
- Reporting secondary diagnoses correctly
- Using modifiers to indicate bilateral procedures
Correct answer: Billing for a higher-level service than what was actually provided
Upcoding is the fraudulent practice of billing for a higher-level or more expensive service than what was actually performed.
Question 6: What is the purpose of a National Correct Coding Initiative (NCCI) edit?
- To assign DRGs for inpatient stays
- To prevent improper payment of procedure codes that should not be billed together (Correct answer)
- To validate ICD-10-CM codes on claims
- To identify fraudulent provider billing
Correct answer: To prevent improper payment of procedure codes that should not be billed together
NCCI edits are bundling edits that prevent Medicare from paying separately for services that should be billed together.
Certified Coding Associate Exam Reimbursement and Compliance 1
What does the acronym 'MS-DRG' stand for?