Quality Control & Assurance Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Control & Assurance flashcards as text
A coding audit reveals that a coder consistently upcodes evaluation and management services. What is the MOST appropriate corrective action?
Answer: Provide targeted education and reaudit within 90 days
Targeted education followed by a reaudit is the standard corrective action for identified coding errors, allowing the coder to improve while confirming the issue is resolved.
Which statistical sampling method selects every nth record from a list to create a representative audit sample?
Answer: Systematic sampling
Systematic sampling selects every nth record from a population, providing an even distribution across the dataset.
A hospital's compliance program identifies a pattern of billing for services not documented. Under the False Claims Act, what is the potential penalty per false claim?
Answer: $2,587 to $25,868
The False Claims Act imposes civil monetary penalties of $2,587 to $25,868 per false claim (adjusted annually for inflation), plus treble damages.
Which document outlines the standards and expectations for coding accuracy and serves as the benchmark during internal audits?
Answer: Coding policies and procedures manual
The coding policies and procedures manual establishes the standards against which coding accuracy is measured during internal audits.
A quality review finds that 8 out of 40 audited records contain coding errors. What is the error rate?
Answer: 20%
8 errors divided by 40 records equals 0.20, or a 20% error rate.
Which type of audit is performed BEFORE claims are submitted to payers to prevent billing errors?
Answer: Prospective audit
A prospective audit reviews claims before submission to identify and correct errors, preventing overpayments and denials.
When a coder queries a physician about an unclear diagnosis, the query must be:
Answer: Non-leading, presenting clinical indicators without suggesting a specific answer
AHIMA and ACDIS guidelines require physician queries to be non-leading, presenting clinical indicators and allowing the physician to respond without bias.