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 Recovery Audit Contractor (RAC) identifies an overpayment. What is the provider's FIRST step in the appeals process?
Answer: Request a redetermination from the Medicare Administrative Contractor
The first level of the Medicare appeals process is requesting a redetermination from the MAC within 120 days of receiving the initial determination.
Which measure is MOST commonly used to evaluate the effectiveness of a coding compliance program over time?
Answer: Trending error rates across multiple audit periods
Trending error rates across audit periods allows compliance officers to evaluate whether education and corrective actions are improving coding accuracy.
Under HIPAA, a covered entity that discovers a breach affecting 500 or more individuals must notify HHS:
Answer: Without unreasonable delay and within 60 days of discovery
HIPAA requires notification to HHS without unreasonable delay and no later than 60 days after discovery of a breach affecting 500 or more individuals.
A coder assigns a higher-weighted DRG than the documentation supports to increase reimbursement. This practice is known as:
Answer: DRG creep (upcoding)
DRG creep, also called upcoding, refers to assigning a higher-severity or higher-paying DRG than the clinical documentation justifies.
Which government agency is primarily responsible for investigating healthcare fraud and abuse?
Answer: OIG
The Office of Inspector General (OIG) is the primary federal agency responsible for investigating healthcare fraud, waste, and abuse.
When performing a focused audit on a specific DRG, what is the recommended minimum sample size for statistical validity?
Answer: 25 to 30 records
A sample of 25 to 30 records is generally considered the minimum for statistical validity in a focused coding audit.
A compliance program's effectiveness is BEST demonstrated by:
Answer: Documented corrective actions and measurable improvements in error rates
Documented corrective actions and measurable reductions in error rates are the strongest evidence that a compliance program is actually working.