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
Which of the following is an example of a 'never event' as defined by CMS that affects hospital reimbursement?
Answer: Wrong-site surgery
Wrong-site surgery is classified as a 'never event' or serious reportable event; CMS does not reimburse for the additional costs of treating conditions that result from these events.
In a coding quality program, 'interrater reliability' refers to:
Answer: The degree of agreement between two or more coders coding the same record
Interrater reliability measures how consistently different coders assign the same codes to the same records, indicating standardization of coding practices.
A hospital implements a computer-assisted coding (CAC) system. Quality assurance for CAC-generated codes should include:
Answer: Coder review and validation of all CAC-suggested codes before submission
CAC systems require human review and validation because they can suggest incorrect codes; coders must verify clinical accuracy before claim submission.
The 'two-midnight rule' affects inpatient admission quality reviews by establishing that:
Answer: CMS generally expects inpatient admission to be appropriate when a physician reasonably expects a stay spanning at least two midnights
The two-midnight rule states that CMS considers inpatient admission appropriate when the physician reasonably expects the patient to need hospital care spanning two midnights.
Which action would BEST demonstrate that a coding department's quality improvement plan is working?
Answer: A statistically significant reduction in error rate from one audit cycle to the next
A measurable, statistically significant reduction in error rate between audit cycles is the strongest evidence of effective quality improvement.
Under the Stark Law, which of the following financial relationships between a physician and an entity is PROHIBITED (unless an exception applies)?
Answer: A physician referring Medicare patients to a hospital where they have an ownership interest
Stark Law prohibits physician self-referrals to entities where the physician has a financial relationship for designated health services billed to Medicare, unless a specific exception applies.
A coder notices that a physician's documentation includes a diagnosis not supported by any clinical indicators in the record. The CORRECT action is to:
Answer: Query the physician to clarify the clinical basis for the diagnosis before coding it
When documentation appears inconsistent with clinical indicators, the coder should query the physician for clarification rather than coding an unsupported diagnosis or omitting it without verification.