Certified Medical Coding Specialist Quality Control & Assurance 3 — Questions and Answers
Question 1: A Recovery Audit Contractor (RAC) identifies an overpayment. What is the provider's FIRST step in the appeals process?
- File a complaint with CMS
- Request a redetermination from the Medicare Administrative Contractor (Correct answer)
- Submit a new claim with corrected codes
- Contact the OIG directly
Correct 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.
Question 2: Which measure is MOST commonly used to evaluate the effectiveness of a coding compliance program over time?
- Number of claims submitted per month
- Trending error rates across multiple audit periods (Correct answer)
- Total reimbursement received quarterly
- Number of coders on staff
Correct 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.
Question 3: Under HIPAA, a covered entity that discovers a breach affecting 500 or more individuals must notify HHS:
- Within 30 days of discovery
- Within 60 days of the end of the calendar year
- Without unreasonable delay and within 60 days of discovery (Correct answer)
- Annually at the end of the fiscal year
Correct 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.
Question 4: A coder assigns a higher-weighted DRG than the documentation supports to increase reimbursement. This practice is known as:
- Unbundling
- DRG creep (upcoding) (Correct answer)
- Downcoding
- Fragmentation
Correct answer: DRG creep (upcoding)
DRG creep, also called upcoding, refers to assigning a higher-severity or higher-paying DRG than the clinical documentation justifies.
Question 5: Which government agency is primarily responsible for investigating healthcare fraud and abuse?
- CMS
- OIG (Correct answer)
- AHRQ
- FDA
Correct answer: OIG
The Office of Inspector General (OIG) is the primary federal agency responsible for investigating healthcare fraud, waste, and abuse.
Question 6: When performing a focused audit on a specific DRG, what is the recommended minimum sample size for statistical validity?
- 5 records
- 10 records
- 25 to 30 records (Correct answer)
- 100 records
Correct 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.
Question 7: A compliance program's effectiveness is BEST demonstrated by:
- The number of policies written
- Documented corrective actions and measurable improvements in error rates (Correct answer)
- The size of the compliance department
- The frequency of staff meetings
Correct 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.
Certified Medical Coding Specialist Quality Control & Assurance 3
A Recovery Audit Contractor (RAC) identifies an overpayment.
What is the provider's FIRST step in the appeals process?