Certified Medical Coding Specialist Quality Control & Assurance 3

Question 1

A Recovery Audit Contractor (RAC) identifies an overpayment. What is the provider's FIRST step in the appeals process?

Accepted Answer

Request a redetermination from the Medicare Administrative Contractor

Answer

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?

Accepted Answer

Trending error rates across multiple audit periods

Answer

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:

Accepted Answer

Without unreasonable delay and within 60 days of discovery

Answer

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:

Accepted Answer

DRG creep (upcoding)

Answer

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?

Accepted Answer

OIG

Answer

The Office of Inspector General (OIG) is the primary federal agency responsible for investigating healthcare fraud, waste, and abuse.

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Quality Control & Assurance 3