Certified Medical Coding Specialist Regulatory Frameworks & Compliance 2 — Questions and Answers
Question 1: Which federal act established the National Correct Coding Initiative (NCCI) to prevent improper coding?
- The Balanced Budget Act of 1997
- The Social Security Act of 1965
- The Omnibus Budget Reconciliation Act of 1993 (Correct answer)
- The Tax Equity and Fiscal Responsibility Act of 1982
Correct answer: The Omnibus Budget Reconciliation Act of 1993
NCCI was established under OBRA 1993 to promote correct coding and control improper coding that leads to inappropriate Medicare payments.
Question 2: A coder notices a physician consistently upcodes E/M services. Under the False Claims Act, who can file a qui tam lawsuit on behalf of the government?
- Only the Office of Inspector General
- Any private individual with knowledge of the fraud (Correct answer)
- Only licensed attorneys
- Only CMS auditors
Correct answer: Any private individual with knowledge of the fraud
The False Claims Act's qui tam provision allows any private individual (a 'whistleblower' or relator) who has knowledge of fraud against the government to file a lawsuit.
Question 3: Under HIPAA, a covered entity must provide a patient with an accounting of disclosures for the past how many years?
- 3 years
- 5 years
- 6 years (Correct answer)
- 10 years
Correct answer: 6 years
HIPAA requires covered entities to provide patients with an accounting of certain disclosures of PHI for the six years prior to the date of the request.
Question 4: Which CMS program uses Recovery Audit Contractors (RACs) to identify and correct improper Medicare payments?
- Comprehensive Error Rate Testing (CERT)
- Recovery Audit Program (Correct answer)
- Targeted Probe and Educate (TPE)
- Zone Program Integrity Contractor (ZPIC)
Correct answer: Recovery Audit Program
The Recovery Audit Program uses RACs to identify and recover improper Medicare payments made to healthcare providers.
Question 5: A hospital submits a claim for a service that was not medically necessary. Which regulation most directly governs this violation?
- Anti-Kickback Statute
- Stark Law
- Medicare Conditions of Participation
- Social Security Act Section 1862(a)(1) (Correct answer)
Correct answer: Social Security Act Section 1862(a)(1)
Social Security Act Section 1862(a)(1) is the statutory basis for denying Medicare payment for services that are not reasonable and medically necessary.
Question 6: Which document outlines the specific diagnoses and procedures that are covered by Medicare for a given service, serving as a reference for medical necessity?
- Local Coverage Determination (LCD) (Correct answer)
- National Coverage Determination (NCD)
- Medicare Benefit Policy Manual
- Advance Beneficiary Notice (ABN)
Correct answer: Local Coverage Determination (LCD)
LCDs are developed by Medicare Administrative Contractors (MACs) and specify diagnoses/conditions under which a service is considered medically necessary in their jurisdiction.
Question 7: When an Advance Beneficiary Notice (ABN) is required and the patient signs it, what is the financial consequence if Medicare denies the claim?
- The provider absorbs the cost
- The patient is liable for the charges (Correct answer)
- The insurance company pays secondary
- The claim is automatically appealed
Correct answer: The patient is liable for the charges
A signed ABN transfers financial liability to the beneficiary for services that Medicare may not cover, allowing the provider to collect from the patient.
Certified Medical Coding Specialist Regulatory Frameworks & Compliance 2
Which federal act established the National Correct Coding Initiative (NCCI) to prevent improper coding?