CHC Healthcare Billing and Coding Compliance Questions and Answers 3

Question 1

The 'two-midnight rule' in Medicare billing primarily governs which type of admission?

Accepted Answer

Inpatient hospital admissions and whether they meet criteria for Part A payment

Answer

CMS's two-midnight rule states that inpatient admission is generally appropriate if the physician expects the patient to require hospital care spanning at least two midnights, qualifying for Part A reimbursement.

Question 2

When a provider receives an overpayment from Medicare, within how many days must it be reported and returned under the ACA's 60-day rule?

Accepted Answer

60 days

Answer

The Affordable Care Act requires that identified Medicare/Medicaid overpayments be reported and returned within 60 days of identification, after which retention of the overpayment becomes a False Claims Act violation.

Question 3

What is the primary purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?

Accepted Answer

To notify a Medicare patient in advance that a service may not be covered and shift financial liability to the patient

Answer

An ABN informs a Medicare beneficiary that a specific service may be denied as not medically necessary, allowing the patient to decide whether to proceed and accept financial responsibility.

Question 4

Which coding system is primarily used for inpatient hospital diagnoses and procedures for Medicare billing under the MS-DRG system?

Accepted Answer

ICD-10-CM/PCS (International Classification of Diseases)

Answer

ICD-10-CM is used for diagnosis coding and ICD-10-PCS for inpatient procedure coding, which together drive the MS-DRG assignment and corresponding Medicare payment.

Question 5

What does 'clawback' mean in the context of healthcare billing compliance?

Accepted Answer

The recovery by a payer of previously paid funds determined to be improper or overpaid

Answer

A clawback occurs when a payer (such as Medicare) recovers funds from a provider due to identified overpayments, billing errors, or compliance violations.

CHC - Certified in Healthcare Compliance Practice Test

CHC - Certified in Healthcare Compliance Practice Test

CHC Healthcare Billing and Coding Compliance Questions and Answers 3