CHC Healthcare Billing and Coding Compliance Questions and Answers 1 — Questions and Answers
Question 1: Which federal statute prohibits submitting claims for services that were not actually rendered to Medicare or Medicaid?
- Anti-Kickback Statute
- False Claims Act (Correct answer)
- Stark Law
- HITECH Act
Correct answer: False Claims Act
The False Claims Act prohibits knowingly submitting false or fraudulent claims for payment to any federal program, including Medicare and Medicaid.
Question 2: What is 'upcoding' in the context of healthcare billing compliance?
- Billing for a service with a higher-value code than the service actually performed (Correct answer)
- Using outdated CPT codes on claims
- Submitting duplicate claims for the same service
- Assigning codes before a procedure is completed
Correct answer: Billing for a service with a higher-value code than the service actually performed
Upcoding involves intentionally billing a more expensive procedure code than the one actually performed to receive higher reimbursement.
Question 3: What does 'unbundling' refer to in healthcare billing?
- Splitting one patient encounter into multiple claims
- Billing component services separately when a bundled code should be used to reduce reimbursement inflation (Correct answer)
- Combining multiple patients' charges on one claim
- Separating physician and facility fees incorrectly
Correct answer: Billing component services separately when a bundled code should be used to reduce reimbursement inflation
Unbundling means billing individual components of a procedure separately when a single bundled CPT code should be used, resulting in higher total reimbursement than intended.
Question 4: Which organization publishes the National Correct Coding Initiative (NCCI) edits used to prevent improper Medicare billing?
- AMA
- CMS (Correct answer)
- OIG
- AHA
Correct answer: CMS
CMS developed and publishes the NCCI to promote national correct coding methodologies and prevent improper payment of Part B claims.
Question 5: In medical documentation for billing, what does the principle of 'if it wasn't documented, it wasn't done' mean for compliance?
- Electronic records are preferred over paper
- Services billed must be supported by clinical documentation in the medical record (Correct answer)
- Verbal orders are not billable
- Physicians must personally document all billable services
Correct answer: Services billed must be supported by clinical documentation in the medical record
Medicare and Medicaid require that all billed services be supported by clinical documentation in the medical record; absent documentation, claims may be denied or subject to recoupment.
Question 6: What is a 'Comparative Billing Report' (CBR) issued by CMS used for in compliance?
- To compare hospital accreditation scores
- To show a provider how their billing patterns compare to peers, flagging potential outliers (Correct answer)
- To audit payroll records for compliance
- To compare state Medicaid billing rules
Correct answer: To show a provider how their billing patterns compare to peers, flagging potential outliers
CBRs provide providers with data comparing their billing patterns to those of similar providers, helping them identify and correct potential anomalies before they become enforcement targets.
CHC Healthcare Billing and Coding Compliance Questions and Answers 1
Which federal statute prohibits submitting claims for services that were not actually rendered to Medicare or Medicaid?