COBGC Compliance and Documentation 2 — Questions and Answers
Question 1: Under HIPAA, which minimum necessary standard applies when a billing staff member requests a patient's OB record for claim submission?
- The full medical record must always be provided
- Only the information reasonably necessary to accomplish the billing purpose should be disclosed (Correct answer)
- Any PHI may be shared freely within the practice
- Minimum necessary does not apply to treatment team members
Correct answer: Only the information reasonably necessary to accomplish the billing purpose should be disclosed
HIPAA's minimum necessary rule requires that only the PHI needed for the specific purpose—here, billing—be disclosed or accessed.
Question 2: A gynecology coder queries a physician about an unspecified diagnosis code. Which element is required for a compliant physician query?
- The coder must suggest the preferred diagnosis to the physician
- The query must present all clinically reasonable options including 'clinically undetermined' (Correct answer)
- Queries are only allowed before the claim is submitted
- The physician must respond within 24 hours or the code is dropped
Correct answer: The query must present all clinically reasonable options including 'clinically undetermined'
AHIMA and ACDIS guidelines require that queries offer all reasonable clinical options, including 'clinically undetermined,' to avoid leading the physician.
Question 3: Which federal law establishes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?
- HIPAA
- The False Claims Act (Correct answer)
- The Anti-Kickback Statute
- EMTALA
Correct answer: The False Claims Act
The False Claims Act (31 U.S.C. §§ 3729–3733) imposes civil and criminal liability on individuals and entities that submit fraudulent claims to federal health programs.
Question 4: In OB/GYN documentation, the phrase 'as above' used to describe a physical examination finding is considered:
- Acceptable shorthand that meets documentation requirements
- Incomplete documentation that may not support the code billed (Correct answer)
- A valid cross-reference as long as it refers to the same encounter
- Sufficient if co-signed by the supervising physician
Correct answer: Incomplete documentation that may not support the code billed
Payers and auditors generally reject 'as above' or 'see above' as insufficient documentation because the specific findings must be recorded to support level of service coding.
Question 5: A practice bills a global OB package but the patient's prenatal care was provided by a different physician group. How should this be handled?
- Bill the global package anyway to maximize reimbursement
- Bill only the delivery and postpartum services actually provided by the billing physician (Correct answer)
- Append modifier -22 to the global package code
- Use an unlisted procedure code for the partial global
Correct answer: Bill only the delivery and postpartum services actually provided by the billing physician
When a physician does not provide the full antepartum care included in the global OB package, only the delivery and postpartum components actually rendered should be billed.
Question 6: Which document serves as the primary compliance roadmap outlining an OB/GYN practice's commitment to ethical billing and coding standards?
- The superbill
- The compliance plan (Correct answer)
- The charge master
- The fee schedule
Correct answer: The compliance plan
A written compliance plan describes the practice's policies, procedures, and training commitments to prevent, detect, and correct fraudulent or erroneous billing.
Question 7: A coder notices that a physician consistently documents a comprehensive history and exam for straightforward OB follow-up visits. This pattern most likely warrants:
- No action—physicians always document the highest level for safety
- An internal audit and potential education on medical necessity and upcoding risk (Correct answer)
- Immediate report to the OIG hotline
- Downcoding all claims retroactively
Correct answer: An internal audit and potential education on medical necessity and upcoding risk
A pattern of over-documentation inconsistent with the clinical scenario suggests upcoding risk and should trigger internal review and provider education before any external action.
COBGC Compliance and Documentation 2
Under HIPAA, which minimum necessary standard applies when a billing staff member requests a patient's OB record for claim submission?