COBGC Compliance and Documentation 4

Question 1

Which OIG compliance guidance element focuses on training and education of staff on fraud and abuse laws?

Accepted Answer

Training and education programs

Answer

The OIG's Seven Elements of an Effective Compliance Program include training and education to ensure all relevant staff understand applicable laws and billing requirements.

Question 2

A physician documents 'patient is G3P2' in an obstetric note. What does 'P2' represent?

Accepted Answer

Two prior term deliveries

Answer

In standard obstetric terminology, 'P' (para) refers to the number of deliveries at or beyond 20 weeks gestation, not the number of pregnancies or live births.

Question 3

Under the Stark Law, a gynecologist who refers patients for in-office laboratory services in which she has a financial interest must meet which condition to avoid a violation?

Accepted Answer

The arrangement must qualify under an applicable Stark Law exception

Answer

The Stark Law (42 U.S.C. § 1395nn) prohibits self-referrals unless the arrangement strictly meets a statutory or regulatory exception.

Question 4

Which documentation element is required to support billing for a cervical colposcopy with biopsy in a GYN office?

Accepted Answer

Clinical indication, procedure description including colposcopic findings, biopsy site(s), and specimen disposition

Answer

Complete procedural documentation must include the reason for the procedure, technique used, intraoperative findings, biopsy sites, and where specimens were sent to support the code billed.

Question 5

A patient's prenatal record is subpoenaed for a legal proceeding. The OB practice should:

Accepted Answer

Consult legal counsel and follow applicable state law before releasing records

Answer

A subpoena alone may not constitute sufficient legal authority under HIPAA; the practice should obtain legal guidance to determine whether a court order, authorization, or protective order is required.

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

COBGC Compliance and Documentation 4