COC Revenue Cycle and Compliance

Question 1

What is the 'clean claim' in the context of the revenue cycle?

Accepted Answer

A claim submitted without errors that requires no additional information for payment

Answer

A claim that has been fully paid by the payer

Answer

A claim with no diagnosis codes

Answer

A claim processed through a clearinghouse

Question 2

Which federal law establishes criminal penalties for healthcare fraud and abuse, including upcoding and unbundling?

Accepted Answer

False Claims Act (FCA)

Answer

HIPAA Privacy Rule

Answer

EMTALA

Answer

STARK Law

Question 3

What is 'upcoding' in medical billing?

Accepted Answer

Reporting a higher-level code than the documented service to increase reimbursement

Answer

Reporting a more specific code than necessary

Answer

Using modifiers to enhance code accuracy

Answer

Adding diagnosis codes to support medical necessity

Question 4

The Correct Coding Initiative (CCI) edits are designed to prevent:

Accepted Answer

Improper unbundling of procedures that should be billed as one code

Answer

Duplicate patient admissions

Answer

Incorrect diagnosis coding

Answer

Untimely claim submission

Question 5

What does the STARK Law (Physician Self-Referral Law) prohibit?

Accepted Answer

Physicians referring patients to entities where they have a financial interest for designated health services

Answer

Physicians billing for services not rendered

Answer

Hospitals charging fees above the Medicare fee schedule

Answer

Discharge planning before 24 hours of admission

Question 6

An 'Advance Beneficiary Notice' (ABN) is required when:

Accepted Answer

Medicare may not cover a service due to medical necessity concerns

Answer

A patient is admitted for inpatient care

Answer

A claim is submitted to a secondary payer

Answer

A procedure requires prior authorization