COC Revenue Cycle and Compliance 1 — Questions and Answers
Question 1: What is the 'clean claim' in the context of the revenue cycle?
- A claim submitted without errors that requires no additional information for payment (Correct answer)
- A claim that has been fully paid by the payer
- A claim with no diagnosis codes
- A claim processed through a clearinghouse
Correct answer: A claim submitted without errors that requires no additional information for payment
A clean claim is one submitted free of errors, with all required information, allowing the payer to process and pay it without requesting additional information.
Question 2: Which federal law establishes criminal penalties for healthcare fraud and abuse, including upcoding and unbundling?
- False Claims Act (FCA) (Correct answer)
- HIPAA Privacy Rule
- EMTALA
- STARK Law
Correct answer: False Claims Act (FCA)
The False Claims Act prohibits knowingly submitting false or fraudulent claims to federal healthcare programs, with penalties including treble damages and fines.
Question 3: What is 'upcoding' in medical billing?
- Reporting a higher-level code than the documented service to increase reimbursement (Correct answer)
- Reporting a more specific code than necessary
- Using modifiers to enhance code accuracy
- Adding diagnosis codes to support medical necessity
Correct answer: Reporting a higher-level code than the documented service to increase reimbursement
Upcoding is the fraudulent practice of billing for a more expensive service than what was actually provided to receive higher reimbursement.
Question 4: The Correct Coding Initiative (CCI) edits are designed to prevent:
- Improper unbundling of procedures that should be billed as one code (Correct answer)
- Duplicate patient admissions
- Incorrect diagnosis coding
- Untimely claim submission
Correct answer: Improper unbundling of procedures that should be billed as one code
CCI edits (National Correct Coding Initiative) are claim edits that prevent inappropriate unbundling of services that should be reported with a single comprehensive code.
Question 5: What does the STARK Law (Physician Self-Referral Law) prohibit?
- Physicians referring patients to entities where they have a financial interest for designated health services (Correct answer)
- Physicians billing for services not rendered
- Hospitals charging fees above the Medicare fee schedule
- Discharge planning before 24 hours of admission
Correct answer: Physicians referring patients to entities where they have a financial interest for designated health services
The Stark Law prohibits physicians from referring Medicare/Medicaid patients to entities in which the physician or an immediate family member has a financial relationship, for designated health services.
Question 6: An 'Advance Beneficiary Notice' (ABN) is required when:
- Medicare may not cover a service due to medical necessity concerns (Correct answer)
- A patient is admitted for inpatient care
- A claim is submitted to a secondary payer
- A procedure requires prior authorization
Correct answer: Medicare may not cover a service due to medical necessity concerns
An ABN must be given to a Medicare beneficiary before services are provided when the provider believes Medicare may deny payment for lack of medical necessity.
COC Revenue Cycle and Compliance 1
What is the 'clean claim' in the context of the revenue cycle?