COC Revenue Cycle and Compliance 1

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 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?

Accepted Answer

False Claims Act (FCA)

Answer

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?

Accepted Answer

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

Answer

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:

Accepted Answer

Improper unbundling of procedures that should be billed as one code

Answer

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?

Accepted Answer

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

Answer

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.

COC - Certified Outpatient Coder Practice Test

COC - Certified Outpatient Coder Practice Test

COC Revenue Cycle and Compliance 1