CPC - Certified Professional Coder Compliance and Regulatory Guidelines Questions and Answers

Question 1

A Medicare patient is scheduled for a procedure that is often covered, but due to the patient's specific diagnosis, it is likely to be denied as not medically necessary.
To ensure the provider can bill the patient if Medicare denies the claim, which of the following must be completed and signed by the patient BEFORE the service is rendered?

Accepted Answer

An Advance Beneficiary Notice of Noncoverage (ABN)

Answer

A Medicare Summary Notice (MSN)

Answer

A Remittance Advice (RA)

Answer

A standard Consent for Treatment form

Question 2

What is the primary purpose of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan?

Accepted Answer

To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit.

Answer

To publish the annual updates to the CPT and ICD-10-CM code sets.

Answer

To establish the relative value units (RVUs) and reimbursement rates for Medicare services.

Answer

To provide clinical guidelines for the treatment of common diseases and conditions.

Question 3

An established Medicare patient with stable, chronic hypertension is seen by a Nurse Practitioner (NP) for a scheduled follow-up. The supervising physician is in the office suite and immediately available but does not personally see the patient. The service was integral to the physician's established plan of care. Under which provision can this service be billed under the physician's NPI to receive 100% of the physician fee schedule rate?

Accepted Answer

"Incident-to" billing guidelines

Answer

New patient visit rules

Answer

Shared/split visit guidelines

Answer

Locum tenens arrangement

Question 4

According to the HIPAA Privacy Rule, which of the following is a permissible use or disclosure of Protected Health Information (PHI) that does NOT require a specific written authorization from the patient?

Accepted Answer

Disclosing a patient's diagnosis to another physician for treatment consultation.

Answer

Releasing a patient's entire medical record to their employer for a pre-employment screening.

Answer

Providing a list of diabetic patients' names and addresses to a pharmaceutical company for marketing purposes.

Answer

Sharing a patient's interesting case details, including name and date of birth, with a colleague in the breakroom.

Question 5

A physician has a significant ownership interest in a local diagnostic imaging center. The physician consistently refers their Medicare and Medicaid patients to this specific center for MRI and CT scans. This practice could be a violation of which federal law?

Accepted Answer

The Physician Self-Referral Law (Stark Law)

Answer

The Health Insurance Portability and Accountability Act (HIPAA)

Answer

The Emergency Medical Treatment and Active Labor Act (EMTALA)

Answer

The Clinical Laboratory Improvement Amendments (CLIA)

Question 6

A coder is determining Medicare coverage for a new procedure. After searching, the coder confirms that no National Coverage Determination (NCD) exists for the service. What is the next official source the coder should consult to determine if the service is covered in their specific geographic area?

Accepted Answer

Local Coverage Determinations (LCDs) from their Medicare Administrative Contractor (MAC).

Answer

The American Medical Association's CPT® Assistant newsletter.

Answer

The most recent OIG Work Plan.

Answer

Medical policies from a major commercial insurance payer.