Compliance, Regulatory & Legal Guidelines Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliance, Regulatory & Legal Guidelines flashcards as text
Which of the following best defines 'unbundling' in the context of medical coding compliance?
Answer: Reporting components of a procedure separately when a comprehensive code exists
Unbundling occurs when individual component codes are billed separately instead of using the single comprehensive code that covers all the components.
A provider submits claims for 'incident-to' services performed by a medical assistant without physician presence. This is most likely:
Answer: A violation of incident-to billing requirements
Incident-to billing requires the supervising physician to be present in the office suite and immediately available, not merely to co-sign documentation.
The OIG Work Plan is best used by compliance officers to:
Answer: Identify areas the OIG plans to review, helping prioritize internal audits
The OIG Work Plan outlines focus areas for upcoming investigations, allowing providers to proactively audit those areas internally.
Which regulation requires Medicare participating providers to inform patients of their right to receive an Advance Beneficiary Notice (ABN)?
Answer: Medicare Claims Processing Manual
The Medicare Claims Processing Manual contains the requirements for issuing ABNs when a service may not be covered because it is considered not medically necessary.
An auditor finds that a coder has been assigning diagnosis codes from the patient's problem list without verifying that the physician addressed those conditions during the current encounter. This violates which coding guideline?
Answer: The guideline that conditions must be documented, evaluated, treated, or managed at the encounter to be coded
ICD-10-CM guidelines state that additional diagnoses may be coded only if they are documented, evaluated, treated, managed, or affect patient care during the encounter.
Which of the following is a key element of an effective healthcare compliance program, as outlined by the OIG?
Answer: Written policies, procedures, and standards of conduct
The OIG's seven elements of an effective compliance program include written policies and procedures as a foundational component.
The National Correct Coding Initiative (NCCI) edits are developed and maintained by:
Answer: CMS to prevent improper Medicare payments
CMS developed and maintains the NCCI edits to promote national correct coding methodologies and prevent improper payment of Medicare Part B claims.