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
A patient was treated for hypertension and type 2 diabetes during the same visit. The coder reported only hypertension because the physician's note focused primarily on it. This is an example of:
Answer: Undercoding, which can be considered a compliance risk
Failing to report all conditions that were addressed or managed during an encounter is undercoding and can result in lost revenue and inaccurate data, which is a compliance concern.
Which of the following actions is required when a provider identifies an overpayment from Medicare?
Answer: Report and return the overpayment within 60 days of identification
Under the Affordable Care Act's 60-day rule, providers must report and return Medicare and Medicaid overpayments within 60 days of identification to avoid False Claims Act liability.
Which law imposes civil monetary penalties on providers who engage in improper claims submission to federal healthcare programs?
Answer: Civil Monetary Penalties Law (CMPL)
The Civil Monetary Penalties Law allows the OIG to impose penalties and exclusion on providers who submit false or fraudulent claims to federal programs.
A retrospective audit reviews claims:
Answer: After the claim has been submitted and payment received
A retrospective audit examines claims after submission and payment to identify patterns of errors, overpayments, or compliance issues.
Under EMTALA, a hospital with an emergency department is required to:
Answer: Perform a medical screening examination for any individual who comes to the ED
EMTALA requires hospitals with EDs to provide a medical screening examination to anyone presenting, regardless of ability to pay, and to stabilize emergency conditions.
When a physician queries a coder asking for clarification on a diagnosis, the query must be:
Answer: Non-leading and based on clinical indicators present in the documentation
Per AHIMA and ACDIS guidelines, physician queries must be non-leading, clinically based, and not designed to prompt a specific answer for reimbursement purposes.
The term 'medical necessity' in the context of Medicare compliance means that a service must be:
Answer: Reasonable and necessary for the diagnosis or treatment of illness or injury
Medicare defines medically necessary services as those that are reasonable and necessary for the diagnosis or treatment of illness or injury, per Section 1862(a)(1)(A) of the Social Security Act.