Compliance, Regulatory & Legal Guidelines Flashcards

Which of the following is the primary distinction between fraud and abuse in healthcare billing?

Answer: Fraud requires intent to deceive; abuse involves improper billing practices without fraudulent intent

Fraud requires knowingly and willfully misrepresenting facts to obtain payment, while abuse refers to practices that are inconsistent with sound fiscal or business practices but lack fraudulent intent.

A coder routinely adds a 'chronic pain' diagnosis code to every outpatient encounter to increase the complexity of MDM. This practice is best characterized as:

Answer: Upcoding through unsupported diagnosis addition

Adding diagnoses not supported by the current encounter's documentation to inflate complexity or reimbursement is upcoding and constitutes fraud.

Which of the following statements about the Anti-Kickback Statute (AKS) is correct?

Answer: AKS prohibits offering, paying, soliciting, or receiving anything of value to induce referrals for federal program services

The AKS broadly prohibits any remuneration intended to induce or reward referrals for items or services covered by federal healthcare programs.

What does the 'two-midnight rule' govern in hospital Medicare billing?

Answer: When a hospital admission is appropriate for inpatient billing versus outpatient/observation

CMS's two-midnight rule states that inpatient admission is generally appropriate when the physician expects the patient to require hospital care spanning at least two midnights.

A compliance officer discovers that a physician's E/M level selections for new patients have been at level 5 (99205) for 95% of encounters. The most appropriate first step is to:

Answer: Conduct an internal audit of documentation supporting those claims

An internal audit is the appropriate first step to determine whether the documentation supports the level selected before taking further action.

Which federal agency is primarily responsible for investigating Medicare and Medicaid fraud and abuse?

Answer: Office of Inspector General (OIG) of HHS

The OIG of HHS is the primary agency responsible for investigating fraud and abuse in HHS programs, including Medicare and Medicaid.

A hospital's compliance program identifies that coders are assigning CC/MCC codes based on nursing notes alone, without physician attestation. The appropriate corrective action is to:

Answer: Require physician query and documentation before coding CC/MCC conditions

For inpatient coding, complication and comorbidity (CC/MCC) codes must be supported by physician documentation, not nursing notes alone, to be coded and reported.