CPC Compliance and Regulatory Guidelines 2

Question 1

Which federal law established the False Claims Act, allowing the government to sue individuals or companies that defraud federal programs?

Accepted Answer

False Claims Act of 1863

Answer

The False Claims Act of 1863 (updated in 1986) allows the government—and whistleblowers—to sue parties that knowingly submit false claims to federal programs like Medicare.

Question 2

Under HIPAA, which type of information is classified as Protected Health Information (PHI)?

Accepted Answer

A patient's name combined with their diagnosis

Answer

PHI is individually identifiable health information that includes any data element that can link a person to their health condition, such as a name paired with a diagnosis.

Question 3

A coder bills a complex office visit when documentation only supports a straightforward visit to increase reimbursement. This is an example of:

Accepted Answer

Upcoding

Answer

Upcoding is reporting a higher-level service than what is documented or medically justified, which constitutes fraud.

Question 4

Which CMS program requires providers to report quality measures and can affect Medicare reimbursement rates?

Accepted Answer

Merit-based Incentive Payment System (MIPS)

Answer

MIPS is part of the Quality Payment Program under MACRA and ties Medicare reimbursement adjustments to quality, cost, improvement activities, and promoting interoperability.

Question 5

What is the primary purpose of an Advance Beneficiary Notice (ABN)?

Accepted Answer

To inform Medicare patients of services that may not be covered so they can decide whether to receive them

Answer

An ABN notifies Medicare beneficiaries before a service is rendered that Medicare may not pay, allowing them to make an informed financial decision.

(CPC) Certified Professional Coder Practice Test

(CPC) Certified Professional Coder Practice Test

CPC Compliance and Regulatory Guidelines 2