CPC Compliance and Regulatory Guidelines 4

Question 1

Which HIPAA rule specifically addresses the security of electronic Protected Health Information (ePHI)?

Accepted Answer

HIPAA Security Rule

Answer

The HIPAA Security Rule requires covered entities and business associates to implement administrative, physical, and technical safeguards to protect ePHI.

Question 2

A Medicare patient is admitted to the hospital. The hospital bills for services provided by an employed physician without separately identifying those services. What billing model does this represent?

Accepted Answer

Provider-based billing

Answer

Provider-based billing occurs when a hospital-owned clinic bills both a facility fee and a professional fee, with the physician's services billed under the hospital's provider number.

Question 3

What does the term 'medical necessity' mean in the context of healthcare billing compliance?

Accepted Answer

Services that are reasonable and necessary for diagnosing or treating an illness or injury based on accepted standards of care

Answer

Medical necessity requires that services be appropriate, consistent with diagnosis, not provided primarily for convenience, and meeting accepted standards of medical practice.

Question 4

Which federal agency oversees the Medicare and Medicaid programs and enforces compliance with their billing requirements?

Accepted Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

CMS administers Medicare and Medicaid and sets the rules, policies, and reimbursement rates for these programs.

Question 5

A physician documents and bills for a service that was actually performed by a medical assistant without physician supervision. This is an example of:

Accepted Answer

Phantom billing

Answer

Phantom billing (also called billing for services not rendered) involves charging for services that were either not performed or not performed by the billed provider.

(CPC) Certified Professional Coder Practice Test

(CPC) Certified Professional Coder Practice Test

CPC Compliance and Regulatory Guidelines 4