CPC Compliance and Regulatory Rules 2 — Questions and Answers
Question 1: Which federal law establishes the Anti-Kickback Statute (AKS) that prohibits offering, paying, soliciting, or receiving anything of value to induce referrals for federal healthcare programs?
- Social Security Act Section 1128B (Correct answer)
- HIPAA Privacy Rule
- Stark Law Section 1877
- False Claims Act 31 U.S.C. § 3729
Correct answer: Social Security Act Section 1128B
The Anti-Kickback Statute is codified at 42 U.S.C. § 1320a-7b(b), which is Section 1128B of the Social Security Act.
Question 2: A medical practice bills Medicare for a service using a CPT code that represents a higher level of service than what was actually performed. This is an example of:
- Downcoding
- Unbundling
- Upcoding (Correct answer)
- Duplicate billing
Correct answer: Upcoding
Upcoding occurs when a provider bills for a higher-level or more expensive service than was actually rendered.
Question 3: Under the OIG Compliance Program Guidance, which element is considered the foundation of an effective compliance program?
- Regular auditing and monitoring
- Written policies and procedures
- Designation of a compliance officer (Correct answer)
- Effective lines of communication
Correct answer: Designation of a compliance officer
The OIG identifies the designation of a compliance officer as the foundational element because this person oversees all other compliance activities.
Question 4: Which statute imposes civil monetary penalties on any person who knowingly presents a false or fraudulent claim to a federal health care program?
- Anti-Kickback Statute
- Stark Law
- False Claims Act (Correct answer)
- Civil Monetary Penalties Law
Correct answer: False Claims Act
The False Claims Act (31 U.S.C. § 3729) imposes civil liability for submitting false or fraudulent claims to the federal government.
Question 5: A coder assigns separate CPT codes for each component of a procedure that should be reported with a single comprehensive code. This practice is known as:
- Upcoding
- Unbundling (Correct answer)
- Overcoding
- Fragmentation
Correct answer: Unbundling
Unbundling is the practice of billing separately for services that should be reported together under one comprehensive CPT code.
Question 6: The National Correct Coding Initiative (NCCI) edits are used by CMS to prevent improper billing of which type?
- Upcoding of E/M services
- Unbundling of CPT codes (Correct answer)
- Duplicate claims submission
- Incorrect modifier usage
Correct answer: Unbundling of CPT codes
NCCI edits are CMS policy guidelines that prevent unbundling by identifying code pairs that should not be billed together.
Question 7: Which of the following is a safe harbor under the Anti-Kickback Statute?
- Paying a referring physician a percentage of collected revenues
- Personal services and management contracts that meet specific criteria (Correct answer)
- Providing free services to patients with deductibles
- Offering gifts to physicians who refer patients
Correct answer: Personal services and management contracts that meet specific criteria
Personal services and management contracts meeting specific criteria are recognized safe harbors under the AKS regulations.
CPC Compliance and Regulatory Rules 2
Which federal law establishes the Anti-Kickback Statute (AKS) that prohibits offering, paying, soliciting, or receiving anything of value to induce referrals for federal healthcare programs?