CPC Compliance & Regulatory Guidelines 2 — Questions and Answers
Question 1: Which federal law established the Anti-Kickback Statute (AKS) that prohibits offering or receiving remuneration to induce referrals for Medicare/Medicaid services?
- HIPAA
- Social Security Act (Correct answer)
- False Claims Act
- Stark Law
Correct answer: Social Security Act
The Anti-Kickback Statute is codified under the Social Security Act (42 U.S.C. § 1320a-7b) and prohibits remuneration intended to induce federal healthcare program referrals.
Question 2: A coder assigns a higher-level E/M code than documentation supports to increase reimbursement. This practice is best described as:
- Unbundling
- Upcoding (Correct answer)
- Downcoding
- Clustering
Correct answer: Upcoding
Upcoding means billing a higher-level or more expensive service than was actually documented or provided, which constitutes fraud.
Question 3: Under the Stark Law (Physician Self-Referral Law), which of the following is a designated health service (DHS) subject to its restrictions?
- Chiropractic manipulation services
- Clinical laboratory services (Correct answer)
- Dental procedures
- Optometry exams
Correct answer: Clinical laboratory services
Clinical laboratory services are explicitly listed as a designated health service under the Stark Law, prohibiting self-referrals absent an applicable exception.
Question 4: A Recovery Audit Contractor (RAC) identifies overpayments by reviewing Medicare claims. What is the RAC's payment model?
- Flat annual fee from CMS
- Contingency fee based on overpayments identified (Correct answer)
- Per-claim review fee
- State-funded grant
Correct answer: Contingency fee based on overpayments identified
RACs are paid on a contingency basis, receiving a percentage of the overpayments (and underpayments) they identify and recover.
Question 5: Which OIG tool allows healthcare providers to voluntarily self-disclose potential fraud and abuse violations to avoid larger penalties?
- Corporate Integrity Agreement (CIA)
- Self-Disclosure Protocol (SDP) (Correct answer)
- Compliance Advisory Report
- Safe Harbor Certification
Correct answer: Self-Disclosure Protocol (SDP)
The OIG's Self-Disclosure Protocol (SDP) allows providers to voluntarily report potential fraud, often resulting in reduced multipliers and penalties compared to government-initiated investigations.
Question 6: What is the purpose of a National Coverage Determination (NCD) issued by CMS?
- Define coding guidelines for new procedures
- Determine whether Medicare covers a specific service nationally (Correct answer)
- Set fee schedule amounts for CPT codes
- Establish medical necessity criteria for state Medicaid programs
Correct answer: Determine whether Medicare covers a specific service nationally
An NCD is a CMS policy decision determining whether Medicare will cover a particular item or service across the entire country.
Question 7: Which compliance document outlines the specific obligations a healthcare provider must meet as part of a settlement with the OIG following a fraud investigation?
- HIPAA Business Associate Agreement
- Corporate Integrity Agreement (Correct answer)
- Compliance Program Guidance
- Local Coverage Determination
Correct answer: Corporate Integrity Agreement
A Corporate Integrity Agreement (CIA) is a legal contract between the OIG and a provider settling a fraud case, specifying mandatory compliance obligations for a set period.
CPC Compliance & Regulatory Guidelines 2
Which federal law established the Anti-Kickback Statute (AKS) that prohibits offering or receiving remuneration to induce referrals for Medicare/Medicaid services?