CPC Compliance & Regulatory Guidelines 3

Question 1

A physician bills for a service that was performed by a medical student without direct supervision. Under Medicare rules, this represents:

Accepted Answer

Fraudulent billing

Answer

Medical students cannot independently bill Medicare; a qualified physician must perform or directly supervise services billed, making unsupervised student billing fraudulent.

Question 2

The 'three-day payment window' rule requires that outpatient services provided within how many days before an inpatient admission must be bundled into the inpatient DRG payment?

Accepted Answer

3 days

Answer

CMS's three-day payment window rule requires that most outpatient diagnostic services and related non-diagnostic services provided within 3 days prior to inpatient admission be included in the DRG payment.

Question 3

Which program uses data analytics and algorithms to proactively identify potentially fraudulent Medicare claims BEFORE payment is made?

Accepted Answer

Fraud Prevention System (FPS)

Answer

The Fraud Prevention System (FPS) uses predictive analytics to flag suspicious claims for review before Medicare payment is issued, unlike RACs which review claims post-payment.

Question 4

Under HIPAA, a 'covered entity' that experiences a breach affecting 500 or more individuals in a state must notify which entity within 60 days of discovery?

Accepted Answer

HHS and prominent media outlets in the affected area

Answer

For breaches affecting 500 or more residents of a state, HIPAA requires notification to HHS and to prominent media outlets serving the affected area, in addition to affected individuals.

Question 5

What does it mean when a provider is placed on the OIG's List of Excluded Individuals and Entities (LEIE)?

Accepted Answer

Federal healthcare programs cannot pay for their services

Answer

Exclusion from federal healthcare programs means no payment can be made by Medicare, Medicaid, or other federal programs for any items or services furnished by the excluded individual or entity.

(CPC) Certified Procedural Coder Practice Test

(CPC) Certified Procedural Coder Practice Test

CPC Compliance & Regulatory Guidelines 3