CPC Compliance, Regulatory & Legal Guidelines 3 — Questions and Answers
Question 1: Which of the following best defines 'unbundling' in the context of medical coding compliance?
- Billing for services not rendered
- Reporting components of a procedure separately when a comprehensive code exists (Correct answer)
- Using an incorrect diagnosis code to obtain coverage
- Adding unsupported diagnoses to increase reimbursement
Correct answer: Reporting components of a procedure separately when a comprehensive code exists
Unbundling occurs when individual component codes are billed separately instead of using the single comprehensive code that covers all the components.
Question 2: A provider submits claims for 'incident-to' services performed by a medical assistant without physician presence. This is most likely:
- Acceptable if the MA is credentialed
- A violation of incident-to billing requirements (Correct answer)
- Permitted under direct supervision rules
- Compliant if the physician co-signs the note
Correct answer: A violation of incident-to billing requirements
Incident-to billing requires the supervising physician to be present in the office suite and immediately available, not merely to co-sign documentation.
Question 3: The OIG Work Plan is best used by compliance officers to:
- Determine correct code assignments for new procedures
- Identify areas the OIG plans to review, helping prioritize internal audits (Correct answer)
- Appeal denied Medicare claims
- Calculate expected reimbursement rates
Correct answer: Identify areas the OIG plans to review, helping prioritize internal audits
The OIG Work Plan outlines focus areas for upcoming investigations, allowing providers to proactively audit those areas internally.
Question 4: Which regulation requires Medicare participating providers to inform patients of their right to receive an Advance Beneficiary Notice (ABN)?
- EMTALA
- HITECH
- Medicare Claims Processing Manual (Correct answer)
- Conditions of Participation
Correct answer: Medicare Claims Processing Manual
The Medicare Claims Processing Manual contains the requirements for issuing ABNs when a service may not be covered because it is considered not medically necessary.
Question 5: An auditor finds that a coder has been assigning diagnosis codes from the patient's problem list without verifying that the physician addressed those conditions during the current encounter. This violates which coding guideline?
- The guideline requiring use of the most specific code available
- The guideline that conditions must be documented, evaluated, treated, or managed at the encounter to be coded (Correct answer)
- The requirement to code to the highest level of specificity
- The rule about sequencing principal diagnosis first
Correct answer: The guideline that conditions must be documented, evaluated, treated, or managed at the encounter to be coded
ICD-10-CM guidelines state that additional diagnoses may be coded only if they are documented, evaluated, treated, managed, or affect patient care during the encounter.
Question 6: Which of the following is a key element of an effective healthcare compliance program, as outlined by the OIG?
- Mandatory reporting of all coding errors to CMS within 24 hours
- Written policies, procedures, and standards of conduct (Correct answer)
- Elimination of all physician incentive compensation
- Requirement that all billing staff hold CPC certification
Correct answer: Written policies, procedures, and standards of conduct
The OIG's seven elements of an effective compliance program include written policies and procedures as a foundational component.
Question 7: The National Correct Coding Initiative (NCCI) edits are developed and maintained by:
- The American Medical Association (AMA)
- The American Academy of Professional Coders (AAPC)
- CMS to prevent improper Medicare payments (Correct answer)
- The Office of Inspector General (OIG)
Correct answer: CMS to prevent improper Medicare payments
CMS developed and maintains the NCCI edits to promote national correct coding methodologies and prevent improper payment of Medicare Part B claims.
CPC Compliance, Regulatory & Legal Guidelines 3
Which of the following best defines 'unbundling' in the context of medical coding compliance?