Medical Billing Software Regulatory Frameworks & Compliance 2 — Questions and Answers
Question 1: Under HIPAA's Minimum Necessary Standard, a billing specialist should request only the PHI required to:
- Satisfy the entire patient record
- Accomplish the intended billing purpose (Correct answer)
- Comply with state law audits
- Complete prior authorization requests
Correct answer: Accomplish the intended billing purpose
The Minimum Necessary Standard limits PHI disclosure to only what is needed to fulfill the specific billing function at hand.
Question 2: Which federal law requires Medicare and Medicaid providers to maintain billing records for a minimum of 6 years?
- HITECH Act
- False Claims Act
- Conditions of Participation (CoP)
- Health Insurance Portability and Accountability Act (HIPAA) (Correct answer)
Correct answer: Health Insurance Portability and Accountability Act (HIPAA)
HIPAA requires covered entities to retain records, including billing documentation, for at least 6 years from creation or last effective date.
Question 3: A provider receives a Medicare Remittance Advice (RA) showing a claim denied as 'not medically necessary.' The correct next step under CMS guidelines is to:
- Immediately write off the balance
- Bill the patient for the full amount
- Review LCD/NCD criteria and appeal if documentation supports necessity (Correct answer)
- Refile the claim with a different diagnosis code
Correct answer: Review LCD/NCD criteria and appeal if documentation supports necessity
CMS guidelines require providers to review Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) before appealing medical necessity denials.
Question 4: The OIG Work Plan is primarily used by compliance officers and billers to:
- Set annual fee schedules for procedures
- Identify areas of billing scrutiny targeted by federal investigators (Correct answer)
- Determine patient eligibility for Medicaid
- Calculate the Medicare Physician Fee Schedule conversion factor
Correct answer: Identify areas of billing scrutiny targeted by federal investigators
The OIG Work Plan publishes the areas where the Office of Inspector General plans to focus fraud and abuse audits each year.
Question 5: Which modifier is appended to a claim when a service is provided by a Qualified Non-Physician Practitioner (NPP) under physician supervision in a teaching setting?
- Modifier GY
- Modifier GX
- Modifier GE (Correct answer)
- Modifier Q5
Correct answer: Modifier GE
Modifier GE indicates that the service was performed by a resident without the presence of a teaching physician under the primary care exception.
Question 6: Under the No Surprises Act (2022), out-of-network providers must send a good faith cost estimate to self-pay patients at least:
- 24 hours before service
- 3 business days before a scheduled service
- 7 business days before a scheduled service (Correct answer)
- 30 days before service
Correct answer: 7 business days before a scheduled service
The No Surprises Act requires good faith estimates to be provided at least 3 business days before a scheduled service for uninsured or self-pay patients.
Question 7: When a claim is submitted with a place of service (POS) code 11 instead of POS 22, the billing impact is:
- No change; POS codes are informational only
- Higher reimbursement because office visits pay more than outpatient hospital (Correct answer)
- Lower reimbursement because hospital outpatient rates exceed office rates for most E&M services
- Automatic claim rejection by all payers
Correct answer: Higher reimbursement because office visits pay more than outpatient hospital
POS 11 (office) typically yields higher reimbursement for E&M services than POS 22 (on-campus outpatient hospital), which is why POS errors can constitute fraud.
Medical Billing Software Regulatory Frameworks & Compliance 2
Under HIPAA's Minimum Necessary Standard, a billing specialist should request only the PHI required to: