CPC - Certified Professional Coder Compliance and Regulatory Rules Questions and Answers

Question 1

A primary care physician is a part-owner of a local imaging center. The physician refers her Medicare patients who need radiology services exclusively to this facility. Under which federal regulation is this financial arrangement most likely to be scrutinized?

Accepted Answer

The Stark Law

Answer

The Stark Law, also known as the Physician Self-Referral Law, prohibits physicians from referring Medicare or Medicaid patients for specific 'designated health services' (DHS), such as radiology, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception is met.

Question 2

According to the Office of Inspector General (OIG), which of the following is considered one of the seven fundamental elements of an effective compliance program for a physician practice?

Accepted Answer

Conducting appropriate training and education for employees.

Answer

The OIG has outlined seven core elements for an effective compliance program. These include: (1) Implementing written policies, procedures, and standards of conduct; (2) Designating a compliance officer or contact; (3) Conducting effective training and education; (4) Developing effective lines of communication; (5) Conducting internal monitoring and auditing; (6) Enforcing standards through well-publicized disciplinary guidelines; and (7) Responding promptly to detected offenses and undertaking corrective action.

Question 3

In which of the following situations must a provider issue a mandatory Advance Beneficiary Notice of Noncoverage (ABN) to an Original Medicare beneficiary?

Accepted Answer

Prior to delivering a service that is typically covered but may not be considered medically necessary for this specific patient.

Answer

A mandatory ABN is required when a provider believes that a service or item, which is usually covered by Medicare, may be denied for this particular patient because it is not considered medically reasonable and necessary. This allows the patient to make an informed decision about receiving and paying for the service. ABNs are not used for services that are never covered by Medicare or for patients in Medicare Advantage plans.

Question 4

A billing department audit reveals that due to a coding error, a physician's practice has received overpayments from Medicare for the past six months. What is the practice's primary legal obligation according to federal law?

Accepted Answer

To report and return the overpayment within 60 days of its identification.

Answer

The Affordable Care Act established the 60-day rule, which requires providers to report and return any identified overpayments from Medicare or Medicaid within 60 days of the date the overpayment was identified. Failure to do so can result in significant penalties under the False Claims Act.

Question 5

What is the primary focus of the federal Anti-Kickback Statute (AKS)?

Accepted Answer

To prohibit offering or receiving remuneration to induce referrals for items or services covered by federal healthcare programs.

Answer

The Anti-Kickback Statute (AKS) is a criminal law that prohibits knowingly and willfully offering, paying, soliciting, or receiving anything of value (remuneration) to induce or reward referrals for items or services payable by federal healthcare programs like Medicare. It is intended to prevent medical decisions from being compromised by improper financial incentives.

CPC - Certified Professional Coder Practice Test

CPC - Certified Professional Coder Practice Test

CPC - Certified Professional Coder Compliance and Regulatory Rules Questions and Answers