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Classification II Final Exam
CPT coding, nonmenclatures, fraud and abuse
27
Health Care
Undergraduate 4
12/05/2010

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Term
Medicare defines fraud as?
Definition
Medicare defines fraud as the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes it knowing that the deception could result in some unauthorized benefit.
Term
What 9 forms does fraud take?
Definition
the most common forms of medicare fraud are:
1. billing for services not furnished
2. misrepresenting a diagnosis to justify a payment
3. soliciting, offering or receiving a kickback
4. unbundling or exploding charges
5. falsifying certificates of medical necessity, plans of treatment and medical record to justify payment
6. billing for additional services not furnished as billed
7. routine waiver of co-payment
Term
who oversees medicare’s payment safeguard program, including carrier and intermediary operations related to fraud, audit, medical review, the collection of over payments and the imposition of civil monetary penalties for certain violations of medicare law?
Definition
OBI or the Office of Benefits Integrity
Term
who is responsible for developing an annual work plan that outlines the ways in which the medicare program is monitored to identify fraud and abuse?
Definition
OIG or Office of the Inspector General
Term
how has the patient-physician relationship has shifted?
Definition
It has become a physician- third party payer relationship. Which leaves the patient at the mercy of the third party payer.
Term
what is the practice of assigning a reimbursement code specifically for the purpose of obtaining a higher level of payment?
Definition
upcoding
Term
what is a mechanism designed to detect & prevent illegal or inappropriate behavior in the work place?
Definition
Corporate Compliance
Term
what are 3 reasons for corporate compliance?
Definition
prevents & detects healthcare fraud & abuse
helps hospitals avoid investigation and conviction
gives hospitals the ability to police themselves
Term
what is regulated by the OIG and is stipulated by the federal false claims act?
Definition
POLICIES AND PROCEDURES FOR CORPORATE COMPLIANCE
Term
what is a strategy of the government to reduce fraud that is a federal-state-local community partnership to combat provider fraud and abuse in medicare and medicaid programs?
Definition
Operation Restore Trust Project
Term
what are the elements of an HIM compliance program?
Definition
•HIM mission statement
•Code of conduct
•Oversight
•Policies and procedures
•Training and education
•Communication
•Auditing and monitoring
•Enforcement
•Problem solution and corrective action
Term
what is a recognized system of preferred terminology for recording disease processes that establishes the correct terms to be used in describing conditions?
Definition
Nomenclature
Term
what is the latest version of the international classification of disease?
Definition
Tenth Ed. ICD-10 released 1992
Term
what was developed by the NCHS – national center for health statistics – and is a derivative work of the ICD-9 developed by the WHO?
Definition
ICD-9-CM
Term
what covers specific diagnostic areas (medical, surgical, chiropractic, etc) and depending on the requirements of each section, the seven characters are assigned different meanings?
Definition
ICD-10
Term
what serves as to provide a uniform language that accurately describes medical, surgical and diagnostic services and thereby serves as an effective means for reliable nationwide communication?
Definition
CPT
Term
what is used to report physician’s services provided to medicare recipients, it is administered by the CMS and includes three levels of codes?
Definition
HCPCS
Term
what is used for coding diagnoses of neoplasms in tumor and cancer registries and in pathology labs?
Definition
ICD-0
Term
what is a multiaxial coding system with five axes for coding mental illness?
Definition
Diagnostic and statistical manual of mental diseases
Term
what is a multiaxial coding system with five axes for coding mental illness?
Definition
Diagnostic and statistical manual of mental diseases
Term
what is developed, maintained and distributed by the college of american pathologists?
Definition
SNOMED
Term
what will read codes for recording and retrieving computerized primary care patient data?
Definition
Clinical Terms Version 3
Term
what is generally accepted as the exchange standard for laboratory results, enabling standards to be developed and adopted relatively quickly to meet a desperate need?
Definition
logical observation identifier names and Codes
Term
What is used to describe the nursing process, document nursing care and facilitate aggregation of data for comparisons at the local, regional, national and international levels?
Definition
Nursing Classification
Term
what is a government funded project from the national library of medicine; it is to help health professionals and researchers retrieve and integrate electronic biomedical information from a variety of source and to make it easy for users to link disparate information systems?
Definition
Unified medical language system
Term
what was originally created to permit the interchange of biomedical image wave forms and related information?
Definition
digital imaging and communication
Term
what is the branch of medical science that deals with classification issues; it is different from coding in that it is about all classification issues, whether they are related to reimbursement or other purposes?
Definition
Nosology
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