Term
What would be more readily available to an internal auditor versus an external auditor?
a. MAC policies
b. Commercial carrier contracts
c. Authorized medical record documentation
d. CMS policies |
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Definition
b. commercial carrier contracts
Rationale: Rationale: An internal auditor has access to provider-specific commercial carrier contracts. An external auditor would need to request the contracts be available at the start of the audit. If an internal audit is being performed, there may be specific commercial payer guidelines, as part of the contract with the provider(s), that the internal auditor should be aware of when performing the audit. External auditors may not have access to contract information that is specific to that provider, unless it is made available to the auditor prior to the onset of the audit. |
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Term
What is considered good parameters for a baseline audit?
a. Focused audit on procedures reported with a high frequency, 10-15 records per practitioner.
b. Random audit of 10-15 records per practitioner.
c. Random audit of 100 records per practice.
d. Focused audit on the top ten procedures reported per provider, 10 records per procedure. |
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Definition
b. Random audit of 10-15 records per practitioner
A baseline audit typically involves random sampling to provide a general overview of compliance and accuracy. |
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Term
How often should an internal audit be conducted minimally?
a. When the practice is first opened
b. Monthly
c. Twice per year
d. Annually |
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Definition
✅ d. Annually
At a minimum, audits should be done annually to ensure ongoing compliance and to identify areas for improvement. |
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Term
What is non-statistical sampling?
a. Sample based on unique services that were defined in the objective and scope and is used in focused audits.
b. Sampling based on provider recommendations.
c. Sampling based on high frequency items, or those items that are considered to be proportionally significant.
d. Sampling based on all possible services within a chosen time frame. |
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Definition
✅ a. Sample based on unique services that were defined in the objective and scope and is used in focused audits.
Non-statistical sampling is judgmental and often based on specific services of concern in a focused audit. |
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Term
What type of audit should you suggest for the practice?
a. Carrier audit
b. Random audit
c. Peer review
d. RAC audit |
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Definition
✅ c. Peer review
A peer review allows providers to evaluate each other's documentation and coding patterns, especially when there’s concern about outliers in E/M utilization. |
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Term
When performing a government audit, the NCCI edits manual can serve what purpose?
a. Provide medical necessity support
b. Support the use of modifiers
c. Determine evaluation and management levels
d. Determine MAC coverage decisions |
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Definition
✅ b. Support the use of modifiers
The NCCI manual helps clarify when modifiers are appropriate, especially regarding bundled services.
https://www.cms.gov/medicare/national-correct-coding-initiative-ncci |
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Term
An audit performed after the claims have been submitted is referred to as what type of audit?
a. Focused audit
b. Prospective audit
c. Retrospective audit
d. Peer review audit |
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Definition
✅ c. Retrospective audit
Retrospective audits review documentation and claims after submission and payment. |
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Term
What tool might be helpful in defining which services to audit for a focused review?
a. Numerical sampling
b. Random sampling
c. Utilization reports
d. RAT-STATS |
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Definition
✅ c. Utilization reports
Utilization reports show patterns of service usage, helping to identify areas that warrant a focused audit. |
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Term
Which type of audit often realizes more objectivity than with an employed auditor?
a. Peer review audit
b. Internal audit
c. Random audit
d. External audit |
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Definition
✅ d. External audit
External auditors bring an independent perspective, ensuring impartiality and objectivity. |
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Term
What type of error might be found by reviewing the encounter form and claim form?
a. The level of service is not supported by the documentation.
b. Keying errors occurring during the data entry process.
c. Medical necessity is not supported for the services.
d. Bundling edits are not being followed. |
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Definition
✅ b. Keying errors occurring during the data entry process.
Comparing encounter forms to claim forms can reveal data entry mistakes like incorrect codes or quantities. |
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Term
What is RAT-STATS?
a. A statistical sampling software required by the OIG when performing audits.
b. A statistical sampling software offered by the OIG to assist in claims review.
c. A database maintained by CMS to determine what services are reported for each region.
d. A database maintained by the OIG to determine outliers for refunds. |
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Definition
✅ b. A statistical sampling software offered by the OIG to assist in claims review.
RAT-STATS is a free tool from the Office of Inspector General (OIG) to help with statistical sampling in audits.
https://oig.hhs.gov/compliance/rat-stats/ |
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Term
Which resource is valuable when performing a surgical audit?
a. NCCI Manual
b. E/M Audit Tool
c. Advance Beneficiary Notice (ABN)
d. CPT® Evaluation and Management Documentation Guidelines |
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Definition
✅ a. NCCI Manual
The NCCI Manual identifies correct coding practices and bundling edits for surgical procedures.
https://www.cms.gov/medicare/national-correct-coding-initiative-ncci |
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Term
A practice contacts an external auditor and explains the practice is billing incident-to services and is not sure they are documenting appropriately, or following the guidelines. What services would the external audit focus on during an audit based on this information?
a. NPP services provided in the practice.
b. Surgical services provided by all providers in the practice.
c. Services provided by all providers in the practice.
d. All E/M services provided by all providers in the practice. |
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Definition
✅ a. NPP services provided in the practice.
Since the concern is about incident-to billing, which typically involves non-physician practitioners (NPPs), the focus would be on those services. |
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Term
Consulting the MAC website for guidance regarding medical necessity coverage decisions can be an opportunity to see if what form is being used and completed correctly?
a. Informed consent
b. Advanced Beneficiary Notice (ABN)
c. E/M audit tool
d. Release of information |
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Definition
✅ b. Advanced Beneficiary Notice (ABN)
ABNs are often required when services may not be covered by Medicare. The MAC website provides guidance on their proper use.
https://www.cms.gov/medicare/medicare-general-information/bni/abn |
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Term
Which resource is valuable when performing an evaluation and management audit for office visits?
a. Surgical Audit Tool
b. NCCI Manual
c. AMA CPT® Evaluation and Management Documentation Guidelines
d. Advance Beneficiary Notice (ABN) |
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Definition
✅ c. AMA CPT® Evaluation and Management Documentation Guidelines
These guidelines provide specific instructions for properly documenting E/M services.
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management |
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Term
What helpful information might be found on a local MAC’s website?
a. To submit E/M documentation for coding by the MAC
b. Links to all commercial carrier’s medical policies
c. To show CPT® code bundling errors when performing the audit
d. LCD guidance regarding medical necessity coverage decisions for services provided |
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Definition
✅ d. LCD guidance regarding medical necessity coverage decisions for services provided
Local Coverage Determinations (LCDs) outline medical necessity requirements and coverage policies for Medicare services. |
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Term
When defining the scope of an audit, which question would NOT apply?
a. Will the audit results be shared?
b. Will the audit be limited to E/M codes only?
c. Will the audit be limited to only government payers?
d. Are all providers to be included in the audit? |
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Definition
✅ a. Will the audit results be shared?
Sharing audit results isn't part of defining the *scope* of an audit, but rather what happens afterward. |
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Term
Which statement is FALSE regarding audits?
a. Audits must be performed internally before external auditors are retained.
b. Audits can identify risk areas within a practice.
c. Audits may be performed internally or externally.
d. Audits can be focused on one service within a practice. |
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Definition
✅ a. Audits must be performed internally before external auditors are retained.
There’s no requirement that internal audits must occur before hiring external auditors. |
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Term
Which statement is TRUE regarding an audit performed on charts for Medicare beneficiaries?
a. National CMS policies override local carrier policy so all Medicare audits should only go by National CMS policies.
b. Commercial insurance policies and CMS National policies should be utilized when performing Medicare audits.
c. National CMS policies and local MAC policies should be utilized when performing Medicare audits.
d. It is necessary to review CMS National policies, local MAC policies, and multiple commercial insurance policies when performing Medicare audits. |
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Definition
✅ c. National CMS policies and local MAC policies should be utilized when performing Medicare audits.
Medicare audits require consideration of both national and local policies. |
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Term
What is an example of how office policies are helpful in an audit?
a. Office policies determine the medical necessity of services performed.
b. Office policies may specify what to bill when a preventive service and problem visit are provided at the same time.
c. Office policies outline termination procedures for employees.
d. Office policies provide specification on OSHA policies. |
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Definition
✅ b. Office policies may specify what to bill when a preventive service and problem visit are provided at the same time.
Clear policies help staff consistently apply billing rules in complex situations. |
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Term
A practice manager runs reports on services billed to Medicare. The reports identify a large number of surgical services reported with modifier 22. As a result, you are hired as an external auditor to review the services identified in the report. What type of audit would you perform?
a. A random audit of all surgical services performed.
b. A focused audit on surgical services with modifier 22.
c. A focused audit on evaluation and management services.
d. A peer review audit on all surgical services. |
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Definition
✅ b. A focused audit on surgical services with modifier 22.
Since the issue identified involves modifier 22, the audit should focus on those services. |
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Term
Which list represents the most comprehensive list of items reviewed in a retrospective audit?
a. Medical record documentation, explanation of benefits or remittance advice, claim form
b. Medical record documentation, encounter form, system reports for charge entry, claim form
c. Encounter form, system reports for charge entry, claim form, explanation of benefits or remittance advice, and payer policies
d. Medical record documentation, encounter form, claim form, explanation of benefits or remittance advice, and payer policies |
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Definition
✅ d. Medical record documentation, encounter form, claim form, explanation of benefits or remittance advice, and payer policies
This comprehensive review ensures accuracy from documentation to payment and payer policies. |
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Term
What is an advantage of a peer review audit?
a. To compare coding to other practices for upcoding trends
b. To identify which physician is undercoding the most in the practice
c. To focus on one type of service to determine compliance
d. To allow providers to learn from each other and improve their practice |
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Definition
✅ d. To allow providers to learn from each other and improve their practice
Peer reviews foster collaboration and shared learning. |
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Term
What is a utilization review?
a. A technique that provides data about the cost of services provided to Medicare beneficiaries.
b. A technique that provides data about how frequently certain services are billed.
c. A review performed by the OIG to determine accuracy of payments.
d. A review performed by CMS to determine which region pays out a higher amount per Medicare beneficiary. |
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Definition
✅ b. A technique that provides data about how frequently certain services are billed.
Utilization reviews identify patterns and frequency of service reporting, useful for audits and compliance. |
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Term
What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of a medical record?
a. Continue practicing without guidance until an issue arises.
b. Establish their own standards.
c. Call HHS and ask for Clarification.
d. Not put any in place. |
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Definition
Answer: b. Establish their own standards.
Rationale: Healthcare institutions are advised to create their own policies and standards to ensure consistent practices in the absence of specific regulations.
Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf |
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Term
Which governing body is responsible for criminal prosecutions relating to the Privacy Rule?
a. Secretary of State
b. Office of Civil Rights
c. Department of Justice
d. Office of Inspector General |
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Definition
Answer: c. Department of Justice
Rationale: The DOJ enforces criminal penalties for violations of HIPAA privacy regulations.
Reference: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/index.html |
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Term
What is CHEDDAR?
a. An optional way of documenting E/M services.
b. A format used to dictate operative notes.
c. A format used to dictate radiology reports.
d. A format required to document E/M services. |
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Definition
Answer: a. An optional way of documenting E/M services.
Rationale: CHEDDAR is a structured format for documenting E/M services, emphasizing organization.
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125121/ |
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Term
Which one is NOT a term used for a radiological view in a radiology report?
a. Prone
b. Swimmers
c. Oblique (OBL)
d. Anteroposterior (AP) |
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Definition
Answer: a. Prone
Rationale: 'Prone' refers to patient positioning, not a radiological view.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK470220/ |
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Term
What is appropriate to document in a radiology report for contrast material used in a radiologic study?
a. A general statement that contrast is used.
b. Contrast material should never be documented in detail.
c. Detailed documentation is only required when a study is performed with and without contrast.
d. The type and amount of contrast used, along with the route of administration is documented. |
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Definition
Answer: d. The type and amount of contrast used, along with the route of administration is documented.
Rationale: Complete documentation ensures clarity and patient safety.
Reference: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/Contrast-Manual/Contrast_Media.pdf |
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Term
When a laboratory report has an abnormal finding, what should be documented?
a. Documentation is not necessary.
b. Initials on the lab report indicating the provider reviewed the report.
c. The abnormal finding should be circled.
d. Circle and sign the abnormal finding and address the abnormality in the diagnosis |
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Definition
Answer: d. Circle and sign the abnormal finding and address the abnormality in the diagnosis.
Rationale: This shows provider review and appropriate follow-up.
Reference: https://www.cms.gov/files/document/qsepresourceslabgenlab.pdf |
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Term
How long does HIPAA require medical records to be maintained?
a. Six years from the date of its creation or the date from which it was last in effect (whichever is later).
b. Five years from the date of its creation or the date from which it was last in effect (whichever is later).
c. Five years past the date of death of the patient.
d. Ten years from the date of its creation or the date from which it was last in effect (whichever is later). |
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Definition
Answer: a. Six years from the date of its creation or the date from which it was last in effect (whichever is later).
Rationale: HIPAA mandates record retention for six years.
Reference: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/index.html |
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Term
In evaluation and management services, what does the O stand for in SOAP and what is included in this section?
a. Original; indicates any original statements made by the patient about the illness.
b. Objective; indicates the physical exam findings of the provider.
c. Operation; lists any operations performed during the visit.
d. Order; indicates the order of severity of the diagnoses for which the patient is being seen. |
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Definition
Answer: b. Objective; indicates the physical exam findings of the provider.
Rationale: The 'Objective' section includes measurable, observed data.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK482263/ |
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Term
In evaluation and management services, what does the A stand for in SOAP and what is included in this section?
a. Activity; documentation supports the patient's level of activity expected.
b. Assessment; the provider documents an assessment of the patient's condition.
c. Action; action items the patient is to take to improve his or her conditions.
d. Advice; the provider's advice to the patient. |
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Definition
Answer: b. Assessment; the provider documents an assessment of the patient's condition.
Rationale: The 'Assessment' section reflects the provider's diagnosis and clinical reasoning.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK482263/ |
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Term
What form is used to allow the release of their medical records?
a. Assignment of benefits
b. Informed consent
c. Release of information
d. Patient registration form |
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Definition
Answer: c. Release of information
Rationale: This form authorizes disclosure of patient health records.
Reference: https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html |
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Term
For therapy services, what is the reason for a progress note?
a. To serve as the plan of care.
b. To indicate services were performed.
c. To serve as the re-certification.
d. To provide justification for the medical necessity of treatment information. |
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Definition
Answer: d. To provide justification for the medical necessity of treatment information.
Rationale: Progress notes show why continued therapy is needed.
Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf |
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Term
In an operative note, where should information be taken to ensure accurate assignment of a CPT® code?
a. From the body of the operative note.
b. In the office visit prior to the surgery.
c. From the header, where the title of the planned surgery is listed.
d. From the OR schedule, based on how the procedure was scheduled by the physician. |
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Definition
Answer: a. From the body of the operative note.
Rationale: The body of the operative report contains the details necessary for accurate coding.
Reference: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hospital_billing_basics.pdf |
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Term
Which type of provider is not required to dictate his or her own operative report?
a. Co-surgeon
b. Surgeons in a surgical team
c. Primary surgeon
d. Assistant surgeon |
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Definition
Answer: d. Assistant surgeon
Rationale: Assistant surgeons are not typically required to dictate operative notes unless specified by facility policy.
Reference: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment-Policy.pdf |
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Term
What is considered protected health information (PHI)?
a. Provider information submitted on a claim for payment.
b. Health information that is randomly gathered for research purposes.
c. Statistical information relating to a specific demographic area.
d. Individually identifiable health information. |
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Definition
Answer: d. Individually identifiable health information.
Rationale: PHI includes information that can be used to identify an individual and relates to health status, provision of healthcare, or payment.
Reference: https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html |
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Term
Which type of signature will CMS allow only in the case of a provider with a proven disability affecting their ability to provide a signature?
a. Electronic
b. Handwritten
c. All of the above are allowed by CMS
d. Rubber Stamp |
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Definition
Answer: d. Rubber Stamp
Rationale: CMS allows rubber stamp signatures only if the provider has a disability preventing a handwritten signature.
Reference: https://www.cms.gov/files/document/signature-requirements-compliance-tips.pdf |
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Term
If a covered entity identifies a material breach of a business associate agreement, and it is not possible to cure the breach or end the violation, what should occur?
a. OIG and the HHS Office for Civil Rights must be notified.
b. The contract must be terminated, and the problem reported to the HHS Office for Civil Rights.
c. The contract can remain, but each patient should be notified of the breach.
d. The contract can remain, but the HHS Office for Civil Rights must be notified. |
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Definition
Answer: b. The contract must be terminated, and the problem reported to the HHS Office for Civil Rights.
Rationale: If resolution is not possible, termination and reporting are required.
Reference: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/index.html |
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Term
What must be included in a business associate agreement?
a. There are no requirements for what is included in the business associate agreement.
b. The permitted and required uses of PHI by the business associate.
c. Each record that is shared with the business associate must be identified individually, including names and dates of service.
d. The name of each person who will see the PHI. |
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Definition
Answer: b. The permitted and required uses of PHI by the business associate.
Rationale: The agreement must specify how PHI will be used and protected.
Reference: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html |
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Term
According to the Joint Commission (JC) Official 'Do Not Use' List, what would be considered an abbreviation that should not be used in a medical record and why?
a. IV; because it can be mistaken for IU.
b. HTN; because there should be more specification on the type of hypertension.
c. PRN; because it may be misunderstood to be a privacy issue.
d. IU; because it can be mistaken for IV or the number 10. |
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Definition
Answer: d. IU; because it can be mistaken for IV or the number 10.
Rationale: 'IU' is prone to misinterpretation and is on the JC 'Do Not Use' List.
Reference: https://www.jointcommission.org/standards/national-patient-safety-goals/ |
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Term
What is a risk of handwritten medical records?
a. Documentation is completed timely.
b. Additional information is included that may not be medically necessary.
c. Documentation is complete and legible.
d. The documentation may be illegible and abbreviated. |
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Definition
Answer: d. The documentation may be illegible and abbreviated.
Rationale: Illegibility and use of non-standard abbreviations in handwritten records are common risks.
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533359/ |
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Term
Under what circumstance may providers use or disclose protected health information without patient consent?
a. Payment, treatment, or operations.
b. Request from a neighbor or close friend.
c. Request from a spouse or another family member.
d. Advertising of the entity’s services. |
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Definition
Answer: a. Payment, treatment, or operations.
Rationale: HIPAA allows PHI disclosures without consent for these specific purposes.
Reference: https://www.hhs.gov/hipaa/for-individuals/faq/496/under-what-circumstances/index.html |
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Term
When a minor procedure is performed in the office, what is the documentation requirement?
a. A reference to the operation without the detail can be included in the documentation for the office visit.
b. A formal operative report must be documented.
c. The detail of the procedure can be included in the documentation for the office visit.
d. The surgery is not required to be documented if it is performed during an evaluation and management service. |
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Definition
Answer: c. The detail of the procedure can be included in the documentation for the office visit.
Rationale: Procedure details should be documented within the office visit note.
Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf |
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Term
When a correction is made in an electronic health record, what must exist?
a. Reliable means to clearly identify the original content and the modified content.
b. The entire medical record duplicated with the corrections only made to the duplication.
c. Identity of a witness to the correction made in the electronic health record.
d. There are no requirements for corrections to electronic medical records. |
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Definition
Answer: a. Reliable means to clearly identify the original content and the modified content.
Rationale: EHR systems must maintain a clear audit trail.
Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf |
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Term
Which option would be excluded from an individual's right to access their PHI?
a. Emergency department notes
b. Psychotherapy notes
c. Operative reports
d. Family practice notes |
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Definition
Answer: b. Psychotherapy notes
Rationale: These are excluded from the right of access under HIPAA.
Reference: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/psychotherapy-notes/index.html |
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Term
Which of the following is an example of information that may be transmitted electronically and covered under the privacy rule?
a. Email
b. Physician credentials
c. Appointment schedules
d. Claim forms |
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Definition
Answer: d. Claim forms
Rationale: Claim forms often contain PHI and are covered under HIPAA rules.
Reference: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/index.html |
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Term
What is informed consent?
a. A way to indicate that a discussion between the patient and the provider took place about a patient’s condition and the treatment options available, to allow the patient an opportunity to ask questionss and make an informed choice on his or her plan of treatment.
b. An agreement to allow the provider to inform other patients about a specific patient’s condition.
c. Communication between the physician’s office staff and the patient relating to the patient’s rights of privacy.
d. A way for the provider to indicate that he or she has communicated his or her wishes to the patient on a specific treatment plan, and that it is the only option a patient has. |
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Definition
Answer: a. A way to indicate that a discussion between the patient and the provider took place about a patient’s condition and the treatment options available, to allow the patient an opportunity to ask questions and make an informed choice on his or her plan of treatment.
Rationale: Informed consent ensures patient autonomy and understanding of treatment options.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK430827/ |
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Term
A Medicare beneficiary is seen by the cardiovascular surgeon for a consultation in the emergency department. A medically appropriate history and exam, and MDM of moderate complexity were performed. Which code is reported?
a. 99284
b. 99243
c. 99221
d. 99253 |
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Definition
Correct Answer: a. 99284
Rationale: With the elimination of payment for consultations, Medicare directs you to report the office and other outpatient and hospital care E/M codes. If a provider is called to the emergency department, Medicare recommends reporting the emergency department E/M codes.
Reference: https://www.cms.gov/files/document/mln901705-telehealth-services.pdf |
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Term
Which coding combination is correct in reporting prolong add-on service code 99417?
a. 99245, 99417
b. 99203, 99417
c. 90838, 99417
d. 99255, 99417 |
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Definition
Correct Answer: a. 99245, 99417
Rationale: CPT® guidelines and parenthetical instructional notes indicate which E/M codes are reported with add-on code 99417. Only outpatient E/M services and the highest level (99205, 99215, 99245, 99345, 99350, and 99483).
Reference: CPT® 2024 Professional Edition |
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Term
A 45-year-old established female patient is seen today at her provider’s office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. She reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. An exam is performed. An EKG is ordered. Metabolic panel and complete blood count labs are drawn. Final diagnosis is suspected benign paroxysmal positional vertigo. To purcha...
a. 99214
b. 99215
c. 99203
d. 99204 |
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Definition
Correct Answer: a. 99214
Rationale: This is a follow-up visit indicating an established patient seen in the clinic. Medical decision making is the determining factor for selecting the E/M level using E/M services guidelines. Undiagnosed problem with uncertain prognosis (Moderate), three unique tests ordered (EKG, metabolic panel, and complete blood count) (Moderate), low level of risk for over-the-counter medication (Minimal). MDM is moderate reporting 99214 supported for this visit.
Reference: CPT® 2024 E/M Guidelines |
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Term
Dr. H sees Mrs. Jones in Clinic Eight for syncope while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. D is also in the neurology department and saw Mrs. Jones last month but is on medical leave for a couple months. Dr. H performs a medically appropriate history and exam. Dr. H orders a CT scan, comprehensive metabolic panel, and CBC panel test. The final diagnosis given is suspected psychogenic syncope.
a. 99203, R55
b. 99214, R55
c. 99202, F48.8
d. 99215, F48.8 |
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Definition
Correct Answer: b. 99214, R55
Rationale: The patient was seen previously by another neurologist in the same group, so she is an established patient. MDM is moderate with tests ordered, and R55 is coded because psychogenic syncope is suspected.
Reference: CPT® 2024 E/M Guidelines |
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Term
Mrs. Farmer’s family physician visits her in the nursing home after a spell of dizziness and confusion. He suspects her electrolytes are out of balance after evaluation and orders CBC, A1C, and electrolytes.
a. 99310
b. 99309
c. 99308
d. 99307 |
|
Definition
Correct Answer: b. 99309
Rationale: Moderate MDM applies: undiagnosed problem with uncertain prognosis, ordering three unique lab tests, low risk.
Reference: CPT® 2024 Nursing Facility Guidelines |
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Term
Which scenario qualifies for a consultation code?
a. Provider requested to take over Coumadin management.
b. Second opinion on lupus, no report back to referring.
c. PCP refers diabetic patient to endocrinologist for treatment suggestions.
d. ED open fracture admitted by ortho. |
|
Definition
Correct Answer: c. PCP refers diabetic patient to endocrinologist for treatment suggestions.
Rationale: Consultations require a request, render opinion, report back.
Reference: CPT® 2024 Consultation Guidelines |
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Term
What is one option in Data Review for Moderate MDM?
a. Any combination of 2 Category 1
b. Any combination of 3 Category 1
c. Must meet Category 3
d. At least 2 out of 3 Categories |
|
Definition
Correct Answer: b. Any combination of 3 Category 1
Rationale: Moderate MDM requires at least three elements from Category 1.
Reference: CPT® 2024 E/M Guidelines |
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Term
Subsequent hospital care for aspiration pneumonia with moderate MDM?
a. 99238
b. 99221
c. 99233
d. 99232 |
|
Definition
Correct Answer: d. 99232
Rationale: Acute illness with systemic symptoms and prescription drug management.
Reference: CPT® 2024 E/M Guidelines |
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Term
Hospital discharge after 45 min + readmission to SNF same day?
a. 99238, 99305
b. 99238
c. 99239
d. 99239, 99305 |
|
Definition
Correct Answer: d. 99239, 99305
Rationale: 45 min discharge supports 99239; SNF admission is 99305.
Reference: CPT® 2024 Discharge and SNF Guidelines |
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Term
Prostate cancer screening with DRE for a Medicare beneficiary?
a. 99387-25, 45990
b. G0027
c. G0102
d. 99397-25, 45990 |
|
Definition
Correct Answer: c. G0102
Rationale: No CPT® code for DRE in prostate screening; G0102 is correct for Medicare.
Reference: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html |
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Term
An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit?
a. 99211-25, 20550-50
b. 99212-25, 20610-50
c. 20610-50
d. 99213-25, 20610-50 |
|
Definition
Correct Answer: c. 20610-50
Rationale: No separately identifiable E/M service beyond the procedure was documented. Code 20610 is used for arthrocentesis/injection of the major joint or bursa. Modifier 50 indicates a bilateral procedure.
Reference: CPT® 2024 Procedure Guidelines |
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Term
A 32-year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs a medically appropriate history and exam and discusses options with the patient on allergy management. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing.
a. 99202
b. 99243
c. 99212
d. 99242 |
|
Definition
Correct Answer: b. 99243
Rationale: All three R’s of consultation (request, render, report) are documented. Low complexity decision-making applies.
Reference: CPT® 2024 Consultation Guidelines |
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Term
A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?
a. Chronic tonsillitis first; acute tonsillitis second.
b. Acute tonsillitis first; chronic tonsillitis second.
c. Only acute tonsillitis is reported.
d. Only chronic tonsillitis is reported. |
|
Definition
Correct Answer: b. Acute tonsillitis first; chronic tonsillitis second.
Rationale: ICD-10-CM guidelines state that when both acute and chronic conditions are documented, both are coded, with acute first.
Reference: ICD-10-CM Guidelines Section I.B.8 |
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Term
ICU - CC: Multi-system organ failure. Critical care time: 35 minutes. What CPT® code(s) is/are reported?
a. 99232
b. 99233
c. 99291
d. 99291, 99292 |
|
Definition
Correct Answer: c. 99291
Rationale: 35 minutes of critical care time supports code 99291 for the first 30-74 minutes of critical care.
Reference: CPT® 2024 Critical Care Guidelines |
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Term
A 15-year-old boy is scheduled for his yearly physical with his pediatrician. At the time of the visit, he complains of lower abdominal pressure and burning when urinating for the past two days. The provider performs the physical and treats the UTI with low MDM. What CPT® codes are reported?
a. 99213, 99394-25
b. 99213-25, 99394
c. 99394
d. 99213 |
|
Definition
Correct Answer: b. 99213-25, 99394
Rationale: The pediatrician provided both preventive and problem-oriented services. Modifier 25 is appended to 99213 to indicate a significant and separately identifiable E/M service.
Reference: CPT® 2024 Preventive Services Guidelines |
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Term
| An established patient presents for follow-up of pneumonia. He was hospitalized for 6 days. Exam, lab review, X-ray interpretation, and prescription changes are documented.
What CPT® code is reported?
a. 99349
b. 99213
c. 99242
d. 99214 |
|
Definition
Correct Answer:
d. 99214
Rationale: Moderate MDM due to acute illness with systemic symptoms and prescription drug management. Reference: CPT® 2024 E/M Guidelines |
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Term
A 90-year-old female was admitted from observation for chest pain to r/o angina. After 10 hrs of observation, she is discharged home same day. What CPT® code is reported?
a. 99235
b. 99236
c. 99238
d. 99221 |
|
Definition
Correct Answer: a. 99235
Rationale: Same-day admission and discharge with moderate MDM supports 99235.
Reference: CPT® 2024 Observation and Inpatient Hospital Care Guidelines |
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Term
What modifier is used to report an E/M service mandated by a court order?
a. 24
b. 62
c. 32
d. 57 |
|
Definition
Correct Answer: c. 32
Rationale: Modifier 32 is appended to indicate services mandated by a third-party payer, government, legislative, or regulatory requirement.
Reference: CPT® 2024 Modifier Guidelines |
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Term
Which appendix in the CPT® code book lists the summary of add-on codes?
a. Appendix L
b. Appendix D
c. Appendix B
d. Appendix A |
|
Definition
Correct Answer: b. Appendix D
Rationale: Appendix D provides a summary listing of all CPT® add-on codes.
Reference: CPT® 2024 Appendices |
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Term
A soccer player is admitted to observation for head trauma on 01/21/20XX and discharged on 01/22/20XX after evaluation. What CPT® codes are reported?
a. 99221, 99239
b. 99221
c. 99221, 99238
d. 99234 |
|
Definition
Correct Answer: c. 99221, 99238
Rationale: Admission and discharge on different calendar dates require reporting both initial hospital care and discharge services separately.
Reference: CPT® 2024 Observation Care Guidelines |
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Term
Trigger point injections provided for chronic pain; no separate E/M documented. What is the correct coding?
a. 20553 with 11 units
b. No separate E/M or modifier 25
c. Codes reported as documented
d. Procedure documentation should be separate |
|
Definition
Correct Answer: b. No separate E/M or modifier 25
Rationale: No additional evaluation supports a separate E/M code or modifier 25. Report only the procedure.
Reference: CPT® 2024 E/M and Procedure Guidelines |
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Term
New patient preventive visit for a 2-year-old child. What CPT® code is reported?
a. 99392
b. 99381
c. 99382
d. 99391 |
|
Definition
Correct Answer: c. 99382
Rationale: New patient preventive service for a child age 1-4 years.
Reference: CPT® 2024 Preventive Services Guidelines |
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Term
New patient evaluated for chronic inguinal hernia. What CPT® and ICD-10-CM codes are reported?
a. 99202, K46.9
b. 99203, K40.90
c. 99204, K40.90
d. 99205, K46.9 |
|
Definition
Correct Answer: c. 99204, K40.90
Rationale: Moderate MDM complexity for chronic condition planning elective surgical repair.
Reference: CPT® 2024 E/M Guidelines |
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Term
5-year-old in ED post-drowning, CPR, intubation, CVC, 1 hour critical care documented. What codes are reported?
a. 92950, 99291-25, 36556, 31603
b. 92950, 99291-25, 36556, 31500
c. 92950, 99285-25, 36556, 31500
d. 92950, 99291 |
|
Definition
Correct Answer: b. 92950, 99291-25, 36556, 31500
Rationale: Critical care with separately reportable CPR, central line placement, and intubation.
Reference: CPT® 2024 Critical Care Guidelines |
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Term
ALS direction, CPR, and 45 min critical care provided. What codes are reported?
a. 92950, 99291
b. 99291, 99288
c. 99291, 99292, 99288
d. 92950, 99291, 99288 |
|
Definition
Correct Answer: d. 92950, 99291, 99288
Rationale: ALS direction (99288), CPR (92950), and critical care excluding CPR time (99291).
Reference: CPT® 2024 Critical Care Guidelines |
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Term
A provider receives multiple denials from Medicare on all claims submitted with 19307-LT, 19307-RT, 19340-LT, 19340-RT. After completing a review of the records to verify the procedures were performed, what recommendation would you make to resolve the denials?
a. Correct the modifiers and resubmit the claim. Medicare requires modifier 59 when the same procedure is performed on more than one anatomic site.
b. Resubmit the claims with a copy of the medical record to show the services were properly documented and coded.
c. Correct the modifiers and resubmit the claim. Medicare requires modifier 50 and one unit for bilateral procedures.
d. Based on the code description, the procedures cannot be performed bilaterally. Resubmit without the LT and RT modifiers. |
|
Definition
Correct Answer: c. Correct the modifiers and resubmit the claim. Medicare requires modifier 50 and one unit for bilateral procedures.
Rationale: MUE edits were changed to 1 for bilateral procedures. Medicare requires modifier 50 on bilateral procedures on one-line item with one unit.
Reference: https://www.cms.gov/medicare/audits-reports/medically-unlikely-edit-mue |
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|
Term
Which of the following code combinations are NOT subject to a multiple procedure payment reduction?
a. 31254, 31287
b. 48150, 49440
c. 21433, 21401
d. 32666, 32674 |
|
Definition
Correct Answer: d. 32666, 32674
Rationale: Add-on codes are not subject to the multiple fee reduction. You can also determine the correct answer by accessing the National Physician Fee Schedule Relative Value File.
Reference: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html |
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Term
When auditing for radiology services, what step is NOT performed?
a. Verify the correct number of views is reported with the proper code.
b. Verify the image obtained meets clinical standards.
c. Verify the order for the test performed is in the record.
d. Verify the diagnosis code supports medical necessity. |
|
Definition
Correct Answer: b. Verify the image obtained meets clinical standards.
Rationale: It is not the responsibility of the auditor to verify the clinical quality of the film.
Reference: AAPC CPMA Study Guide, Radiology Audit Section |
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Term
A patient with carcinoma of the descending colon presents for chemotherapy administration at the infusion center. What codes are reported?
a. 96413, 96375, J9190 x 2, J1100 x 20, Z51.12, C18.8
b. 96415, 96375, J9190, J1100, J1644, Z51.0, C18.9
c. 96413, J9190, J1100, J1642, Z51.11, C18.6
d. 96413, 96415, 96375, J9190 x 2, J1100 x 20, J1644, Z51.11, C18.6 |
|
Definition
Correct Answer: d. 96413, 96415, 96375, J9190 x 2, J1100 x 20, J1644, Z51.11, C18.6
Rationale: Coding based on CPT® Index for chemotherapy administration and ICD-10-CM for diagnosis sequencing.
Reference: CPT® Professional Code Book, Chemotherapy Infusion Guidelines; ICD-10-CM Guidelines I.C.2.e.2 |
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Term
What modifier is appended to indicate a service is provided under the primary care exception without the presence of a teaching physician?
a. Modifier TC
b. Modifier GC
c. Modifier 25
d. Modifier GE |
|
Definition
Correct Answer: d. Modifier GE
Rationale: Modifier GE is appended when services are provided by a resident under the primary care exception without the teaching physician's presence.
Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/teaching-physicians-fact-sheet-ICN006437.pdf |
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Term
When auditing CBC tests for a primary care physician, you review the record and verify the tests were performed, but there is no order. When you question the provider, he indicates there is a standing order to perform a CBC on every patient. What do you advise the provider?
a. Standing orders are acceptable as long as the policy is in writing.
b. Because a CBC is a low reimbursed test, this should not trigger an audit.
c. This is an audit finding. Standing orders cannot be used in this manner.
d. This is standard practice for most offices that perform CBCs on site. |
|
Definition
Correct Answer: c. This is an audit finding. Standing orders cannot be used in this manner.
Rationale: Standing orders alone are not usually acceptable documentation that tests are reasonable and necessary.
Reference: Federal Register/Vol. 63. No. 163/Monday, August 24, 1998 |
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Term
Which one of the following would be an audit finding for psychiatric services?
a. Reporting code 90832 only.
b. Reporting codes 99214 and 90838 on the same date of service.
c. Reporting code 90863 only.
d. Reporting codes 90791 and 90785 on the same date of service. |
|
Definition
Correct Answer: c. Reporting code 90863 only.
Rationale: Code 90863 is an add-on code and cannot be reported alone; it must be reported with psychotherapy.
Reference: CPT® Professional Code Book, Psychiatry Guidelines |
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Term
How are revisions to coding guidelines identified in the CPT® code book?
a. Green font with underlined text.
b. A red bullet icon.
c. A lightning bolt icon.
d. Green text with opposing arrows. |
|
Definition
Correct Answer: d. Green text with opposing arrows.
Rationale: The revisions to coding guidelines are identified by green text enclosed by opposing arrows.
Reference: CPT® Professional Code Book, Introduction Section |
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Term
How are new codes identified in the CPT® code book?
a. Green text with opposing arrows
b. A lightning bolt icon
c. A bullet icon
d. Green font with underlined text |
|
Definition
Correct Answer: c. A bullet icon
Rationale: New CPT® codes are identified by a red bullet icon next to the code.
Reference: CPT® Professional Code Book, Introduction Section |
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Term
Which statement is TRUE regarding the discussion portion of the audit report?
a. In the case where there is no binding rule to declare an error, it is appropriate to identify any concerns regarding the potential for post-payment risk.
b. The discussion portion should contain a brief overview of issue-oriented risk areas that were identified.
c. The recommendations for each claim should be addressed in the discussion.
d. When there is no binding rule, the potential post-payment risk should not be reported. |
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Definition
Correct Answer: A
Explanation: Even when no specific regulation identifies an error, an auditor should identify potential post-payment risk. The discussion section provides this analysis.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
In an audit report, which section would identify the specific binding standards or criteria that were applied during the course of the audit?
a. Summary
b. Issue-oriented findings
c. Standard of review
d. Discussion |
|
Definition
Correct Answer: C
Explanation: The Standard of Review identifies applicable regulations, laws, and policies used in the audit.
Reference: https://www.cms.gov/files/document/chapter-3-verifying-potential-errors-and-calculating-overpayment-amount.pdf |
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Term
Question 3:
Which statement is TRUE regarding an audit report?
a. It is not necessary to be objective as long as the provider understands the risks involved.
b. The report should be as lengthy as possible in an attempt to validate the results.
c. The report should be written in legal language regardless of how easy it is to understand to protect the auditor.
d. Do not overstate potential risks (for example, by suggesting that documentation or coding mistakes are fraudulent or will land the provider in jail). |
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Definition
Correct Answer: D
Explanation: The auditor should avoid overstating risk and remain objective.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
Question 4:
What type of insurance carrier might be considered a state regulated commercial insurance plan?
a. Workers’ Compensation
b. Medicare
c. TriCare
d. Aetna |
|
Definition
Correct Answer: A
Rationale: State regulated insurance plans are most commonly found associated with first party medical claims in an auto insurance case (where the state law requires or provides for such coverage) or workers' compensation claims.
Reference: https://content.naic.org/ |
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Term
Question 5:
What type of information can be found in the provider's contract with the insurance carrier?
a. The insurance benefits for each patient covered by that carrier.
b. The provider's obligation to follow the insurance company's medical policies.
c. Potential risks to specific providers.
d. Utilization patterns of the provider compared to all other providers of the same specialty in that region. |
|
Definition
Correct Answer: B
Explanation: Provider contracts often require adherence to payer medical policies.
Reference: https://www.ama-assn.org/delivering-care/patient-support-advocacy/managed-care-contracting |
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Term
Question 6:
Which statement is TRUE regarding NCCI?
a. NCCI edits should not be used in an audit as they are not regulatory information.
b. NCCI edits identify all code pairs that are permissible to report together under any circumstance.
c. NCCI edits identify discrepancies between patient age and diagnosis codes.
d. NCCI identifies code pairs and exceptions where a modifier may be used to override the code pair. |
|
Definition
Correct Answer: D
Explanation: NCCI edits identify code pairs that are generally not separately payable but may be overridden with a modifier when appropriate.
Reference: https://www.cms.gov/medicare/national-correct-coding-initiative-edits |
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Term
Question 7:
Once an error has been identified and the provider educated, what is recommended to ensure compliance improves?
a. Continued annual audits.
b. Once the auditor has educated the provider, there is no further obligation.
c. Frequent continued focused audits on the specified error.
d. Continued random audits for the practice with increased frequency. |
|
Definition
Correct Answer: C
Explanation: Focused audits ensure that providers are addressing the specific errors identified.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
Question 8:
Which statement is TRUE regarding the written audit report?
a. The report must be organized, concise, and well written.
b. The audit report can be an effective educational tool.
c. All of the above.
d. The recommendations can serve as a roadmap for achieving compliance. |
|
Definition
Correct Answer: C
Explanation: The audit report should be clear, educational, and actionable.
Reference: https://library.ahima.org/doc?oid=301477 |
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Term
Question 9:
Which option represents information that may be found in a contract between a provider and a commercial insurance plan that is pertinent to an auditor?
a. Whether the provider is obligated to conform to the insurance company's published medical policies.
b. Whether the provider is required to perform annual audits of their coding.
c. Whether the provider is required to report the nurse to doctor ratio for the clinic.
d. Whether the provider is required to disclose when new employe... |
|
Definition
Correct Answer: A
Explanation: Provider contracts frequently specify that the provider must follow the payer's published medical policies.
Reference: https://www.ama-assn.org/delivering-care/patient-support-advocacy/managed-care-contracting |
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Term
Question 10:
What should an audit report identify?
a. An analysis of the findings
b. Key findings identified
c. Rationale and recommendations
d. All of the above |
|
Definition
Correct Answer: D
Explanation: An audit report should contain findings, analysis, rationale, and recommendations.
Reference: https://library.ahima.org/doc?oid=301477 |
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Term
Question 11:
What should the writing style of an audit report be?
a. The writing style is irrelevant
b. Scientific
c. Persuasive
d. Argumentative |
|
Definition
Correct Answer: C
Rationale: The writing style of an audit report should be persuasive, as opposed to purely scientific (which is boring to read) or argumentative.
Reference: https://library.ahima.org/doc?oid=301477 |
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Term
Question 12:
What act would be considered a False Claims Act (FCA) violation under what is known as the "reverse false claims provision" of the FCA?
a. Reporting a higher level of E/M code than is supported by the documentation.
b. Reporting more units than allowed by MUE.
c. Reporting two services together that were identified as bundled by NCCI.
d. Failure to refund an overpayment. |
|
Definition
Correct Answer: D
Explanation: Failing to refund an identified overpayment is a violation of the reverse false claims provision.
Reference: https://www.govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap7-subchapXI-partA-sec1320a-7k.pdf |
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Term
Question 13:
Which statement is TRUE regarding an IRO?
a. An IRO must remain independent.
b. An IRO can consult and advise the auditee.
c. An IRO can perform audits based on its own standards.
d. An IRO can provide implementation of corrective action. |
|
Definition
Correct Answer: A
Explanation: An IRO must maintain independence and objectivity.
Reference: https://oig.hhs.gov/compliance/corporate-integrity-agreements/faq.asp |
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Term
Question 14:
Why is the auditor's ability to effectively communicate the audit results and recommendations the most critical step in the audit process?
a. Findings are of little value if the auditee does not understand the basis for them, the cause of any error, or the necessary steps to accomplish an appropriate corrective action plan.
b. As long as there is a well-written report, it is not necessary to discuss the report with the auditee.
c. The provider must have a chance to discuss the res... |
|
Definition
Correct Answer: A
Explanation: Clear communication of audit results ensures the provider understands and can implement necessary corrective actions.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
Question 15:
Which section of an audit report would you report consistent findings that attribute to a specific procedure code or particular provider?
a. Standard of review
b. Summary
c. Issue-oriented findings
d. Recommendations |
|
Definition
Correct Answer: C
Explanation: Issue-oriented findings categorize and detail findings by specific issues or codes.
Reference: https://library.ahima.org/doc?oid=301477 |
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Term
Question 16:
What is the reason audit findings should be discussed with the audited provider?
a. To provide a risk analysis, identify problem areas, and recommend corrective action with supporting documentation.
b. To identify abuse areas before providing the information to Medicare.
c. To identify areas where the provider has committed fraudulent activities before providing the information to the OIG.
d. To become friends with the provider so he will hire you as an auditor resource again. |
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Definition
Correct Answer: A
Explanation: Discussing findings with providers ensures clarity on risks, issues, and recommended actions.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
Question 17:
Of the examples below, which may require an auditor to identify non-standard coding and reimbursement rules?
a. Medicare plans
b. Medicaid plans
c. Auto and Workers' Compensation
d. Commercial insurance carriers |
|
Definition
Correct Answer: C
Explanation: Auto and Workers' Compensation payers may use non-standard rules differing from traditional Medicare/Medicaid/commercial payers.
Reference: https://content.naic.org/ |
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Term
Question 18:
How long is a Corporate Integrity Agreement (CIA) usually in force?
a. Ten years
b. Three years
c. Five years
d. Two years |
|
Definition
Correct Answer: C
Explanation: Most CIAs are in effect for five years.
Reference: https://oig.hhs.gov/compliance/corporate-integrity-agreements/ |
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Term
Question 19:
Which statement is TRUE regarding the recommendations section of an audit report?
a. The recommendations section should contain recommendations for resolving any detected errors.
b. The recommendations section should include details of each claim affected by the errors detected during the audit.
c. The order of the recommendations is irrelevant as long as they are all listed.
d. If there are no binding rules for the post-payment risks detected, they should not be included in the ... |
|
Definition
Correct Answer: A
Explanation: The recommendations section should offer actionable guidance on how to resolve errors.
Reference: https://library.ahima.org/doc?oid=301477 |
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Term
Question 20:
What is an auditor's role in the OIG's Self-Disclosure Protocol (SDP)?
a. The auditor usually helps the provider complete the SDP.
b. Assisting in the disclosure of a Stark self-referral law violation.
c. Identifying the scope of the error and auditing the documentation.
d. Developing a corrective action plan. |
|
Definition
Correct Answer: C
Explanation: An auditor identifies the scope and nature of an issue that might warrant self-disclosure.
Reference: https://oig.hhs.gov/compliance/self-disclosure-info/protocol.asp |
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Term
Question 21:
What is an IRO?
a. Independent Review Organization
b. Irreversible Reporting Options
c. Inconclusive Reporting Options
d. Independent Random Organization |
|
Definition
Correct Answer: A
Explanation: IRO stands for Independent Review Organization.
Reference: https://oig.hhs.gov/compliance/corporate-integrity-agreements/ |
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Term
Question 22:
For Medicare, which administrative agency is responsible for interpretation of the statutory requirements?
a. The Department of Defense
b. Office of Inspector General
c. Health Care Fraud Prevention and Enforcement Action Team
d. Health and Human Services |
|
Definition
Correct Answer: D
Explanation: HHS oversees Medicare’s statutory interpretation and enforcement.
Reference: https://www.hhs.gov/ |
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Term
Question 23:
Which statement is TRUE regarding speaking with providers?
a. Overemphasize the areas that need improvement and identify the monetary risk at hand for the provider so that he or she is listening.
b. Providers have little time so be brief and to the point. Avoid taking time to focus on what the provider(s) did well, go directly to the areas for improvement.
c. Detail each individual error with the provider while speaking to him to make sure he or she goes through them all.
d. Focu... |
|
Definition
Correct Answer: D
Explanation: Positive reinforcement combined with constructive feedback fosters provider engagement and compliance improvement.
Reference: https://oig.hhs.gov/documents/compliance-guidance/876/physician_practices.pdf |
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Term
Question 24:
When there is a conflict between CMS' Internet Only Manuals (IOMs) and federal regulations, which provisions take precedence?
a. Regulatory provisions
b. Whichever is stricter
c. Whichever is more lenient
d. The IOMs |
|
Definition
Correct Answer: A
Explanation: Federal regulations supersede CMS guidance if a conflict exists.
Reference: https://www.ecfr.gov/ |
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Question 25:
What provides an entity the ability to self-disclose potential instances of fraud involving federal healthcare programs for which liability arises under the Civil Monetary Penalty Law?
a. Corporate Integrity Agreement (CIA)
b. OIG Self-Disclosure Protocol (SDP)
c. Self-Referral Disclosure Protocol (SRDP)
d. Exclusions List |
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Definition
Correct Answer: B
Explanation: The SDP enables providers to self-report potential violations under the Civil Monetary Penalty Law.
Reference: https://oig.hhs.gov/compliance/self-disclosure-info/protocol.asp |
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Question 1:
Which of the following actions may result in a False Claims Act violation?
a. A provider submits claims to Medicare for office visits provided to Medicare beneficiaries.
b. A provider accepts insurance-only payments from Medicare beneficiaries.
c. A provider routinely waives the copay for Medicare beneficiaries.
d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries. |
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Definition
Answer: d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries.
Rationale: Knowingly submitting claims for services or supplies not rendered is fraud under the FCA.
Reference: https://www.justice.gov/civil/false-claims-act |
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Question 2:
The False Claims Act (FCA) allows for reduced penalties if the person in violation self-discloses if which conditions exist?
a. The person furnishes all information about the violation within 30 days after which the defendant first obtained the information.
b. There is no additional criminal prosecution, civil action, or administrative action with respect to the violation.
c. The person fully cooperates with the investigation.
d. All of the above. |
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Definition
Answer: d. All of the above.
Rationale: Reduced penalties are possible if the violator self-discloses within 30 days, fully cooperates, and no government action is already underway.
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Question 3:
Which one of the following actions is an example of fraud or misconduct subject to the False Claims Act?
a. The provider determines he has forgotten to document the size of one lesion removed and makes an addendum in the patient’s chart.
b. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim.
c. The provider receives a lab result back and documents in the patient’s chart that the lab result indicates a malignant lesion.
d. The provider reviews his records and determines the documentation supports the claims sent for lesion excisions. |
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Definition
Answer: b. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim.
Rationale: Falsifying documentation to increase reimbursement is a fraudulent act under the FCA.
Reference: https://www.justice.gov/civil/false-claims-act |
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Question 4:
In the NCCI edits, what does modifier indicator one (1) represent?
a. A modifier may be used to bypass the edits if the documentation supports the modifier.
b. The NCCI edit is not in effect.
c. A modifier is not allowed to bypass the NCCI edits.
d. Modifiers are not applicable to the edits. |
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Definition
Answer: a. A modifier may be used to bypass the edits if the documentation supports the modifier.
Rationale: Modifier indicator 1 allows bypassing an NCCI edit if appropriate documentation supports the use of a modifier.
Reference: https://www.cms.gov/medicare/coding/nationalcorrectcodinit-ed |
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Term
The False Claims Act (FCA) allows for reduced penalties if the person in violation self-discloses if which conditions exist?
a. The person furnishes all information about the violation within 30 days after which the defendant first obtained the information.
b. There is no additional criminal prosecution, civil action, or administrative action with respect to the violation.
c. The person fully cooperates with the investigation.
d. All of the above. |
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Definition
Answer: d. All of the above.
Rationale: Reduced penalties are possible if the violator self-discloses within 30 days, fully cooperates, and no government action is already underway.
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Term
Which one of the following actions is an example of fraud or misconduct subject to the False Claims Act?
a. The provider determines he has forgotten to document the size of one lesion removed and makes an addendum in the patient’s chart.
b. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim.
c. The provider receives a lab result back and documents in the patient’s chart that the lab result indicates a malignant lesion.
d. The provider reviews his records and determines the documentation supports the claims sent for lesion excisions. |
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Definition
Answer: b. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim.
Rationale: Falsifying documentation to increase reimbursement is a fraudulent act under the FCA.
Reference: https://www.justice.gov/civil/false-claims-act |
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Term
In the NCCI edits, what does modifier indicator one (1) represent?
a. A modifier may be used to bypass the edits if the documentation supports the modifier.
b. The NCCI edit is not in effect.
c. A modifier is not allowed to bypass the NCCI edits.
d. Modifiers are not applicable to the edits. |
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Definition
Answer: a. A modifier may be used to bypass the edits if the documentation supports the modifier.
Rationale: Modifier indicator 1 allows bypassing an NCCI edit if appropriate documentation supports the use of a modifier.
Reference: https://www.cms.gov/medicare/coding/nationalcorrectcodinit-ed |
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Term
Which of the following actions may result in a False Claims Act violation?
a. A provider submits claims to Medicare for office visits provided to Medicare beneficiaries.
b. A provider accepts insurance-only payments from Medicare beneficiaries.
c. A provider routinely waives the copay for Medicare beneficiaries.
d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries. |
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Definition
Answer: d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries.
Rationale: Knowingly submitting claims for services or supplies not rendered is fraud under the FCA.
Reference: https://www.justice.gov/civil/false-claims-act |
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Term
The False Claims Act (FCA) allows for reduced penalties if the person in violation self-discloses if which conditions exist?
a. The person furnishes all information about the violation within 30 days after which the defendant first obtained the information.
b. There is no additional criminal prosecution, civil action, or administrative action with respect to the violation.
c. The person fully cooperates with the investigation.
d. All of the above. |
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Definition
Answer: d. All of the above.
Rationale: Reduced penalties are possible if the violator self-discloses within 30 days, fully cooperates, and no government action is already underway.
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Question 1
Which of the following actions may result in false claims act violation?
a. A provider submits claims to Medicare for office visits provided to Medicare beneficiaries.
b. A provider accepts insurance only payments from Medicare beneficiaries.
c. A provider routinely waives the copay for Medicare beneficiaries.
d. A provider knowingly submits claims to Medicare for DME supplies not provided to Medicare beneficiaries. |
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Definition
Answer: d
Rationale: Knowingly submitting false claims is a direct violation of the False Claims Act (FCA).
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Question 2
The False Claims Act (FCA) allows for reduced penalties if the person in violation self-discloses if which conditions exist?
a. Furnishes information within 30 days.
b. No additional actions have commenced.
c. Fully cooperates with investigation.
d. All of the above. |
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Definition
Answer: d
Rationale: All listed conditions must be met for reduced penalties under FCA.
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Term
Question 3
Which one of the following actions is an example of fraud or misconduct subject to the False Claims Act?
a. Addendum to document lesion size.
b. Altering records to support higher-level billing.
c. Documenting malignant lesion from lab results.
d. Reviewing records to confirm documentation. |
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Definition
Answer: b
Rationale: Altering records to justify a higher claim level is fraud.
Reference: https://oig.hhs.gov/fraud/false-claims-act/ |
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Term
Question 4
In the NCCI edits, what does modifier indicator one (1) represent?
a. Modifier may bypass edit with documentation.
b. NCCI edit not in effect.
c. Modifier not allowed to bypass edit.
d. Modifiers not applicable to edits. |
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Definition
Answer: a
Rationale: Modifier indicator 1 allows bypass if documentation supports it.
Reference: https://www.cms.gov/medicare/national-correct-coding-initiative-edits |
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Question 5
In a Corporate Integrity Agreement (CIA), does the OIG specify the Independent Review Organization to be used?
a. No; but OIG can request a new IRO.
b. Yes; CIA lists five IROs.
c. No; OIG has no input.
d. Yes; specific IRO named in CIA. |
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Definition
Answer: a
Rationale: OIG does not specify but can reject a provider’s selection.
Reference: https://oig.hhs.gov/compliance/corporate-integrity-agreements/ |
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Question 6
The Federal False Claims Act provides the government can assess:
a. Up to ten times damages.
b. Up to five times damages.
c. Up to four times damages.
d. Up to three times damages. |
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Definition
Answer: d
Rationale: FCA imposes treble (three times) damages.
Reference: https://www.law.cornell.edu/uscode/text/31/3729 |
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Question 7
What is CoP?
a. Medicaid’s Coordination of Physicians Groups
b. Commercial Programs
c. Medicare’s Conditions of Participation
d. TriCare’s Compliance of Physicians Guidance |
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Definition
Answer: c
Rationale: CoP is the Medicare Conditions of Participation.
Reference: https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs |
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Question 8
What can a provider do if they disagree with a demand letter sent as a result of a Recovery Audit?
a. Submit review to MAC within 120 days.
b. Discussion period request within 120 days.
c. Submit review to MAC within 15 days.
d. Discussion period request within 30 days. |
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Definition
Answer: d
Rationale: Provider may request discussion within 30 days.
Reference: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/recoveryauditprogram |
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Question 9
Which option is considered a material breach of a CIA?
a. Failure to fire auditors.
b. Failure to engage an IRO.
c. Failure to hire an internal auditor.
d. Failure to hire an OIG employee. |
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Definition
Answer: b
Rationale: Failing to use an IRO as agreed is a material breach.
Reference: https://oig.hhs.gov/compliance/corporate-integrity-agreements/cia-faq/ |
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Question 10
Recovery auditors may perform two types of reviews. What is an automated review?
a. Review with human record review.
b. Records are required.
c. Review based solely on claims and guidelines.
d. Review based on denials. |
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Definition
Answer: c
Rationale: Automated reviews use claims data, no medical records needed.
Reference: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/recoveryauditprogram |
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Question 11
Which OIG publication is released monthly to identify projects to be addressed during the fiscal year?
a. OIG Work Plan
b. Semiannual Report to Congress
c. Compendium of Unimplemented Recommendations
d. OIG Compliance Plan Guidance |
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Definition
Answer: a
Rationale: The OIG Work Plan outlines audits and reviews planned.
Reference: https://oig.hhs.gov/reports-and-publications/workplan/ |
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Question 12
When a provider is excluded under the Exclusions Statute, what must they do at the end of the exclusionary period?
a. Automatically reinstated.
b. Cannot be reinstated.
c. Apply for group provider number.
d. Apply for reinstatement. |
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Definition
Answer: d
Rationale: Reinstatement requires an application to the OIG.
Reference: https://oig.hhs.gov/exclusions/reinstatement.asp |
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Question 13
You audit a provider reporting multiple units of CPT code 11042. What references show this is incorrect?
a. MUE table only.
b. HCPCS and NCCI PTP edits.
c. CPT codebook and NCCI PTP edits.
d. CPT codebook and MUE table. |
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Definition
Answer: d
Rationale: CPT codebook and MUE limits must both be referenced.
Reference: https://www.cms.gov/medicare/coding/ncci-edits |
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Question 14
In the NCCI edits, what does modifier indicator nine (9) represent?
a. Modifier may bypass edit with documentation.
b. Modifier not allowed.
c. Only modifier 59 can bypass.
d. Modifiers not applicable; edit not in effect. |
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Definition
Answer: d
Rationale: Indicator 9 means the NCCI edit is not in effect.
Reference: https://www.cms.gov/medicare/ncci/ncci-modifier-indicators |
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Term
| Dr. Que completes a 15-minute psych eval but bills for 30-45 minutes. Dr. Que may be liable for: a. Fraud - Upcoding b. Fraud - Unbundling c. Abuse - Higher fee schedule for Medicare patients d. Abuse - Billing unnecessary services |
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Definition
| Answer: a Rationale: Billing higher-level services than provided is fraud (upcoding). Reference: https://oig.hhs.gov/compliance/provider-compliance-training/files/FraudWasteAbuseTraining508.pdf |
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Term
Question 16
Which factor is NOT considered when evaluating proposals for the OIG Work Plan?
a. Work with partner organizations.
b. Mandatory reviews.
c. Congressional requests.
d. TriCare war-related accident payments. |
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Definition
Answer: d
Rationale: TriCare war-related accident payments are not a factor.
Reference: https://oig.hhs.gov/reports-and-publications/workplan/ |
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Question 17
When non-compliant conduct is found, what should be documented?
a. Incident date, termination date.
b. Incident date, reporting party, responsible party, follow-up action.
c. Incident date, OIG report date.
d. Non-compliance action, OIG report date. |
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Definition
Answer: b
Rationale: Documentation should include incident date, reporter, responsible person, and action taken.
Reference: https://oig.hhs.gov/compliance/compliance-resource-portal/ |
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Question 18
A provider disagrees with an OIG Civil Monetary Penalty demand letter. What should they do?
a. Request hearing before HHS ALJ.
b. Send a letter with supporting evidence.
c. Take evidence to federal court.
d. Do nothing; OIG will reassess. |
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Definition
Answer: a
Rationale: The provider may request a hearing before an HHS ALJ.
Reference: https://oig.hhs.gov/compliance/civil-monetary-penalty-authority/ |
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Question 19
The OIG's guidance for small practices identifies which risk areas?
a. Claims submission, HIPAA, audits, inducements.
b. Claims submission, background checks, HIPAA, audits.
c. Coding/billing, necessity, documentation, inducements.
d. Coding/billing, background checks, documentation, inducements. |
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Definition
Answer: c
Rationale: The four areas are coding/billing, necessity, documentation, inducements.
Reference: https://oig.hhs.gov/compliance/compliance-resource-portal/ |
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Question 20
In the NCCI edits, what does modifier indicator zero (0) represent?
a. Modifiers not applicable.
b. Modifier may bypass edit.
c. Modifier not allowed to bypass edit.
d. NCCI edit not in effect. |
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Definition
Answer: c
Rationale: Indicator 0 means no modifier can bypass the edit.
Reference: https://www.cms.gov/medicare/ncci/ncci-modifier-indicators |
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Question 21
OIG compliance guidance lists which risk area?
a. Under coding
b. Unbundling
c. Same-day rule violation
d. Overuse of E/M codes |
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Definition
Answer: b
Rationale: Unbundling is a listed risk area.
Reference: https://oig.hhs.gov/compliance/compliance-resource-portal/ |
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Question 22
A provider disagrees with a demand letter sent by the OIG. What rights do they have?
a. Self-disclosure after demand letter.
b. Send documentation to OIG by mail.
c. Respond with payment only.
d. Request hearing before HHS ALJ. |
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Definition
Answer: d
Rationale: Providers can request an ALJ hearing.
Reference: https://oig.hhs.gov/compliance/civil-monetary-penalty-authority/ |
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Question 23
What is another name for the Federal False Claims Act (FCA)?
a. Kennedy-Kassebaum Law
b. Operation Restore Trust
c. Stark Law
d. Lincoln Law |
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Definition
Answer: d
Rationale: FCA is also known as the Lincoln Law.
Reference: https://www.justice.gov/civil/false-claims-act |
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Question 24
Recovery auditors may perform different types of reviews. What review requires medical records?
a. Semi-automated
b. Independent
c. Complex
d. Automated |
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Definition
Answer: c
Rationale: Complex reviews require medical records.
Reference: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/recoveryauditprogram |
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Question 25
What regulation increases penalties for violating the FCA?
a. Medicare Physician Fee Schedule Final Rule
b. Federal Civil Penalties Inflation Adjustment Act
c. Anti-Kickback Statute
d. Stark Laws |
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Definition
Answer: b
Rationale: Penalties are adjusted by the Inflation Adjustment Act.
Reference: https://www.federalregister.gov/documents/2023/12/19/2023-27829/civil-monetary-penalties-inflation-adjustments |
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