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Which element is NOT required for the physical therapy plan of care? Physician co-signature for each session.
What type of font indicates new additions and revisions in the CPT® code book each year? Green font
modifier 22 Additional two hours were spent in lysis of adhesions and to identify the point of obstruction.
When auditing for radiology services, what step is NOT performed? Verify the image obtained meets clinical standards.
How are revisions to coding guidelines identified in the CPT® code book? Green text with opposing arrows.
What should the writing style of an audit report be? Persuasive
n an audit report, which section would identify the specific binding standards or criteria that were applied during the course of the audit? Standard of review
In an audit report, what should be included in the background component? Identity of the entity, provider(s) being audited, audit objectives, type of audit, scope of audit, and identity and qualifications of the auditor should be detailed.
What is the reason audit findings should be discussed with the audited provider? To provide a risk analysis, identify problem areas, and recommend corrective action with supporting documentation.
How long is a Corporate Integrity Agreement (CIA) usually in force? Five years
When there is a conflict between CMS' Internet Only Manuals (IOMs) and federal regulations, which provisions take precedence? Regulatory provisions
What statement is TRUE regarding an IRO? An IRO must remain independent.
What may require an auditor to identify non-standard coding and reimbursement rules? Auto and Workers' Compensation
What statement is TRUE regarding NCCI? NCCI identifies code pairs and exceptions where a modifier may be used to override the code pair.
What type of insurance carrier might be considered a state regulated commercial insurance plan? Workers’ Compensation
For Medicare, which administrative agency is responsible for interpretation of the statutory requirements? Health and Human Services
Which audit example represents a prospective audit? An audit to evaluate if a provider's documentation supports ICD-10-CM coding.
Once an error has been identified and the provider educated, what is recommended to ensure compliance improves? Frequent continued focused audits on the specified error.
Who regulates TriCare? Department of Defense
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? OIG Self Disclosure Protocol (SDP)
What type of information can be found in the provider's contract with the insurance carrier? The provider's obligation to follow the insurance company's medical policies.
What is an IRO? Independent Review Organization
What is a rebuttal audit? An audit in response to a payer audit, in which the auditor is tasked with validating or refuting the conclusions of the payer audit.
What is an auditor's role in the OIG's Self-Disclosure Protocol (SDP)? Identifying the scope of the error and auditing the documentation.
The False Claims Act (FCA) allows for reduced penalties if the person a. The person furnishes information about the violation within 30 days b. There is no additional criminal prosecution, civil action, or administrated action with the respect to the violation. c. The person fully cooperates with the investigation.
The OIG lists potential risk areas Unbundling
When non-compliance is identified, what does the OIG recommend? Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken.
What are the MIPS performance categories? I, II, III, IV
MIPS stands for: Merit-Based Incentive Payment Systems
What is another name for the Federal False Claims Act (FCA)? Lincoln Law
Example of fraud or misconduct subject to the False Claims Act? Falsifying a medical chart notation Submitting claims for services not performed, not requested, or unnecessary Submitting claims for expired drugs Upcoding and/or unbundling services
What does the Physician Self-Referral Law (Stark Law) ban? Self-referrals to designated health services
In the NCCI edits, what does modifier indicator nine (9) represent? 9 = The use of modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date. This indicator was created so that no blank spaces would be in the indicator field.
In the NCCI edits, what does modifier indicator nine (0) represent? 0 = A CCM is not allowed and will not bypass the edits.
In the NCCI edits, what does modifier indicator nine (1) represent? 1 = A CCM is allowed and will bypass the edits.
When a Discovery Sample is performed, what error rate requires a Full Sample to be reviewed? An error rate that exceeds five percent.
The OIG Work Plan is divided into seven parts. Which option is a part of the OIG Work Plan most applicable to physician services? Medicare Part A and Part B
Example of fraudulent activity? Billing for services at a higher level than provided or necessary
What is Fraud? Intentional deception or misrepresentation of the fact that can result in unauthorized benefits or payment.
In the NCCI edits, what does modifier indicator one (1) represent? A modifier may be used to bypass the edits if the documentation supports the modifier.
Difference between 1995 & 1997 E/M guidelines: The 1995 E/M Documentation Guidelines are vague in the description of the exam whereas the 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams.
A Corporate Integrity Agreement (CIA) has core requirement, what is not one of them? Hire an OIG employee to oversee the compliance efforts.
What regulation is the penalty for violating the False Claims Act (FCA) increased by? he Federal Civil Penalties Inflation Adjustment Act
A provider consistently charges a higher level of E/M service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse, and why? Fraud; the provider intentionally over-coded to gain financially.
Under a CIA, 50 sampling units are selected for review. What is this sample referred to as? Discovery sample
Based on the compliance program guidance documents by the OIG, what should be documented when non-compliant conduct is found? Date of incident, name of the reporting party, name of the person responsible for taking action, follow-up action taken.
The OIG's Compliance Program Guidance for Individual and Small Physician Group Practices identifies four risk areas affecting physician practices. What are the four risk areas? Coding and billing; reasonable and necessary services; documentation; and improper inducements, kickbacks, and self-referrals.
Which OIG publication is released monthly? OIG Work Plan
For therapy services, what is the reason for a progress note? To provide justification for the medical necessity of treatment information.
When utilizing templates to document in a medical record, what documentation must be included in the template? Elaboration on abnormal findings.
When referring to radiological services, what is the requirement for the images obtained? The actual images must be retained.
In an operative note, where should information be taken to ensure accurate assignment of a CPT® code? From the body of the operative note.
What form is required to be obtained from the patient prior to completing a surgical procedure? Informed consent
What program was established by HIPAA to combat fraud and abuse committed against all health plans, both public and private? Health Care Fraud and Abuse Control Program
Which type of provider is not required to dictate his or her own operative report? Assistant surgeon
When a laboratory report has an abnormal finding, what should be documented? Circle the abnormal finding and address the abnormality in the diagnosis and treatment plan.
How long does HIPAA require medical records to be maintained? Six years from the date of its creation or the date from which it was last in effect (whichever is later).
What is a risk of handwritten medical records? The documentation may be illegible and abbreviated.
What type of health plan is exempt from HIPAA? Employer who solely establishes and maintains the plan with fewer than 50 participants.
What is CHEDDAR? An optional way of documenting E/M services.
What does CHEDDAR stand for: Chief complaint, History of present illness, Exam, Details, Drugs and dosages, Assessment, Return visit information or referral.
Which governing body is responsible for criminal prosecutions relating to the Privacy Rule? Department of Justice
Under what circumstance may providers use or disclose protected health information without patient consent? Payment, treatment, or operations.
What is considered protected health information (PHI)? Individually identifiable health information.
How must medical records be retained? A specific requirement does not exist
What is the Health Care Fraud and Abuse Control Program? A program established by HIPAA to combat fraud and abuse in healthcare
What form is used to allow the release of their medical records? Release of information
Abbreviation that should not be used in a medical record and why? IU; because it can be mistaken for IV or the number 10.
What standards are set by the Privacy Rule set? Standards for how protected health information is used
In evaluation and management services, what does the O stand for in SOAP? What is included in this section? Objective; indicates the physical exam findings of the provider.
Why is it important to read the body of an operative note as an auditor? To identify if the details in the documentation support the surgery listed in the header, if additional procedures have been performed, or if modifiers should be used
Which option would be excluded from an individual's right to access their PHI? Psychotherapy notes
What form is used to record patient demographic information, insurance and financial information, and emergency contacts? Patient registration form
When tissue glue is used to close a wound involving the epidermis layer how is it reported? As though it was a simple closure
Context Patient's statements regarding what he or she was doing, their environmental factors, or the circumstances surrounding the complaint.
What category of codes should be used to report an evaluation and management service provided to a patient in a psychiatric residential treatment center? Nursing facility services
The main function of Category III CPT codes is: To allow data collection for these services
How are skin grafts measured? Square centimeters
The definition of outpatient for procedures includes: Ambulatory surgeries, ER visits and observation only patients
How are lacerations measured? Centimeters
Difference between foreign body and loose body? A loose body is cartilage, bone, or tissue found near a joint. Foreign body is an ICD-10 code, loose body removal is a CPT code
What is the minimum signature assignment of the author of an entry in the medical record? The first inital, last name and credentials
What is the minimum signature assignment(s) of the author of an entry in the medical record? The first initial, last name and credentials
Based on Joint Commission accreditation guidance for personal data, what two elements must be evident in the medical record: Personal biographical data and consent for treatment or authorization for treatment form
Who would NOT be expected to submit operative notes? Surgical assistants
What is the appropriate way to dispose of PHI that is no longer needed? Discard it in a locked shredding receptacle
When must ABNs be signed? Far enough in advance that the beneficiary or representative has time to consider the options and make an informed decision
SOAP and CHEDDAR are two formats of medical record documentation. Which section of each format would you find the patient's history? S in SOAP and H in CHEDDAR
Patients can request copies of disclosure of PHI under HIPAA for how long: six (6) year period of time
A provider knows that an evaluation and management service they provide on the same date as a major procedure will be bundled, so he submits the claim for the E/M with a different date of service. This is an example of: Fraud
For the civil monetary penalties, for false or fraudulent claims, up to how many times of the amount damages are for each false claim submitted? Three times the amount improperly claimed
Which type of case is not prosecuted under the federal false claims act? Physician tax issues
A full sample must be reviewed and a systems review must be conducted when the net financial error rate of the sampling equals or exceeds what percent? 5%
Where is information regarding potential reviews found? OIG Work Plan
What supporting references will you need to conduct the audit? CPT® Evaluation and Management (E/M) Office or Other Outpatient Code and Guideline Changes,1995, and 1997 CMS Documentation Guidelines based on the date of service
The Stark Statute applies to: Physicians who refer Medicare and Medicaid patients to entities for designated health care services with which the provider or immediate family member has a financial relationship
When can a RAC extrapolate the overpayment(s) on claims? RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund.
Whenever the provider performs a minor procedure with an E/M service, the minor surgery is reimbursed but the E/M service is denied. You review 10 charts and all cases are documented and coded correctly. What could be the reason for the denial? The payer contract may bundle the E/M service when performed on the same day as the minor surgery.
A provider receives a denial on a Medicare claim due to lack of medical necessity. Which resource is a valuable tool for providers to limit denials for medical necessity? LCDs with associated articles
A comprehensive audit is: Large number of claims selected for a review that might be focused on specific procedure and/or diagnosis codes
How is RAT-STATS used by an auditor? Software used in performing statistical random samples and evaluating results
What are the recommended number of charts to audit per provider and the minimum frequency of the audit according to the OIG Recommended Compliance Plan? 10 records per provider each year
Evaluation and Management documentation is often captured in SOAP format, which is the acronym for: Subjective, Objective, Assessment, Plan
Failure to have which of the following forms in the medical record will result in payment sent to the beneficiary? Assignment of benefits form
In addition to the nature or purpose of the treatment and risks and benefits involved, the informed consent must include which of the following information? Alternative treatment options and the risks and benefits of alternative treatment options.
Outpatient physical therapy services cannot be initiated until: An initial plan of care has been established.
When auditing operative reports, the header describing the procedure: may not fully support the procedure documented in the body of the report.
During an audit of a paper medical record, the auditor finds a correction was made using white-out and initialed by the nurse. This method of correction is: unacceptable because the original content is not readable.
An auditor identifies claims for services provided by a non-physician provider as Incident-to during the month the physician was on vacation. This would be considered: Fraud
The penalties for violation of the Stark law include program exclusion for knowing violations and: potential $15,000 CMP (prior to inflation) for each service.
The False Claims Act allows for reduction of penalties to two times the amount of damages (as opposed to three times) under what condition? The person fully cooperates with the investigation of the violation.
The compliance program guidance (CPG) document identifies four risk areas most likely to affect a physician’s practice. The risk areas include: Coding and billing, reasonable and necessary services, documentation, improper inducements.
An auditor identifies a procedure that has a modifier appended. This is an indication that: The procedure performed was altered, but the definition of the code has not changed.
An audit performed on one provider would be considered a: Focused audit
When performing a retrospective audit, the auditor will need to have which of the following materials? Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies and CMS-1500 form.
A sample is gathered of the CPT®/HCPCS codes that have the highest dollar charges. This would be considered which type of sampling? Proportional
Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose? Identify the financial error rate of the selected sample
An annual audit is the minimum requirement an IRO must conduct under which of the following agreements? Corporate Integrity Agreement
Created by: ehalbhuber
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