CHC Exam Study Guide 2026/2027 | Actual Questions and
Answers Latest Updated 2026/2027 (Graded A+)
• Question
Federal Sentencing Guidelines - Culpability Score Aggravating Factors
Correct Answer: I. 1. upper-level employee
II. participates, condones, or ignores offense
III. 2. repeat offense
IV. 3. hinder investigation
V. 4. awareness and tolerance of violation is pervasive
• Question
Federal Sentencing Guidelines - Culpability Score Mitigating Factors
Correct Answer: I. 1. effective compliance
II. program
III. 2. reported promptly
IV. 3. cooperation with investigation
V. 4. accept responsibility
• Question
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program
Correct Answer: I. 1. written
II. standards of conduct
III. 2. Chief Compliance Officer
IV. 3. effective education and training
V. 4. audits and evaluations to monitor compliance
VI. 5. reporting processes and procedures for complaints
VII. 6. appropriate disciplinary mechanisms
VIII. 7. investigation and remediation of systematic problems
• Question
The only thing worse than not having a policy is...
Correct Answer: ...having a policy and not following it.
• Question
Medicare reimbursement - hospital inpatient codes
Correct Answer: International Classification of Diseases (ICD)
• Question
Medicare reimbursement - physician codes
Correct Answer: Current Procedural Technology (CPT)
,• Question
Questions to guide the scope of an internal investigation.
Correct Answer: 1. What is the origin of the issue? 2. When did the issue originate? 3.
How far back should the investigation go? 4. Can extrapolation of a statistical sample be
used?
• Question
It is in the best interest of the organization to have the board _______.
Correct Answer: ...take an active rather than a passive role in compliance.
• Question
Six tips for saving on future costs of compliance.
Correct Answer: I. 1. embed quality into existing processes
II. 2. centralize common processes and controls
III. 3. improve human resources infrastructures
IV. 4. improve information systems processes
V. 5. emphasize training
VI. 6. monitor marketing and compensation
• Question
Baseline Audit Process
Correct Answer: I. 1. outline the current operational standards
II. 2. identify real and potential weaknesses
III. 3. offer recommendations
• Question
Compliance Program - Measures of Effectiveness
Correct Answer: I. 1. staff knowledge
II. 2. all 7 elements included
III. 3. comparing issues year to year
IV. 4. tracking and trending complaints
V. 5. tracking corrective actions
VI. 6. reviewing current audits
VII. 7. educational session pre and post tests
VIII. 8. tracking bill denials
IX. 9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
,• Question
Modifier
Correct Answer: a two digit alpha/numeric code used in conjunction with CPT or HCPCS
codes that may increase or decrease reimbursement
gives new meaning to the code
• Question
International Classification of Diseases (ICD)
Correct Answer: a statistical classification system that arranges diseases and injuries
into groups according to established criteria (signs and symptoms)
• Question
Current Procedural Terminology (CPT)
Correct Answer: American Medical Association publishes and maintains this coding
system
• Question
Organized Health Care Arrangements (OHCA)
Correct Answer: HIPAA arrangement between clinically integrated setting (ex: hospitals
and medical staff)
• Question
Diagnosis Related Group (DRG)
Correct Answer: an inpatient classification system based on: principal diagnosis,
secondary diagnosis, surgical factors, age, sex, and discharge status
• Question
Healthcare Common Procedure Coding System (HCPCS)
Correct Answer: for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version
• Question
Upcoding
Correct Answer: providers use a billing code that reflects a higher payment rate for a
device or service provided than the actual device or service furnished to the patient
, • Question
Unbundling
Correct Answer: submitting bills by piecemeal or in fragmented fashion to maximize
reimbursement
• Question
Outlier
Correct Answer: additional payment for patients with long hospital length of stay
• Question
Billing and Coding Concerns (*)
Correct Answer: 1. coding advice (if not in book - get in writing) 2. significant increases
in volume (*) (find out why increase) 3. hiring external consultants (need BAA, if provide
patient care - check OIG sanction list) 4. number of auditors for Part B audits 5. teaching
physicians (*) (physician must be physically present and involved in managing care) 6.
co-pay waivers (cannot routinely waive) 7. record does not support code 8. research
payments (cannot bill Medicare for costs covered by sponsor) 9. disagreements (get 3rd
party opinion) 10. DOCUMENTATION
• Question
"Incident To" services
Correct Answer: services commonly furnished in a physician's office by a nurse
practitioner in which there is direct physician personal supervision and are billed under
the physician's provider number (does not apply in hospital setting)
physician must be present to bill (*)
• Question
Two-Midnight Rule
Correct Answer: CMS will consider a claim as inpatient if the patient in hospital bed over
two midnights
• Question
72 Hour Rule/3 Day Window Project (*)
Correct Answer: all diagnostic outpatient charges and other related outpatient charges
within 72 hours prior to an inpatient admission are bundled into inpatient stay
reimbursement
Answers Latest Updated 2026/2027 (Graded A+)
• Question
Federal Sentencing Guidelines - Culpability Score Aggravating Factors
Correct Answer: I. 1. upper-level employee
II. participates, condones, or ignores offense
III. 2. repeat offense
IV. 3. hinder investigation
V. 4. awareness and tolerance of violation is pervasive
• Question
Federal Sentencing Guidelines - Culpability Score Mitigating Factors
Correct Answer: I. 1. effective compliance
II. program
III. 2. reported promptly
IV. 3. cooperation with investigation
V. 4. accept responsibility
• Question
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program
Correct Answer: I. 1. written
II. standards of conduct
III. 2. Chief Compliance Officer
IV. 3. effective education and training
V. 4. audits and evaluations to monitor compliance
VI. 5. reporting processes and procedures for complaints
VII. 6. appropriate disciplinary mechanisms
VIII. 7. investigation and remediation of systematic problems
• Question
The only thing worse than not having a policy is...
Correct Answer: ...having a policy and not following it.
• Question
Medicare reimbursement - hospital inpatient codes
Correct Answer: International Classification of Diseases (ICD)
• Question
Medicare reimbursement - physician codes
Correct Answer: Current Procedural Technology (CPT)
,• Question
Questions to guide the scope of an internal investigation.
Correct Answer: 1. What is the origin of the issue? 2. When did the issue originate? 3.
How far back should the investigation go? 4. Can extrapolation of a statistical sample be
used?
• Question
It is in the best interest of the organization to have the board _______.
Correct Answer: ...take an active rather than a passive role in compliance.
• Question
Six tips for saving on future costs of compliance.
Correct Answer: I. 1. embed quality into existing processes
II. 2. centralize common processes and controls
III. 3. improve human resources infrastructures
IV. 4. improve information systems processes
V. 5. emphasize training
VI. 6. monitor marketing and compensation
• Question
Baseline Audit Process
Correct Answer: I. 1. outline the current operational standards
II. 2. identify real and potential weaknesses
III. 3. offer recommendations
• Question
Compliance Program - Measures of Effectiveness
Correct Answer: I. 1. staff knowledge
II. 2. all 7 elements included
III. 3. comparing issues year to year
IV. 4. tracking and trending complaints
V. 5. tracking corrective actions
VI. 6. reviewing current audits
VII. 7. educational session pre and post tests
VIII. 8. tracking bill denials
IX. 9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
,• Question
Modifier
Correct Answer: a two digit alpha/numeric code used in conjunction with CPT or HCPCS
codes that may increase or decrease reimbursement
gives new meaning to the code
• Question
International Classification of Diseases (ICD)
Correct Answer: a statistical classification system that arranges diseases and injuries
into groups according to established criteria (signs and symptoms)
• Question
Current Procedural Terminology (CPT)
Correct Answer: American Medical Association publishes and maintains this coding
system
• Question
Organized Health Care Arrangements (OHCA)
Correct Answer: HIPAA arrangement between clinically integrated setting (ex: hospitals
and medical staff)
• Question
Diagnosis Related Group (DRG)
Correct Answer: an inpatient classification system based on: principal diagnosis,
secondary diagnosis, surgical factors, age, sex, and discharge status
• Question
Healthcare Common Procedure Coding System (HCPCS)
Correct Answer: for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version
• Question
Upcoding
Correct Answer: providers use a billing code that reflects a higher payment rate for a
device or service provided than the actual device or service furnished to the patient
, • Question
Unbundling
Correct Answer: submitting bills by piecemeal or in fragmented fashion to maximize
reimbursement
• Question
Outlier
Correct Answer: additional payment for patients with long hospital length of stay
• Question
Billing and Coding Concerns (*)
Correct Answer: 1. coding advice (if not in book - get in writing) 2. significant increases
in volume (*) (find out why increase) 3. hiring external consultants (need BAA, if provide
patient care - check OIG sanction list) 4. number of auditors for Part B audits 5. teaching
physicians (*) (physician must be physically present and involved in managing care) 6.
co-pay waivers (cannot routinely waive) 7. record does not support code 8. research
payments (cannot bill Medicare for costs covered by sponsor) 9. disagreements (get 3rd
party opinion) 10. DOCUMENTATION
• Question
"Incident To" services
Correct Answer: services commonly furnished in a physician's office by a nurse
practitioner in which there is direct physician personal supervision and are billed under
the physician's provider number (does not apply in hospital setting)
physician must be present to bill (*)
• Question
Two-Midnight Rule
Correct Answer: CMS will consider a claim as inpatient if the patient in hospital bed over
two midnights
• Question
72 Hour Rule/3 Day Window Project (*)
Correct Answer: all diagnostic outpatient charges and other related outpatient charges
within 72 hours prior to an inpatient admission are bundled into inpatient stay
reimbursement
