CMCA PRACTICE EXAM 136 Questions with Verified Answers,100% CORRECT

CMCA PRACTICE EXAM 136 Questions with Verified Answers The Joint Commission (JC) requires the Factors that Affect Learning must be assessed for a hospital or hospital owned physician practice as well as other health care facilities. When assessing this element what does this include? A. The patient's ability to read, method of learning and understanding. B. Any language or physical disabilities. C. Cultural beliefs. D. All the above - CORRECT ANSWER D. All the above Report copies and printouts, films, scans, and other radio logic service image records must be retained for how long according to Federal Regulations? A. 10 years B. 7 years C. 5 years D. 3 years - CORRECT ANSWER C. 5 years At which point should a provider repay over payments reported by self-disclosure to the office of Inspector General? A. Make the payment to your carrier immediately. B. Make the payment at the conclusion of the OIG injury. C. Make the payment to the carrier prior to the self disclosure. D. Make the payment to the OIG with a self disclosure report. - CORRECT ANSWER B. Make the payment at the conclusion of the OIG injury Which of the following may be considered essential element (s) of an operative report and will allow for accurate coding? A. The approach B. The type of anesthesia required C. The location and severity of wounds repaired D. All of the above - CORRECT ANSWER D. All of the above Which of the following is NOT a covered entity under HIPPA? A. Physician B. Health Plan C. Health Care Consultant D. Physician Assistant - CORRECT ANSWER C. Health Care Consultant When referring to the authentication of a medical record entry, what does this entail? A. Legible signature of author and date signed B. A physician's order for ancillary services C. An original document filed in the record D. The patient's personal information - CORRECT ANSWER A. Legible signature of author and date signed What is the time limit mandated by CMS for adding a late entry to the medical record? A. One Week B. One Month C. One Year D. No time limit - CORRECT ANSWER D. No time limit When should a ABN be signed? A. Prior to performing a statutorily excluded procedure for a Medicare beneficiary. B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. C. Prior to submitting a claim to Medicaid for a non- service. D. After performing a procedure and finding it is denied. - CORRECT ANSWER B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. Under a Corporate Integrity Agreement (CIA), how many claims must be randomly selected to review to determine the financial error rate? A. 15 B. 50 C. 75 D. 100 - CORRECT ANSWER B. 50 When using LCDs and CMS program Guidance as a resource for an audit, what should the auditor keep in mind? A. QICs are bound by NCDs, LMRPs, and CMS Program guidance, but ALJs and MACs are not. B. Local carriers and QICs are bound by LCDs and LMRPs C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. D. Local Carriers, QICs, ALJs, and MACs are all bound by NCDs and CMS program guidance. - CORRECT ANSWER C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. When reporting the claims review findings under a CIA audit, the Independent Review Organization (IRO) must provide: A. A detailed analysis listing the patient files reviewed and findings and previous audit disclosures for all services B. A detailed report with a narrative explanation of finding and supporting rationale approved by the providers attorney. C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. D. A list of data reviewed and findings in a narrative form - CORRECT ANSWER C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. Which statement is most accurate regarding NCCI? A. NCCI are national coding guidelines and must be followed regardless of the insurance carrier. B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. C. Each individual carrier will have its own bundling edits and will not use NCCI. D. NCCI edits are suggested ways to bundle procedure codes, but are not necessary to review during an audit. - CORRECT ANSWER B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. A provider request you to perform an audit of claims that have been denied payment by XYZ insurance. Since the physician contracted with XYZ insurance, all claims submitted that include the E/M service and EKG interpretation on the same day have been denied for the EKG interpretation. You review the medical record and the EOB and determine the services are documented and coded correctly. Which of the following items will you need to complete your audit? A. Provider contract with XYZ insurance. B. Provider internal billing polices. C. RAC statement of work D. OIG work plan for the current year. - CORRECT ANSWER A. Provider contract with XYZ insurance. According to the "OIG Compliance Program for Individual and Small Group Physician Practices," There are essential elements for a compliance plan. These elements included: A. Mandatory employment of an internal auditor B. Conduct appropriate training and education C. Disciplinary action for employees who file a qui tam suit D. Develop an effective E/M Audit Tool with reproducible results. - CORRECT ANSWER B. Conduct appropriate training and education John presents today for his yearly physical and during the encounter he alerts his physician to some abdominal issues he has been having including sharp pains that come and go and have been increasing in severity especially after eating. After examination the doctor orders an ultrasound which is performed in the office and medications and schedules a follow-up for two weeks. What is the appropriate modifier for this encounter? A. No modifier necessary B. 25 C. 57 D. 24 - CORRECT ANSWER B. 25 Which of the following accurately describes the financial impact for appending modifier 24 to an E/M service performed during the global period of a major surgery? A. The E/M service will not be paid when performed during the global period. B. The E/M service will be paid at 20% of the physician fee schedule C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. D. The E/M service will not be paid and a ABN should be signed since the service provided is unrelated to the surgery. - CORRECT ANSWER C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. Select the scenario that would support medical necessity for observation services. A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. B. A patient who is recovering from abdominal surgery who requires observation until awake from anesthesia. C. A patient who is receiving infusion chemotherapy for the first time and is anxious about that procedure D. A patient who is dependent on a ventilator and requires pulse oximetry to monitor 02 staturation - CORRECT ANSWER A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. When may a focused audit be initiated? A. After a prepayment or retrospective audit has identified a specific problem B. When the auditor first decides to conduct an audit C. To compare coding and billing patterns for the entire practice D. To ensure compliance with all coding guidelines - CORRECT ANSWER A. After a prepayment or retrospective audit has identified a specific problem Which of the following represents the most logical initial step in the audit process? A. Develop an audit tool and tally form B. Determine the objective(s), the type, and the scope of the audit C. Gather the medical records to be audited. D. Analyze the audit and compare the documentation to the procedure and diagnosis code(s) billed. - CORRECT ANSWER B. Determine the objective(s), the type, and the scope of the audit What are the the Seven Elements defined by the OIG? - CORRECT ANSWER The Seven Elements defined by the OIG are: 1. Implementing written policies and procedures 2. Designating a compliance officer and compliance committee 3. Conducting effective training and education 4. Developing effective lines of communication 5. Conducting internal monitoring and auditing 6. Enforcing standards through well-publicized disciplinary guidelines 7. Responding promptly to detected problems and undertaking corrective action The office of Inspector General (OIG) - CORRECT ANSWER The mission of the Office of Inspector General is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs Fraud - CORRECT ANSWER Fraud is an intention deception made for personal gain. Fraud is a crime and a civil law violation Abuse - CORRECT ANSWER Abuse is an act that directly or indirectly results in unnecessary reimbursement without defined intent. A qui tam suit - CORRECT ANSWER (Whistle blower) One in which an action that will grant the plaintiff a portion of the recovered penalty and gives the rest of it to the state. How often does the Compliance program Guidance for Individual and Small Group Physician Practices recommends employees be trained on compliance programs? - CORRECT ANSWER As soon as possible after their start date and receive refresher training on an annual basis or as appropriate. Improper Payments - CORRECT ANSWER The discovery of billing errors does not man that the provider should freeze billing of all services. At Minimum, the provider should hold billing services with noted deficiencies until the appropriate corrective action plan is implemented. Federal Anti-Kickback Law - CORRECT ANSWER Prohibits the knowing and willful solicitation, offer, payment, or receipt of any remuneration (broadly interpreted to encompass anything of value), whether direct or indirect, in cash or in like kind, to induce or in return for referring an individual, or purchasing or arranging for an item of service for which payment may be mad under the Medicare, Medicaid, or other government health program. Safe Harbor Provisions - CORRECT ANSWER Describes various payment and business practices that, although they potentially implicate the Federal Anti-Kickback Statute, are not reated as offenses under the statute. The Safe Harbor provisions are updated by the OIG and maintained on their website. False Claims - CORRECT ANSWER A false Claim includes a claim that does not conform to Medicare's (or other programs) requirements for reimbursement. The Civil False Claim Acts - CORRECT ANSWER Imposes civil monetary penalties of between $5,500 and $11,000 plus three times the value of each claim. It prohibits the knowing submission of a false or fraudulent claim for payment to the United States, the knowing use of a false record or statement to obtain payment on a false or fraudulent claim, or a conspiracy to defraud the United States by having a false or fraudulent claim allowed or paid The Criminal False Claim Act: - CORRECT ANSWER Prohibits knowingly and willfully making or causing to be made any false statement or representation of material fact in any claims or application for benefits under federally funded health plans as well as commercial carriers. Violations are felonies and are punishable by up to five years imprisonment and/or $25,000 in fines. The Civil Monetary Penalties Law: - CORRECT ANSWER Provides for the imposition of civil monetary penalties up to $10,000 per false service claimed, plus assessments equal to three times the amount claimed, for services that the provider knows or should know were not provided as claimed or for claims the provider knows or should know are false or fraudulent. Other federal criminal laws: - CORRECT ANSWER Also may be used to prosecute the submission of false claims, including prohibitions on making false statements to the government and engaging in mail fraud. Felony convictions will result in exclusion from Medicare for a minimum of a five-year period. Option for Providers - CORRECT ANSWER Self Disclosure: Fines may be less if a practice self-disclosed its knowledge of the violation. Appeal Rights: A practice has the right to an appeal process, and may choose to request a hearing before an administration law judge (ALJ). The OIG and the respondent have the right to present evidence and make arguments to the ALJ, who issues a written decision. Additional Appeal: The ALJ's decision may be appealed administratively and to federal court. OIG Work Plan - CORRECT ANSWER OIG Work Plan The OIG Work Plan is released annually and identifies priority areas for OIG review/ investigation, which the agency believes are HHS' most vulnerable programs and activities, with the goal to improve HHS agency efficiency and effectiveness Corporate Integrity Agreement (CIA) What is a Corporate Integrity Agreement? - CORRECT ANSWER It is an agreement between the OIG and a health care provider or other entity. CIA agreements are detailed and restrictive agreements imposed on providers when serious misconduct (fraudulent or abusive type action) is discovered through an audit or self-disclosure. The government may enter into a CIA with an entity instead of seeking to exclude the entity from Medicare, Medicaid, and other federal health care programs. The typical term of a comprehensive CIA is five years Discovery Sample - CORRECT ANSWER The claims review procedures require a Discovery Sample. A Discovery Sample is used to determine the financial error rate. The Discovery Sample is a review of 50 units to be randomly selected. The purpose of conducting a Discovery Sample as part of the claims review is to determine the net financial error rate of the sample that is selected. If the net financial error rate equals or exceeds 5 percent, the results of the Discovery Sample are used to determine the Full Sample size. The Full Sample size is based on an estimate of the variability of the overpayment amount in the population from which the sample was drawn. The results of the Discovery Sample allow the reviewer to estimate how many sample units need to be reviewed in order to estimate the overpayment in the population within certain confidence and precision levels (eg, generally, a 90 percent confidence and 25 percent precision level Stark Law - CORRECT ANSWER The Stark Law is primarily defined as a physician self-referral law, 42 USC 1395nn. Physician self-referral is defined by the Stark Laws as: the practice of a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement. The Stark Law was sponsored by Congressman Pete Stark (Calif.). Individuals such as Stark contend such arrangements may encourage over-utilization of services, in turn driving up health care costs. This law prohibits a physician from making a referral to an entity with which the physician or his or her immediate family has a financial relationship if the referral is for the furnishing of designated health services, unless the financial relationship fits into an exception set forth in the statute or impending regulations. What services are not targeted by the Stark Law? - CORRECT ANSWER Services such as sleep studies, EKGs, NCVs, and Holter monitoring, or services personally performed or provided by the referring physician are, however, not targeted by the Stark Law. Referral for services provided by non-physician providers is exempt as well. The exceptions to the Stark Law covered relationships internal to a physician group include items such as those involving in-office ancillary services or certain compensation/ownership arrangements. The Joint Commission - CORRECT ANSWER The Joint Commission (JC), formerly the Joint Commission on Accreditation of Health Care Organizations (better known as JCAHO), is a private sector United States-based, not-for-profit organization. The Joint Commission operates voluntary accreditation programs for hospitals and other health care organizations. RAC Audits CMS Recovery Audit Contractor (RAC) Program - CORRECT ANSWER CMS has implemented a system to identify improper payments, fraud, and abuse in the Medicare system. When should a Self disclosure occur? - CORRECT ANSWER Self disclosure should occur within 30 days of knowing about the violation, and does not require any form of legal assistance. Payments relating to the disclosed matter should not be made until the conclusion of the OIG inquiry to allow the OIG time to verify the information disclosed How often are records requested from RAC auditors and how many? - CORRECT ANSWER Each 45 days, records may be requested based on the entity's size: less than 5 providers—10 records 6-24 providers—25 records 25-49 providers—40 records 50 or more providers—50 records RAC Audit Appeals Process - CORRECT ANSWER Providers who choose to appeal must send a rebuttal of the findings directly to the RAC within 15 days of receiving the RAC's letter identifying an overpayment. Note, however, this does not stop the clock on the 120 day time period during which a request for redetermination (first level appeal) from the Medicare contractor must be submitted. Additionally, the clock is still running with regard to the interest accrued when money is not refunded within 30 days of the request. Providers who choose to send a rebuttal to the RAC will want to either simultaneously file a request for redetermination to the Medicare contractor or carefully track the status of the rebuttal and be prepared to file the request for redetermination within the 120-day time period, if needed. Medicaid appeals processes will vary from state to state as well as Medicare Advantage appeals will vary by MCO PATH Audits - CORRECT ANSWER Another HIPAA mandated audit process under the jurisdiction of the OIG operation is the Physicians at Teaching Hospitals (PATH) Audit. This audit process has two forms: purely government-conducted audits (PATH I), and a self-audit alternative (PATH II). This self-audit process implies through the OIG interpretation as having more lenient penalties for self disclosure of deficiencies, but does not guarantee this initiative. PATH II - CORRECT ANSWER PATH II gives teaching institutions the opportunity to designate a third-party auditor of their choice to be approved by the OIG prior to any government-initiated audit. Some advantages of the PATH II process are the ability to select an institution's own auditor, with the approval of OIG, and the ability to control the audit process in a way that minimizes disruption of ordinary operation. The auditor must be an independent organization, and may not have a pre-existing relationship with the facility. There is no provision for credit of the cost of the audit against any repayment to Medicare. The cost of the self-audit must be weighed against the potential savings in repayment obligations and the waiver of confidentiality Conditions of Participation (CoP) - CORRECT ANSWER Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) are rules and guidelines set forth by CMS to ensure health care organizations meet minimum standards when providing services under the Medicare and Medicaid programs. CMS considers the health and safety standards of their requirements to be the foundation for improving not only the quality of their participant's health care but also protecting the patient's health and safety. These standards are expected to be the minimum and accrediting organizations should seek to exceed the Medicare standards set forth in the CoPs/CfCs CoPs and CfCs apply to the following health care organizations: - CORRECT ANSWER Ambulatory Surgical Centers (ASCs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Critical Access Hospitals (CAHs) End-Stage Renal Disease Facilities Federally Qualified Health Centers Home Health Agencies Hospices Hospitals Hospital Swing Beds Intermediate Care Facilities for Persons with Mental Retardation(ICF/MR) Organ Procurement Organizations (OPOs) Portable X-Ray Suppliers Programs for All-Inclusive Care for the Elderly Organizations (PACE) Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services Psychiatric Hospitals Religious Nonmedical Health Care Institutions Rural Health Clinics Long Term Care Facilities Transplant Centers Medical Record should include - CORRECT ANSWER Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results Assessment, clinical impression, or diagnosis Medical plan of care Date and legible identity of the observer If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be accessible to the treating and/or consulting provider. Appropriate health risk factors should be identified The patient's progress, response to, changes in treatment, and revision of diagnosis should be documented. Current CPT® and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Record Retention - CORRECT ANSWER According the CMS Conditions of Participation (CoP), providers and facilities such as Ambulatory Surgery Centers, Critical Access Hospitals, Skilled Nursing facilities, etc., must meet or exceed standards of accreditation. These CoPs have a requirement that medical records be kept for five years, six years for Critical Access Hospitals (CAH). The following are other recommendations by the AMA: If a patient is a minor, the statute of limitations for medical malpractice claims may not apply until the patient reaches the age of majority. Immunization records always must be kept. To preserve confidentiality when discarding old records, all documents should be destroyed. Before discarding old records, patients should be given an opportunity to claim the records or have them sent to another provider, if it is feasible to give them the opportunity. State laws vary on other specific record retention policy. On average most state policies require: Records be retained for six years Minor records must be retained until the individual reaches 18 years of age. Regulatory Forms and Consent - CORRECT ANSWER Consent for General Treatment Assignment of Benefits Medical Records Release Informed ConsentHIPAA Privacy Form Advanced Beneficiary Notice (ABN)—when applicable Financial Policy Non-Covered Consent Form—when applicable Medicare Advanced Beneficiary Notice (ABN) - CORRECT ANSWER An ABN must be given each time a provider believes a service will not be covered if the provider wishes to bill the beneficiary directly for the service. ABNs are not necessary for statutorily excluded services. They are only necessary for services normally covered by Medicare but which in a particular circumstance the provider believes will not be covered for lack of medical necessity, exceeding treatment options, or other reason. GA Modifier - CORRECT ANSWER To properly notify Medicare an ABN has been signed appropriately by a Medicare beneficiary. The GA modifier is used when an item or service is expected to be denied as not reasonable or necessary for the patient and/or their current condition. When the modifier is used appropriately, Medicare will process the claim and if denied will apply the balance to the patient responsibility. If the GA modifier is not used, the claim will not be applied to patient responsibility. GX modifier - CORRECT ANSWER Notice of liability issued, voluntary under payer policy. Use of this modifier indicates the services delivered are excluded from Medicare coverage by statute, and the charge is being filed on the patient's behalf. In this case, the service is filed to Medicare to obtain a denial, usually for a secondary insurance. The GX modifier should not be used on any services covered by Medicare GY modifier - CORRECT ANSWER is used for items statutorily excluded from Medicare reimbursement. The use of the GY modifier will cause the claim automatic denial. Often these services are billed by the provider to obtain the Medicare denial for the secondary insurance purposes. GZ modifier - CORRECT ANSWER is a modifier that reports to Medicare that the service may not meet medical necessity guidelines, and an ABN was NOT obtained from the patient. The GZ modifier will result in automatic claim denial Health Insurance Portability and Accountability Act (HIPAA) - CORRECT ANSWER HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996. Title I, the first rule under HIPAA, addresses portability of insurance when employees change jobs. It regulates the availability and breadth of group health plans and some limited individual health insurance policies. State law takes precedence to HIPAA policy only when the state law is more restrictive in nature. HIPAA rules apply to "covered entities:" - CORRECT ANSWER Health plans Health care clearinghouses Health care providers who conduct certain financial and administrative transactions electronically. Business Associates Agreement - CORRECT ANSWER —This document spells out the requirements for business associates to disclose protected health information (PHI) while representing the practice. Business associates are entities or individuals who are not a part of the covered entity's workforce, are not covered entities themselves, but process PHI on the behalf of a covered entity. Allowed Uses and Disclosures - CORRECT ANSWER HIPAA allows certain uses and disclosures without a signed authorization from the patient. This includes treatment, payment, and health care operations. Business Associates - CORRECT ANSWER Business Associates (BAs) are individuals or entities who are neither part of your workforce nor covered entities in their own right, but process protected health information (PHI) on behalf of a covered entity such as a private practice. The original HIPAA Privacy Rule required covered entities to establish a list of business associates and to have each business associate sign a Business Associate Agreement (BAA) in the same manner as covered entities. However, the rule required the covered entities working with these BAs to monitor the BAs' use of PHI and to enforce protections. The covered entity would have to terminate the relationship if the covered entity learned that the BA violated the BAA. The Health Information Technology for Economic and Clinical Health (HITECH) Act - CORRECT ANSWER Effective February 17, 2010, The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology. With this implementation it became necessary for business associates to comply with HIPAA regulations themselves: develop policies and procedures to comply with security regulations, train their staff, periodically audit themselves for compliance, become subject to enforcement inspections, and even to some extent monitor the covered entities with which they have the BA relationship. This means not only must covered entities monitor their business associates, but business associates also have the responsibility of monitoring covered entities with which they have a BAA. If there is a breach of PHI, covered entities and BAs must: - CORRECT ANSWER Notify HHS and major media outlets if the breach involves 500 or more participants. Notify affected individuals in writing within 60 days of becoming aware of the breach. Provide in the notice to individuals at least five specific categories of information. Send a notice by first-class mail to each affected individual's last known address. If the address available is no longer applicable, the covered entity may use an alternate method such as e-mail. If there are at least 10 individuals whose PHI has been breached and no current address is available, the notice of the breach must be posted on the covered entity's website. Anesthesia Documentation - CORRECT ANSWER Anesthesia codes are selected based on the site of surgery and in some cases the type of surgery. Anesthesia services are reimbursed based on the anesthesia code and the total units billed. On the CPMA exam, 1 unit of time is equal to 15 minutes. The calculation used to determine the total units is Base Units + Time Units + Modifying Units (BTM). The units are then multiple by the anesthesia conversion factor. The anesthesia report MUST include the anesthesia start and stop times as well as any time the anesthesia provider is not in attendance for the case. The time involved providing services such as insertion of central lines, arterial lines, and postoperative pain blocks prior to anesthesia is not included in the total anesthesia time. The physical status modifiers are: - CORRECT ANSWER P1: A normal, healthy patient P2: A patient with mild systemic disease P3: A patient with severe systemic disease P4: A patient with severe systemic disease with a constant threat to life P5: A moribund patient who is not expected to survive without the operation P6: A declared brain-dead patient whose organs are being removed for donor purposes Anesthesia Modifiers - CORRECT ANSWER AA: Anesthesia performed personally by anesthesiologist QK: Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals QS: Monitored anesthesia care service QX: CRNA service, with medical direction by a physician QY: Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist QZ: CRNA service; without medical direction by a physician Operative Notes - CORRECT ANSWER Operative reports should include the following four sections or elements: the heading, indications of the surgery, body/detail of the procedure or surgery being performed and the findings of the surgery/procedure. The following information should be found in the operative report. Information and documentation styles can vary per provider and facility: Date of surgery Patient name/Date of Birth Pre-op diagnosis Post-op diagnosis Procedure performed Name of primary surgeon, co-surgeon, assistant surgeon, residents as applicable Name of anesthesiologist/CRNA Indications for the procedures Consents obtained Detail of the procedure which includes: Preparation of patient for surgery Surgical approach Instruments and supplies used Anesthesia used Complications Condition of patient after procedure Modifier 22 - CORRECT ANSWER This modifier indicates the surgical encounter was somehow more extensive or greater than is normally expected based on CPT® code description. The documentation of the encounter should include medical necessity to support what made the service more work on this given encounter. Only additional work/services performed above and beyond those within the code description are worthy of the modifier 22. Services that are merely utilizing a new technique or new equipment would not support the utilization of this modifier. Modifier 24: - CORRECT ANSWER This E/M modifier would be appended to E/M services provided during the global surgical period that are not routine postoperative care and are additionally reimbursable. The documentation of this type of an encounter should include components that support why the encounter was not a routine service related to the surgical encounter Modifier 51: - CORRECT ANSWER The multiple procedures modifier indicates more than one stand alone procedure was performed during an operative session and the procedures were related or performed in correlation with one another. The documentation would simply need to include the details of the procedures Modifier 52 - CORRECT ANSWER Reduced services should be reported when all components of a billable CPT® code were not performed and the service was not fully delivered according to the description. The documentation should be inclusive of the service performed and any impending reasons why the full procedure was not performed during the surgical encounter. Modifier 58: - CORRECT ANSWER Staged procedures are performed when a provider is planning to do a procedure in multiple sessions. The best example of staged services in separate encounters would be skin grafts when a provider performs the first graft and he or she may be unsure if another graft will be required. Another example within the same session would be a procedure that begins as a diagnostic procedure but leads to an open procedural service. The documentation does not have to specifically reflect the next procedure or the date of it, but should indicate that additional services may be forthcoming. Modifier 59 - CORRECT ANSWER Distinct procedural services modifier is used when the services provided were for separately specified reasons or sites of service. This modifier is an unbundling modifier and is used in instances when the procedures are typically inclusive of one another but for documented reasons should be reimbursed (eg, separate sessions or anatomic locations). The documentation should be inclusive for either the specified reason and/or the specific anatomical sites of service Modifier 78 - CORRECT ANSWER This modifier is used when a provider performs a surgical service and then has to return the patient to the operating room, as an unplanned procedure or complication. A good example of this type of encounter would be a patient who presents during the postoperative period with a staph infection in the surgical site and I&D of the wound is required in the OR setting. The documentation should include what makes the surgical encounter billable as an unrelated service to the global surgical encounter. National Correct Coding Initiative (NCCI) - CORRECT ANSWER CMS developed a system to prevent inappropriate payment of services that should not be reported together. This system is known as National Correct Coding Initiative (NCCI) and effectively replaced the CMS rebundling program in a continued effort toward a uniform payment policy method. Radiology Related Modifiers - CORRECT ANSWER Technical Component—Modifier TC— reports overhead cost of performing the service which includes the technologist, equipment used, film, and film processing. Professional Component—Modifier 26— reports reading and interpretation of the radiologic service by the provider. This identifies the provider's portion of the service. Global Service—Includes both professional and technical components of the service—the combination of the technical and professional portions of a procedure. Modifiers TC and 26 are not reported when reporting the global service. Radiology Documentation - CORRECT ANSWER The specific anatomical location: If performed in an office setting the E/M documentation may have already included the anatomical site. Because the radiology report stands independent of the encounter, the specific anatomic site of service would need to be included.The number of views: Determines the code reported for the service. This affects the reimbursement of the service, and must be documented within the radiology report. The finding of the radiological encounter: Affects the diagnosis codes reported. Radiation Therapy - CORRECT ANSWER Clinical Treatment Planning: This service is billable regardless of the radiation treatment performed for the patient. There are three coding choices for the planning event: simple, intermediate, and complex. Based on the documentation of the planning session, the auditor should be able to differentiate these levels by the following guidelines: Simple Planning: A session that requires no interpretation of test for the appropriate planning for therapy. Intermediate Planning: A session that requires a level of interpretation and analysis of the provider to develop a plan for the patient's treatment. The planning is considered to be of moderate difficulty. Complex Planning: This session requires the provider's expertise for complex interpretation and planning for therapy. Complex planning may include CT and MR localization, special lab testing, special planning and mapping to protect the normal structures and it includes three or more areas that require treatment. Treatment Parameters and Development - CORRECT ANSWER The treatment parameters are established through simulation and dosimetry. Simulation sets the radiation therapy treatment target area, and dosimetry is the calculation of how much (eg, dose of radiation) to be delivered to the tumor. These codes vary based on the complexity of the treatment. Simulation: Simple: A single area that generally only requires one to two films Intermediate: Involves three or more areas that direct to one or two treatment areas, and require two or more films of each area with or without fluoroscopy. Complex: Performed for three or more areas of malignancy with tangential ports and complex blocking and require additional complex verifications and testing. Additionally, simulation that requires contrast material will also meet the criteria of complex setting. Dosimetry: Basic Dosimetry: May be used any time during the course of therapy when calculation of dosage is needed Treatment Management - CORRECT ANSWER Radiation treatment is billed in units of five fractions or treatments (not sequential) and are expected to include an overview of the patient and his or her condition. The provider's encounter for the treatment should document that the port films were reviewed and the treatment dose/delivery/ parameters were reviewed, as well as the patient's set-up. The patient should have had at minimum one examination for medical evaluation. This is an extensive evaluation of the patient and the documentation should appropriately reflect this. The examination portion of the encounter is more focused on how the patient is responding to the treatments and the coordination of the care of the patient, as well as extensively assessing the patient's overall health to include electrolyte and hydration management. If the documentation does not include details of five fractions/treatments and is inclusive of the evaluation service then the services would not be supported. Treatment includes normal follow-up care during the course of treatment and for three months following its completion. Pathology/Laboratory - CORRECT ANSWER The Pathology/Laboratory section of the CPT® codes—80047 through 89398—are used to report services in clinical laboratory, microbiology, virology, cytology, histology, and pathology. Laboratory panels are inclusive of all tests listed for that panel. The tests included in the panel cannot be billed separately if all of the tests are performed. Separately reporting these services would be interpreted as unbundling and may be interpreted as fraud in an over utilization circumstance. Do not report two or more panel codes including any of the same constituent tests performed from the same patient collections. For example, do not code a comprehensive metabolic panel (80053) in addition to basic metabolic panel (80048) or hepatic function panel (80076). Documentation is required to support the medical necessity of laboratory testing, such as an ICD-9-CM code. There must be an attending/treating provider's order for each test documented in the patient's medical record. Tests performed without a supporting order should be deemed as non-billable. If the ordering provider submits an ICD-9-CM code, the laboratory must use that code unless there is a reason to question the ordering provider to change the code. The laboratory must receive and maintain the documentation to alter the claim. Some tests are Qualitative and others are Quantitative. Qualitative tells if the substance is present or absent. Quantitative tells the amount of substance present. If a drug is present (qualitative), then how much is present in the body (quantitative) is determined. An encounter form is not an acceptable "order" for lab services. Psychiatric Services - CORRECT ANSWER Most psychiatric services are billed based on the amount of time spent with the patient. Time becomes a crucial requirement of psychiatric documentation. Additional documentation requirements are discussed below. Interactive Complexity Interactive complexity is an add on code reported for patients who communication factors complicate the delivery of psychiatric services. This code can not be reported with E/M codes. The only appropriate base codes are listed in a parenthetical note following code 90785. Psychiatric Diagnostic Interview Codes are for the diagnostic evaluation of a patient and are services every psychiatric provider will likely use. This is one of the few psychiatric services that is not time-based. The code selection is based on whether medical services were also performed. There are, however, some specific rules that apply to this service: May be provided by Physician, Clinical Psychologist (CP), or Licensed Clinical Social Workers (LCSW) Code may be reimbursable if other family, friends, health care advisors, or other informant are seen in lieu of the patient. May only bill once per diagnosis onset. If there is a hiatus from illness and the patient is later re-admitted, billing may be approved. In this instance, the documentation of the encounter should not begin as, "the patient is here for a follow-up of..." Ophthalmological Services - CORRECT ANSWER Intermediate Ophthalmology Service should be billed for a patient with a new or existing problem complicated with a new diagnostic or management problem. Codes 92002 (new patient) and 92012 (established patient). These services require the documentation of a diagnosis, history, and medical observation of the patient condition. The exam must be documented to include external ocular and adnexal examination. Comprehensive Ophthalmology Service should be billed for a patient whose treatment includes the initiation of a diagnostic or treatment plan. Codes 92004 (new patient) and 92014 (established patient). These services also require the documentation of a history, medical observation, external and ophthalmoscopic examinations, gross visual fields, and basic sensorimotor examination. Intravenous Infusion Services - CORRECT ANSWER Infusion service is a relatively small section in the CPT® manual, yet they are among the most difficult for providers, coders, and auditors to decipher.Key Factors When Auditing Infusions: There must be an order from the physician or other qualified health care professional for infusion services. Typical hierarchy of infusion coding is chemotherapy, therapeutic, hydration, but should only be applied to facility based infusion services. Physician based services decipher the primary code as the service representing the reason for infusion and the given date of service. Start and stop time of infusions must be documented. Only one initial code per day, regardless of type of infusion, unless separate sites or sessions are medically necessary. An infusion of less than 15 minutes is considered a push. Chemotherapy infusion codes are typically associated with HCPCS J codes. Ensure the correct dosage and units are documented and billed. Items included are local anesthesia, IV start, access to indwelling IV, sub-q catheter or port, flush at conclusion, standard supplies, and preparation of chemotherapy agent. Hydration is typically included in chemotherapy and therapeutic infusions, unless it is called for additionally in the protocol. Two medications running through one bag/ one line are reported with one infusion administration code, not two. This is typically reported as a piggy back service or IVPB (intravenous piggy back). It is appropriate to code for each drug separately. A port flush provided with an E/M encounter additionally is billable; however, a port flush with a nursing encounter are not both supported as separate services Physical Therapy Services - CORRECT ANSWER The therapist should document: The total time or the beginning and ending time for each session defined by a timed code, and The total time in which the patient is involved in services defined by untimed codes and unattended codes. Time spent performing each individual physical therapy technique such as manual therapy, electrical stimulation, etc. Each component utilized for an individual technique must be documented. For example, if 20 leg presses were performed as part of manual therapy, the leg presses should be documented and "labeled" as manual therapy. Treatment Documentation - CORRECT ANSWER Initial Physical Therapy Evaluation Documentation (97001)—Guidelines for the Initial Evaluation are very clear on what must be included. The medical necessity must be substantiated by including the diagnoses for the services needed and the requesting provider. Each of the additional requirements is discussed below. Past Medical History—Should be obtained on elements that influence the Physical Therapy treatment rendered. The documentation should also include the diagnosis, information regarding the patient's functional status prior to the onset of the condition as well as the current functional status, how long the problem has existed, and any pertinent prior physical therapy treatment information. Examination—There are no specific guidelines as to how much examination information must be contained within the medical record, but examination documentation is a required component. Plan of Care Required components of a plan of care include: Plan of treatment including long-term goals Frequency and duration of treatment Diagnoses Specific modalities to be employed Rehab potential Additional optional components of a plan of care include: Short-term goals Goals and duration for the current episode of care Physical therapy services are reported with a modifier GP indicating they were provided under an outpatient physical therapy plan of care. 95 vs 97 guidelines Exams - CORRECT ANSWER Exam The biggest difference between the 1995 and 1997 documentation guidelines is the examination. 1995 examinations are based on the organ systems and body areas. 1997 examinations are based on bullets outlined through specific system examinations. Modifier 24 - CORRECT ANSWER Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional during a Postoperative Period. This modifier is added to an evaluation and management code to specify the service was performed during a postoperative period but is unrelated to the surgical diagnosis. Modifier 25 - CORRECT ANSWER Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. This modifier is added to an E/M code to indicate the patient's service is separate from that required for the procedure and a clearly documented encounter which either addresses issue(s) not pertaining to the procedure, or was the distinct service of defining the procedure indicated on that date of service. Different diagnoses are not required for reporting E/M services on the same day. Modifier 57 - CORRECT ANSWER This modifier is used when the provider makes a decision to perform major surgery the same day as the visit or the next day. Surgical packages include preoperative, surgery, and postoperative services; however, sometimes surgical decisions are made during an E/M visit that requires immediate surgical intervention. Common encounter structure formats may follow the SOAP or CHEDDAR formats. - CORRECT ANSWER These formats present the elements in the following style: SOAP SOAP notes refer to a particular format of recording information regarding the treatment process. S = Subjective O = Objective A = Assessment P = Plan CHEDDAR C = Chief complaint, presenting problems, subjective statements H = History; social and physical history of presenting problem as well as contributing information E = Examination, including extent of body system(s) examined D = Details of problem and complaints, etc. D = Drugs and dosage—a list of current medications used with dosage and frequency, etc. A = Assessment of observations, etc. R = Return visit information incident-to Auditing Rules - CORRECT ANSWER Incident-to charts should first be identified and separated from other charts being audited. A chart is identified as being an incident-to service when the provider on the CMS-1500 claim form differs from the provider on the medical record. Physicians cannot bill incident-to other physicians. split/shared - CORRECT ANSWER Split/ shared visits in the hospital setting do not require incident-to rules Compliance Audits: - CORRECT ANSWER These audits are performed strictly in an effort to evaluate the provider's compliance with documentation rules and guidelines. These audits may be performed by an internal compliance team or outsourced to a third party auditor. These audits tend to focus only on the documentation content as it compares to the necessary rules and guidelines. There are many different compliance audits that could be performed and are performed for various reasons; the most common being pre- and postpayment audits. Audits are typically performed by the practice, a third party consultant, health plan, or government agency. A clear understanding of the types of audits is imperative Prepayment (prospective) Audit - CORRECT ANSWER This type of audit is performed on services prior to claim submission by the practice or consultant or at the time of claim submission by the payer. These audits are typically provided for larger group practices or hospital-based practices. Postpayment (retrospective) Audit: - CORRECT ANSWER :A postpayment audit is the most commonly performed audit. These audits are performed on services that have already been posted, filed and paid by the payer. This audit will typically be performed for the smaller physician practice. These audits help in monitoring claims submission, trends related to denials as well as ensuring proper coding, documentation and billing Risk Management Audits: - CORRECT ANSWER This type of audit is focused on how patient care is delivered from the beginning of the encounter through the entire process as well as practice liability. This audit will focus on a variety of patient care continuity and practice liability issues such as: Facilities Assessment Telephone Procedures/Scheduling Clinical Documentation Informed Consent Information Systems Physician/Patient Communication Continuity of Care Patient Accounts and Billing Procedures Referrals and Consults Medications Malpractice Claims Management and Legal Advice Personnel Issues Focused Audits: - CORRECT ANSWER Focused audits appear to be associated with specific problems related to inaccurate coding and are found most commonly through the production/ utilization report. The audit may focus on a particular service that is being over- or underutilized by the provider. This audit process should not always be the type of audit performed because a more across-the-board audit should be the standard audit approach. A focused audit should be performed when a provider is suspected of not appropriately using a particular service code. A baseline audit typically includes - CORRECT ANSWER 10-15 records per provider as recommended by the OIG There should be three notations of each performed audit: - CORRECT ANSWER Services billed Documentation level of the services billed Medical necessity level of the services billed It is important that every encounter be scored and reported based on documentation content as well as the medical necessity of the service. For compliance reasons, be sure the summarization for the compliance plan includes the following information: - CORRECT ANSWER Date of the audit Who requested the audit How many records were reviewed Which providers were audited A statement indicating a detailed report has been provided to each provider audited A statement indicating a one-on-one or group session was provided for each provider audited to review the findings A concise overview of the findings A statement regarding intended or needed follow up to be performed to adhere to the necessary compliance components Identification of the auditor performing the service Once the audit has been performed and all deficiencies have been reported and reviewed, a plan for corrective action should be implemented. The corrective action should include: - CORRECT ANSWER Review with each provider regarding the findings to include appropriate actions to correct going forward. Review with the compliance officer to ensure he or she has an understanding of the level of compliance the audit identifies. Education for the provider(s) and all appropriate billing/coding/nursing staff regarding the deficiencies noted in the audit, the guidelines, and necessary requirements to meet or exceed compliance in the future. Develop, implement and then educate forthcoming policies relevant to the findings of the audit. Make restitution with any carrier for services that are not billed appropriately. Failure to reimburse a carrier for services billed inappropriately could be interpreted as fraud. This is a form of self disclosure. Schedule a follow-up audit to evaluate the hopeful increase in compliance. All corrective action performed should be maintained by the practice to show its initiative toward compliance. IRO - CORRECT ANSWER Independent Review Organization RAC - CORRECT ANSWER Recovery Audit Contractor CoP - CORRECT ANSWER Conditions of Participation CfC - CORRECT ANSWER Conditions for Coverage Preparing a bid request includes which of the following: A. Verifying References. B. Identifying potential contractors. C. Recommending a contractor to the board. D. Verifying contractor insurance. - CORRECT ANSWER B Legal review prior to executing a contract will assist the association in the event that: A. A subcontractor is used. B. A performance bond is required. C. There is a budgetary shortfall. D. The board has questions or concerns. - CORRECT ANSWER D Rather than describing the scope of work in detail in the contract, a manager may: A. Attach the bid specifications. B. Call each contractor to describe the job. C. Be on-site to oversee project content. D. Suggest the board meet the contractor to talk about the scope of work. - CORRECT ANSWER A In older condominiums, an association should have what type of contract covering mechanical equipment? A. Time and materials B. Specific repair C.Service D. Preventative maintenance - CORRECT ANSWER D For which project would a board most likely want to use a consultant to help develop bid specifications? A.Landscape renovation project B. Repairing and/or replacing roofs C. Painting the interior of lobbies and hallways D. Repairing HVAC and boilers - CORRECT ANSWER B In what type of contract would a waiver of lien be recommended? A. Repair of the HVAC system B.Re-roofing the buildings C. Repair of the pool pump D. Annual tree pruning - CORRECT ANSWER B In terms of compensation , a contract should state: A. Who provides insurance coverage B. Each employees rate to perform work C. When and on what terms payment(s) will be made D. Requirement for a payment bond - CORRECT ANSWER C Alternative dispute resolution includes which of the following methods? A. Mediation B. Subrogation C.Litigation D.Indemnification - CORRECT ANSWER A Employment contracts need not included: A.Legal Sources B.Interests C.Termination D.Notice - CORRECT ANSWER B What is the best way to communicate managements expectation for an employee to complete regular and special tasks during a certain time-period? A.Job orientation B. Job duties C.Establishing performance goals D. Performance reviews - CORRECT ANSWER C When staff members help to develop policies and procedures, they are more: A. Likely to get acknowledged for their contributions. B. Committed to their job C. Committed to implement them D. Likely to be satisfied with their job - CORRECT ANSWER C Discipline as a part of the HR management can include: A. Counseling the employee B. Selecting using a progressive system C. Terminating an under-performing employee D. Gathering performance information from other employees - CORRECT ANSWER A Which tool is mot effective for defining the employees duties? A. Personnel Policy B. Job Description C. Routine performance reviews D. State or local labor regulations - CORRECT ANSWER B The purpose of a personnel manual or employee handbook is to: A. Provide the format for job evaluations B. Define individual job descriptions C. Detail the programs the company offers D. Explain he employee rights and responsibilities - CORRECT ANSWER D What "duty" do the Board members and the manager have to the members? A. Accountability B. Loyalty C. Service D. Conduct - CORRECT ANSWER B Which of the following would impact the operation of a newly installed entry control system? A. Communicating the access control policy to residents B. Identifying warranty procedures C. Developing a capital replacement budget line item D.Informing the associations insurance agent - CORRECT ANSWER A Who has the ultimate responsibility for the care and maintenance of the common areas, facilities and physical property? A. The board of directors B. The association manager C. The developer until turnover D. The executive committee - CORRECT ANSWER A In an initial letter you end to an owner who has violated one of the associations adopted rules, which of the following is included? A. The amount of fine assessed B. Steps to amend the rules C. The offer to meet to hear the owners viewpoint D. What the outcome of similar cases has been - CORRECT ANSWER C When developing a rule, it must be consistent with: A. Fine schedules as approved by the courts B. Board recommendations and resolutions C. Guidelines established within the governing documents D. Applicable statutes and governing documents - CORRECT ANSWER D The primary purpose of a community association is to: A. Guarantee property tax benefits B. Protect the financial health of the owners C. Provide owners protection from municipal laws D. Deal with governance and business - CORRECT ANSWER D The Board of directors receives its authority to perform its specific duties through the: A. Community charter B. Governing Documents C. Board resolutions D. Board member job descriptions - CORRECT ANSWER B In preparing the associations annual financial report, many governing documents specify: A. Retaining a independent tax specialist. B. Retaining an independent certified public accountant. C. The establishment of a finance committee D. The use of he management company's accountant - CORRECT ANSWER B Which of the following is within the authority of the Board of Directors? A. Creating By-laws B. Being paid for their service C. Establishing programs D. Amending the declaration - CORRECT ANSWER C In the hierarchy of a community associations governing documents , which of the following is the highest authority? A. Bylaws B. Articles of Incorporation C. Declaration D. Mortgage lender requirements - CORRECT ANSWER C When a dispute is mediated, an uninvolved third party facilitates discussion and: A. Makes the final judgement fr both parties B. Presents a decision which the parties are free to reject C.Assist both parties in reaching a mutually acceptable agreement D. Decision is binding upon both parties - CORRECT ANSWER C You have a proprietary lease in XYZ development. Which of the following best describes your interest in the property? A. A time-share interest B. A divided interest C. An undivided interest D. Stock membership - CORRECT ANSWER D Management conducts its tasks for the day to day operation of the association in accordance with the: A. Minutes B. Contract C. Board Presidents instructions D. Resolutions - CORRECT ANSWER B A board exercises its fiduciary responsibility by: A. Authorizing the manager to enforce rules B. Establishing internal controls C. Authorizing of a committee to adopt due process procedures D. Voting to eliminate parking rules - CORRECT ANSWER B Which of the following has the greatest regulatory influence on the management of a community association? A. Federal statutes B. Articles of incorporation C. Specific State Statutes D. General State Statutes - CORRECT ANSWER C Which of the following types of insurance coverage is one of limited value to a community association? A. Liability B. Assessment fee receivable C. Workers compensation D. Commercial umbrella - CORRECT ANSWER B