CHC Study Guide with Complete Solutions

CHC Study Guide with Complete Solutions Federal Sentencing Guidelines - Culpability Score Aggravating Factors - ANSWER- 1. upper-level employee participates, condones, or ignores offense 2. repeat offense 3. hinder investigation 4. awareness and tolerance of violation is pervasive Federal Sentencing Guidelines - Culpability Score Mitigating Factors - ANSWER-1. effective compliance program 2. reported promptly 3. cooperation with investigation 4. accept responsibility Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program - ANSWER-1. written standards of conduct 2. Chief Compliance Officer 3. effective education and training Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 2/101 4. audits and evaluations to monitor compliance 5. reporting processes and procedures for complaints 6. appropriate disciplinary mechanisms 7. investigation and remediation of systematic problems The only thing worse than not having a policy is... - ANSWER-...having a policy and not following it. Medicare reimbursement - hospital inpatient codes - ANSWER-International Classification of Diseases (ICD) Medicare reimbursement - physician codes - ANSWER-Current Procedural Technology (CPT) Questions to guide the scope of an internal investigation. - 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? It is in the best interest of the organization to have the board _______. - ANSWER- ...take an active rather than a passive role in compliance. Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 3/101 Six tips for saving on future costs of compliance. - ANSWER-1. embed quality into existing processes 2. centralize common processes and controls 3. improve human resources infrastructures 4. improve information systems processes 5. emphasize training 6. monitor marketing and compensation Baseline Audit Process - ANSWER-1. outline the current operational standards 2. identify real and potential weaknesses 3. offer recommendations Compliance Program - Measures of Effectiveness - ANSWER-1. staff knowledge 2. all 7 elements included 3. comparing issues year to year 4. tracking and trending complaints 5. tracking corrective actions 6. reviewing current audits 7. educational session pre and post tests Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 4/101 8. tracking bill denials 9. organizational survey results 10. audit results 11. compliance topics on department/organization agendas Modifier - 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 International Classification of Diseases (ICD) - ANSWER-a statistical classification system that arranges diseases and injuries into groups according to established criteria (signs and symptoms) Current Procedural Terminology (CPT) - ANSWER-American Medical Association publishes and maintains this coding system Organized Health Care Arrangements (OHCA) - ANSWER-HIPAA arrangement between clinically integrated setting (ex: hospitals and medical staff) Diagnosis Related Group (DRG) - ANSWER-an inpatient classification system based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 5/101 Healthcare Common Procedure Coding System (HCPCS) - ANSWER-for medication, maintained by CMS CMS contracts with American Medical Association to use CPT coding for the Medicare program using this expanded version Upcoding - 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 Unbundling - ANSWER-submitting bills by piecemeal or in fragmented fashion to maximize reimbursement Outlier - ANSWER-additional payment for patients with long hospital length of stay Billing and Coding Concerns (*) - 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) Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 6/101 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 "Incident To" services - 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 (*) Two-Midnight Rule - ANSWER-CMS will consider a claim as inpatient if the patient in hospital bed over two midnights 72 Hour Rule/3 Day Window Project (*) - ANSWER-all diagnostic outpatient charges and other related outpatient charges within 72 hours prior to an inpatient admission are bundled into inpatient stay reimbursement False Cost Reports (*) - ANSWER-submission of charges to Medicare which are unrelated to medical care, such as administrative overhead Copyright ©SOPHIABENNETT 2025 ACADEMIC YEARALL RIGHTS RESERVED. Page 7/101 Credit Balances - Failure to Refund (*) - ANSWER-provider has 60 days to refund credit balances (*) PPS Transfer Project - ANSWER-PPS transfer of patient (rather than discharge) and receiving payment Advance Beneficiary Notice (ABN) - ANSWER-a written form that a provider gives to a Medicare beneficiary that informs the beneficiary that Medicare