026
Comprehensive HFMA CRCR Study
Guide 2025
Through what document does a hospital establish compliance standards?
A. Code of Ethics
B. Mission Statement
C. Code of Conduct
D. Compliance Checklist
Rationale: A Code of Conduct defines compliance standards and expected behaviors for staff.
The other documents may express values or procedures but not compliance guidelines.
What is the purpose of the OIG Work Plan?
A. To audit individual hospitals
B. To identify acceptable compliance programs in various provider settings
C. To set hospital reimbursement rates
D. To track patient satisfaction
Rationale: The OIG Work Plan helps healthcare organizations focus compliance efforts on areas
of high risk.
If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window
rule?
A. Diagnostic services only
B. Non-diagnostic services provided Tuesday through Friday
C. Services after discharge
D. All outpatient services within seven days
Rationale: The three-day DRG window includes non-diagnostic services within three days
before admission for Medicare billing.
What does a modifier allow a provider to do?
A. Report a specific circumstance affecting a service without changing the code
B. Change the CPT code
C. Delete unnecessary codes
D. Avoid claim denial
Rationale: Modifiers clarify unique service situations while retaining the base procedure code.
If outpatient diagnostic services are provided within three days of a Medicare admission, what
must happen to these charges?
A. Include them in the inpatient bill
B. Ignore them
C. Bill them separately to the Part B carrier
D. Add to the deductible
,026
Rationale: Outpatient diagnostic services within three days must be billed separately under Part
B per Medicare rules.
What is a recurring or series registration?
A. One registration record created for multiple days of service
B. A record for each visit
C. Emergency patient record
D. Discharge note
Rationale: This type of registration simplifies patient data management for ongoing or repeated
visits.
What are nonemergency patients who come for service without prior notification called?
A. Walk-ins
B. Unscheduled patients
C. Admissions
D. Outpatients
Rationale: “Unscheduled” patients are those arriving without prearranged appointments.
Which statement applies to the observation patient type?
A. Short-term inpatients
B. Used to evaluate the need for inpatient admission
C. Outpatients staying less than one hour
D. Emergency cases only
Rationale: Observation status helps determine if full inpatient care is necessary.
Which services must hospice programs provide around the clock?
A. Therapy and housekeeping
B. Physician, Nursing, and Pharmacy
C. Physical therapy only
D. Counseling and transportation
Rationale: Hospice care regulations require 24-hour access to essential medical support services.
Scheduler instructions are used to prompt the scheduler to do what?
A. Cancel appointments
B. Complete the scheduling process correctly based on service requested
C. Register the patient twice
D. Verify insurance
Rationale: Scheduler instructions ensure accuracy and compliance during the appointment
setup.
The time needed to prepare the patient before service is the difference between arrival time and:
A. Check-in
B. Procedure time
C. Admission
D. Billing completion
Rationale: Preparation time measures readiness from patient arrival to procedure start.
, 026
Medicare requires that when a test is ordered with an LCD or NCD, the order must include:
A. CPT code only
B. Documentation of medical necessity
C. Patient consent
D. Prior authorization number
Rationale: LCD/NCD compliance requires proof that the test is medically necessary.
What is the advantage of a pre-registration program?
A. It reduces processing time at the time of service
B. It replaces billing
C. It speeds insurance payments
D. It reduces patient responsibility
Rationale: Pre-registration ensures smooth patient check-in by collecting data ahead of time.
What data are required to establish a new MPI entry?
A. Insurance and address
B. Responsible party’s full legal name, DOB, and SSN
C. Emergency contact only
D. Patient’s last visit date
Rationale: These identifiers ensure unique and accurate patient records.
Which statement is true about third-party payments?
A. Patients pay directly
B. Payments are received from the payer responsible for covered services
C. Providers receive payments from donors
D. Only applies to Medicaid
Rationale: Third-party payers reimburse providers on behalf of insured patients.
Which provision protects the patient from expenses beyond a set level?
A. Co-pay
B. Stop loss
C. Deductible
D. Premium
Rationale: Stop-loss limits the maximum amount a patient pays out-of-pocket.
What documentation must a PCP send to authorize a specialist visit?
A. Lab order
B. Admission note
C. Referral
D. Claim form
Rationale: Referrals are required by HMOs to approve specialist care.
Under EMTALA, providers may not ask for insurance information if it delays:
A. Discharge
B. Medical screening and stabilizing treatment
C. Billing
Comprehensive HFMA CRCR Study
Guide 2025
Through what document does a hospital establish compliance standards?
A. Code of Ethics
B. Mission Statement
C. Code of Conduct
D. Compliance Checklist
Rationale: A Code of Conduct defines compliance standards and expected behaviors for staff.
The other documents may express values or procedures but not compliance guidelines.
What is the purpose of the OIG Work Plan?
A. To audit individual hospitals
B. To identify acceptable compliance programs in various provider settings
C. To set hospital reimbursement rates
D. To track patient satisfaction
Rationale: The OIG Work Plan helps healthcare organizations focus compliance efforts on areas
of high risk.
If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window
rule?
A. Diagnostic services only
B. Non-diagnostic services provided Tuesday through Friday
C. Services after discharge
D. All outpatient services within seven days
Rationale: The three-day DRG window includes non-diagnostic services within three days
before admission for Medicare billing.
What does a modifier allow a provider to do?
A. Report a specific circumstance affecting a service without changing the code
B. Change the CPT code
C. Delete unnecessary codes
D. Avoid claim denial
Rationale: Modifiers clarify unique service situations while retaining the base procedure code.
If outpatient diagnostic services are provided within three days of a Medicare admission, what
must happen to these charges?
A. Include them in the inpatient bill
B. Ignore them
C. Bill them separately to the Part B carrier
D. Add to the deductible
,026
Rationale: Outpatient diagnostic services within three days must be billed separately under Part
B per Medicare rules.
What is a recurring or series registration?
A. One registration record created for multiple days of service
B. A record for each visit
C. Emergency patient record
D. Discharge note
Rationale: This type of registration simplifies patient data management for ongoing or repeated
visits.
What are nonemergency patients who come for service without prior notification called?
A. Walk-ins
B. Unscheduled patients
C. Admissions
D. Outpatients
Rationale: “Unscheduled” patients are those arriving without prearranged appointments.
Which statement applies to the observation patient type?
A. Short-term inpatients
B. Used to evaluate the need for inpatient admission
C. Outpatients staying less than one hour
D. Emergency cases only
Rationale: Observation status helps determine if full inpatient care is necessary.
Which services must hospice programs provide around the clock?
A. Therapy and housekeeping
B. Physician, Nursing, and Pharmacy
C. Physical therapy only
D. Counseling and transportation
Rationale: Hospice care regulations require 24-hour access to essential medical support services.
Scheduler instructions are used to prompt the scheduler to do what?
A. Cancel appointments
B. Complete the scheduling process correctly based on service requested
C. Register the patient twice
D. Verify insurance
Rationale: Scheduler instructions ensure accuracy and compliance during the appointment
setup.
The time needed to prepare the patient before service is the difference between arrival time and:
A. Check-in
B. Procedure time
C. Admission
D. Billing completion
Rationale: Preparation time measures readiness from patient arrival to procedure start.
, 026
Medicare requires that when a test is ordered with an LCD or NCD, the order must include:
A. CPT code only
B. Documentation of medical necessity
C. Patient consent
D. Prior authorization number
Rationale: LCD/NCD compliance requires proof that the test is medically necessary.
What is the advantage of a pre-registration program?
A. It reduces processing time at the time of service
B. It replaces billing
C. It speeds insurance payments
D. It reduces patient responsibility
Rationale: Pre-registration ensures smooth patient check-in by collecting data ahead of time.
What data are required to establish a new MPI entry?
A. Insurance and address
B. Responsible party’s full legal name, DOB, and SSN
C. Emergency contact only
D. Patient’s last visit date
Rationale: These identifiers ensure unique and accurate patient records.
Which statement is true about third-party payments?
A. Patients pay directly
B. Payments are received from the payer responsible for covered services
C. Providers receive payments from donors
D. Only applies to Medicaid
Rationale: Third-party payers reimburse providers on behalf of insured patients.
Which provision protects the patient from expenses beyond a set level?
A. Co-pay
B. Stop loss
C. Deductible
D. Premium
Rationale: Stop-loss limits the maximum amount a patient pays out-of-pocket.
What documentation must a PCP send to authorize a specialist visit?
A. Lab order
B. Admission note
C. Referral
D. Claim form
Rationale: Referrals are required by HMOs to approve specialist care.
Under EMTALA, providers may not ask for insurance information if it delays:
A. Discharge
B. Medical screening and stabilizing treatment
C. Billing
