CHC UPDATED EXAM TEST PAPER QUESTIONS AND
SOLUTIONS RATED A+
✔✔CHC: Local Coverage Determination - ✔✔= what medicare will cover on the loca
✔✔CHC: National Coverage Determination - ✔✔- like local, but on national side
- national always trumps local
✔✔CHC: Medicare Code Editor - ✔✔- If something is wrong with claim, editor has to
manually fix the claim
✔✔CHC: Grouper - ✔✔- at the facility level
- provides primary DRG that hospital can bill under
✔✔CHC: Pricer - ✔✔- what you can expect to be paid for the primary drug
✔✔CHC: Remittance Advice - ✔✔- once claim process/paid, provides everything about
the payment
✔✔CHC: CMS 1500 Form - ✔✔- physical form
- provider form
- A370P (electronic form)
✔✔CHC: CMS 1450 or UB-04 - ✔✔- physical form
- inpatient form
- A370I (electronic form
✔✔CHC: Documentation of Evaluation & Management Services - ✔✔- 3 key
components in selecting the level of E & M Services:
* 1) History
* 2) Examination
* 3) Medical Decision Making
✔✔CHC: 4 types of history (E&M) - ✔✔- 1) Problem Focused History - fell/hurt elbow <-
- history of this problem
- 2) Expanded Problem Focus History
- 3) Detailed history
,- 4) Comprehensive history - all history - yours & family
- based on how much history you need to get
- document in medical records
✔✔CHC: 4 types of examination - ✔✔- 1) Problem focused examination
- 2) expanded problem focus examination
- 3) detailed examination
- 4) comprehensive examination
- based on how much exam of patient needs to be done
- document in medical record
✔✔CHC: Complexity of Medical Decision Making - ✔✔- straight-forward
- low complexity
-moderate complexity
- high complexity
- CHC: from easiest to difficult/complex. the more difficult, the higher the reimbursement
- based on how much info doctor has to look at
✔✔CHC EXAM - ✔✔- As a best practice policies and procedures SHOULD be reviewed
annually
- Include those affected by the policy and procedure in the design
- The infrastructure is the basic framework of the organization
- size, financial resources and scope of program impacts the infrastructure
- there is no one size fits all compliance program
✔✔CHC EXAM - ✔✔- The Board and/or CEO needs to understand the importance and
adopt a resolution supporting the compliance program
- The Compliance Officer should not report to counsel or be counsel for an organization
- The Compliance Officer should be independent
, - The compliance committee is advisory to the Compliance Officer and help with
oversight of the program
- Careful attention should be given to committee membership selection
- The Compliance Officer should be a high level individual and have authority to make
decisions
- Skill sets that the Compliance Officer brings are important, but when selecting, choose
someone with exemplary personal characteristics
✔✔CHC EXAM - ✔✔- senior management must "walk to walk" and "talk the talk" to
facilitate staff buy in
- Physicians must understand that compliance is not an imposition but a necessity
- Buy-in is critical to the effectiveness of the compliance program. Involve everyone,
listen, react in a timely manner, educate
- Can have policy without procedure but shouldn't have procedure without a policy
✔✔Why Develop a Compliance Program - ✔✔- Detecting wrong doing =
audit/monitoring
- promotes a culture of ethical behavior and commitment to compliance with the law
- aids in preventing and detecting wrong-doing
- provides "safe" mechanisms for reporting and seeking help in getting it right the first
time (hotline = ethicspoint)
- raises awareness of organizations exception
- positive impact to corporate reputation/culture; public image
- simply good business practice
- polices/procedures - first place to show employees what the expectations will be
✔✔CHC EXAM - ✔✔'Within the letter of the law" <-- help raise issues without the fear of
retaliation
✔✔CHC Exam - ✔✔- No transparency in accountability and materials (development of
compliance program) Enron.
* Financial controls were weak = material
SOLUTIONS RATED A+
✔✔CHC: Local Coverage Determination - ✔✔= what medicare will cover on the loca
✔✔CHC: National Coverage Determination - ✔✔- like local, but on national side
- national always trumps local
✔✔CHC: Medicare Code Editor - ✔✔- If something is wrong with claim, editor has to
manually fix the claim
✔✔CHC: Grouper - ✔✔- at the facility level
- provides primary DRG that hospital can bill under
✔✔CHC: Pricer - ✔✔- what you can expect to be paid for the primary drug
✔✔CHC: Remittance Advice - ✔✔- once claim process/paid, provides everything about
the payment
✔✔CHC: CMS 1500 Form - ✔✔- physical form
- provider form
- A370P (electronic form)
✔✔CHC: CMS 1450 or UB-04 - ✔✔- physical form
- inpatient form
- A370I (electronic form
✔✔CHC: Documentation of Evaluation & Management Services - ✔✔- 3 key
components in selecting the level of E & M Services:
* 1) History
* 2) Examination
* 3) Medical Decision Making
✔✔CHC: 4 types of history (E&M) - ✔✔- 1) Problem Focused History - fell/hurt elbow <-
- history of this problem
- 2) Expanded Problem Focus History
- 3) Detailed history
,- 4) Comprehensive history - all history - yours & family
- based on how much history you need to get
- document in medical records
✔✔CHC: 4 types of examination - ✔✔- 1) Problem focused examination
- 2) expanded problem focus examination
- 3) detailed examination
- 4) comprehensive examination
- based on how much exam of patient needs to be done
- document in medical record
✔✔CHC: Complexity of Medical Decision Making - ✔✔- straight-forward
- low complexity
-moderate complexity
- high complexity
- CHC: from easiest to difficult/complex. the more difficult, the higher the reimbursement
- based on how much info doctor has to look at
✔✔CHC EXAM - ✔✔- As a best practice policies and procedures SHOULD be reviewed
annually
- Include those affected by the policy and procedure in the design
- The infrastructure is the basic framework of the organization
- size, financial resources and scope of program impacts the infrastructure
- there is no one size fits all compliance program
✔✔CHC EXAM - ✔✔- The Board and/or CEO needs to understand the importance and
adopt a resolution supporting the compliance program
- The Compliance Officer should not report to counsel or be counsel for an organization
- The Compliance Officer should be independent
, - The compliance committee is advisory to the Compliance Officer and help with
oversight of the program
- Careful attention should be given to committee membership selection
- The Compliance Officer should be a high level individual and have authority to make
decisions
- Skill sets that the Compliance Officer brings are important, but when selecting, choose
someone with exemplary personal characteristics
✔✔CHC EXAM - ✔✔- senior management must "walk to walk" and "talk the talk" to
facilitate staff buy in
- Physicians must understand that compliance is not an imposition but a necessity
- Buy-in is critical to the effectiveness of the compliance program. Involve everyone,
listen, react in a timely manner, educate
- Can have policy without procedure but shouldn't have procedure without a policy
✔✔Why Develop a Compliance Program - ✔✔- Detecting wrong doing =
audit/monitoring
- promotes a culture of ethical behavior and commitment to compliance with the law
- aids in preventing and detecting wrong-doing
- provides "safe" mechanisms for reporting and seeking help in getting it right the first
time (hotline = ethicspoint)
- raises awareness of organizations exception
- positive impact to corporate reputation/culture; public image
- simply good business practice
- polices/procedures - first place to show employees what the expectations will be
✔✔CHC EXAM - ✔✔'Within the letter of the law" <-- help raise issues without the fear of
retaliation
✔✔CHC Exam - ✔✔- No transparency in accountability and materials (development of
compliance program) Enron.
* Financial controls were weak = material
