An audit performed after the claims have been submitted
is referred to as what type of audit? C
A) Peer review audit a retrospective audit is performed on data from claims that
B) prospective audit have already been submitted for payment and processed
C) retrospective audit by the insurance carrier
D) focused audit
What would be considered parameters for a baseline
audit?
A
A) random audit of 10-15 records per practitioner
a baseline audit should be 10-15 records per practitioner
B) focused audit on procedures reported with a high
and include a sampling of various levels of E/M services,
frequency, 10-15 records per practitioner
along with oflce and surgical procedures selected ran-
C) random audit of 100 records per practice
domly
D) focused audit on the top 10 procedures reported per
provider, 10 records per procedure
what is/are the advantages of a peer review audit?
D
A) provides feedback among providers
a peer review audit may be performed if the clinical de-
B) clinical decision-making can be addressed
cision-making is being questioned, based on the docu-
C) coding accuracy
mented exam and treatment plan.
D) all of the above
C
which type of audit often realizes more objectivity than
with an employed auditor? one advantage of an external audit is that the practice may
realize more objectivity than with an employed auditor in
A) peer review audit some cases
B) internal audit
C) external audit in addition, when a practice pays for an outside service,
D) random audit the feedback is considered valuable and is taken very
seriously
, how often should an internal audit be conducted mini-
mally? C
A) monthly at a minimum, the internal audit should be considered
B) twice per year annually (and more often if problem areas have been
C) annually identified)
D) when the practice is first opened
when defining the scope of an audit, which question
B
would NOT apply?
whether the audit results will be shared does not deter-
A) will the audit be limited to only government payers
mine the scope of the audit. the scope not only defines
B) will the audit results be shared
what will be audited, and from what period, but also
C) will the audit be limited to E/M codes only
defines what will not be a part of the audit
D) are all providers to be included in the audit
which tool might be helpful in defining which services to
audit for a focused review?
D
A) RAT-STATS
utilization review and data mining provide insight into
B) numerical sampling
billing patterns and can help uncover areas of risk
C) random sampling
D) utilization reports
when performing a government audit, the NCCL edits
manual can serve what purpose B
A) provide medical necessity support the NCCI manual can help support the use of modifiers
B) support the use of modifiers (e.g. modifier 25, 59), and can help to point out bundling
C) determine evaluation and management levels errors when performing the audit
D) determine MAC coverage decisions
which resource is valuable when performing an e/m au-
A
dit?
, A) MDM risk table
B) NCCI manual any audit of evaluation and management services would
C) surgical audit tool require that the auditor have access to the MDM risk table
D) advance beneficiary notice (ABN)
from an audit perspective, consulting the MAC website for
guidance regarding medical necessity coverage decision
Advanced Beneficiary Notice (ABN)
can be an opportunity to see if what form is used and
completed correctly?
what is an example of how oflce policies are helpful in an oflce policies may specify what to bill when a preventive
audit? service and problem list are provided at the same time
sample based on unique services that were defined in the
what is non-statistical sampling?
objective and scope and is used in focused audits
audits must be performed internally before external audits
what is false regarding audits?
are retained
as an auditor, you have completed an audit of a practice
and noticed that one provider consistently submitted level
5 visits. his utilization pattern compared to the rest of
the practice shows higher levels of E/M services reported peer review
overall. concerned that the provider is not supporting the
medical necessity of the visits in the documentation, what
type of audit should you suggest for the practice?
a technique that provides data about how frequently cer-
what is a utilization review?
tain services are billed
a practice contacts an external auditor and explains the
practice is billing incident-to services and is not sure they
are documenting appropriately, or following the guide- NPP services provided in the practice
lines. what services would the external audit focus on
during an audit based on this information?
what is numerical sampling?
, Sampling based on all possible services within a chosen
time frame.
which resource is valuable when performing an evaluation AMA CPT evaluation and management documentation
and management audit for oflce visits? guidelines
what is an example of support documentation that is
correct use of modifiers, including modifier 25
found in the NCCI manual?
what would be more readily available to an internal audi-
commercial carrier contracts
tor versus an external auditor?
to allow providers to learn from each other and improve
what is a an advantage of a peer review audit?
their practice
what type of error might be found by reviewing the en-
keying errors occurring during the data entry process
counter form and claim form?
a database maintained by the OIG to determine outlier for
what is RAT-STATS?
refunds
what is a true statement regarding an audit performed on national CMS policies and local MAC policies should be
charts for medicare beneficiaries? utilized when performing medicare audits
as an auditor, you work for a CPA firm who has been asked
to perform an audit of a new practice to determine risk
areas for their documentation. there have not been any random audit
prior audits at this practice. what type of audit should be
performed?
a practice manager runs reports on services billed to
medicare. the reports identify a large number of surgical
services reported with modifier 22. as a result, you are a focused audit on surgical services with modifier 22
hired as an external auditor to review the services identi-
fied in the report. what type of audit would you perform?
sampling based on high frequency items, or those items
what is proportional sampling?
that are considered to be proportionally significant
is referred to as what type of audit? C
A) Peer review audit a retrospective audit is performed on data from claims that
B) prospective audit have already been submitted for payment and processed
C) retrospective audit by the insurance carrier
D) focused audit
What would be considered parameters for a baseline
audit?
A
A) random audit of 10-15 records per practitioner
a baseline audit should be 10-15 records per practitioner
B) focused audit on procedures reported with a high
and include a sampling of various levels of E/M services,
frequency, 10-15 records per practitioner
along with oflce and surgical procedures selected ran-
C) random audit of 100 records per practice
domly
D) focused audit on the top 10 procedures reported per
provider, 10 records per procedure
what is/are the advantages of a peer review audit?
D
A) provides feedback among providers
a peer review audit may be performed if the clinical de-
B) clinical decision-making can be addressed
cision-making is being questioned, based on the docu-
C) coding accuracy
mented exam and treatment plan.
D) all of the above
C
which type of audit often realizes more objectivity than
with an employed auditor? one advantage of an external audit is that the practice may
realize more objectivity than with an employed auditor in
A) peer review audit some cases
B) internal audit
C) external audit in addition, when a practice pays for an outside service,
D) random audit the feedback is considered valuable and is taken very
seriously
, how often should an internal audit be conducted mini-
mally? C
A) monthly at a minimum, the internal audit should be considered
B) twice per year annually (and more often if problem areas have been
C) annually identified)
D) when the practice is first opened
when defining the scope of an audit, which question
B
would NOT apply?
whether the audit results will be shared does not deter-
A) will the audit be limited to only government payers
mine the scope of the audit. the scope not only defines
B) will the audit results be shared
what will be audited, and from what period, but also
C) will the audit be limited to E/M codes only
defines what will not be a part of the audit
D) are all providers to be included in the audit
which tool might be helpful in defining which services to
audit for a focused review?
D
A) RAT-STATS
utilization review and data mining provide insight into
B) numerical sampling
billing patterns and can help uncover areas of risk
C) random sampling
D) utilization reports
when performing a government audit, the NCCL edits
manual can serve what purpose B
A) provide medical necessity support the NCCI manual can help support the use of modifiers
B) support the use of modifiers (e.g. modifier 25, 59), and can help to point out bundling
C) determine evaluation and management levels errors when performing the audit
D) determine MAC coverage decisions
which resource is valuable when performing an e/m au-
A
dit?
, A) MDM risk table
B) NCCI manual any audit of evaluation and management services would
C) surgical audit tool require that the auditor have access to the MDM risk table
D) advance beneficiary notice (ABN)
from an audit perspective, consulting the MAC website for
guidance regarding medical necessity coverage decision
Advanced Beneficiary Notice (ABN)
can be an opportunity to see if what form is used and
completed correctly?
what is an example of how oflce policies are helpful in an oflce policies may specify what to bill when a preventive
audit? service and problem list are provided at the same time
sample based on unique services that were defined in the
what is non-statistical sampling?
objective and scope and is used in focused audits
audits must be performed internally before external audits
what is false regarding audits?
are retained
as an auditor, you have completed an audit of a practice
and noticed that one provider consistently submitted level
5 visits. his utilization pattern compared to the rest of
the practice shows higher levels of E/M services reported peer review
overall. concerned that the provider is not supporting the
medical necessity of the visits in the documentation, what
type of audit should you suggest for the practice?
a technique that provides data about how frequently cer-
what is a utilization review?
tain services are billed
a practice contacts an external auditor and explains the
practice is billing incident-to services and is not sure they
are documenting appropriately, or following the guide- NPP services provided in the practice
lines. what services would the external audit focus on
during an audit based on this information?
what is numerical sampling?
, Sampling based on all possible services within a chosen
time frame.
which resource is valuable when performing an evaluation AMA CPT evaluation and management documentation
and management audit for oflce visits? guidelines
what is an example of support documentation that is
correct use of modifiers, including modifier 25
found in the NCCI manual?
what would be more readily available to an internal audi-
commercial carrier contracts
tor versus an external auditor?
to allow providers to learn from each other and improve
what is a an advantage of a peer review audit?
their practice
what type of error might be found by reviewing the en-
keying errors occurring during the data entry process
counter form and claim form?
a database maintained by the OIG to determine outlier for
what is RAT-STATS?
refunds
what is a true statement regarding an audit performed on national CMS policies and local MAC policies should be
charts for medicare beneficiaries? utilized when performing medicare audits
as an auditor, you work for a CPA firm who has been asked
to perform an audit of a new practice to determine risk
areas for their documentation. there have not been any random audit
prior audits at this practice. what type of audit should be
performed?
a practice manager runs reports on services billed to
medicare. the reports identify a large number of surgical
services reported with modifier 22. as a result, you are a focused audit on surgical services with modifier 22
hired as an external auditor to review the services identi-
fied in the report. what type of audit would you perform?
sampling based on high frequency items, or those items
what is proportional sampling?
that are considered to be proportionally significant
