CPMA 2026 Exam Prep: Medical Auditor —
Questions with Answer Rationales Coding
Audits | Documentation Compliance | Risk
Assessment | Evaluation | Healthcare
Regulations Review
SECTION 1: COMPLIANCE & REGULATORY GUIDELINES (Questions
1–30)
Question 1. Which option is NOT part of the seven elements that should be
included in a compliance plan based on the OIG's recommendations?
A) Responding promptly to detected offenses and developing corrective action
B) Conducting effective training and education
C) Identifying employees on the exclusions list
D) Developing effective lines of communication
Rationale: The seven OIG-recommended elements of a compliance plan 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, and (7) responding promptly to detected offenses and developing
corrective action. Identifying employees on the exclusions list is an operational
task, not one of the seven structural elements.
Question 2. The OIG's Compliance Program Guidance for Individual and Small
Physician Group Practices identifies four risk areas affecting physician practices.
What are the four risk areas?
A) Claims submission; background checks; HIPAA violations; audit compliance
B) Coding and billing; reasonable and necessary services; documentation;
improper inducements, kickbacks, and self-referrals
,C) Unbundling; upcoding; downcoding; modifier misuse
D) Stark Law; Anti-Kickback Statute; False Claims Act; Exclusion Statute
Rationale: The OIG's Compliance Program Guidance for Individual and Small
Physician Group Practices specifically identifies four risk areas: coding and billing,
reasonable and necessary services, documentation, and improper
inducements/kickbacks/self-referrals.
Question 3. A provider consistently charges a higher level E/M service than is
documented to help cover the cost of his declining practice. Would this be fraud or
abuse, and why?
A) Abuse; charging one level higher on each visit does not show intent
B) Abuse; the provider's practice is common and therefore would not be
considered fraudulent
C) Fraud; any over-coding of services would be considered fraudulent
D) Fraud; the provider intentionally over-coded to gain financially
Rationale: Fraud requires intent. The provider's deliberate over-coding to gain
financially demonstrates the intent element required for fraud. Abuse, by contrast,
involves billing practices that are inconsistent with accepted medical or business
practices but lack intentional deception.
Question 4. When non-compliance is identified, what does the OIG recommend?
A) Continue to watch the employee in non-compliance until the incidents meet a
federal level before taking action
B) Take disciplinary action and document the date of the incident, name of
the reporting party, name of the person responsible for taking action, and the
follow-up action taken
C) Immediately terminate employment for the party found in non-compliance,
regardless of the severity of the offense
D) Take no action unless the non-compliance is reported externally
Rationale: The OIG recommends taking disciplinary action and documenting the
incident date, reporting party, person responsible for action, and follow-up action
taken. This documentation is essential for demonstrating an effective compliance
program.
,Question 5. What is a Qui Tam Relator?
A) A person who is prosecuted under the False Claims Act
B) The defendant in a Stark Law case
C) A person listed on the OIG exclusions list
D) A person who brings civil action for violation under the False Claims Act
for themselves and the government
Rationale: A Qui Tam Relator is a private individual who brings a civil action on
behalf of the government under the False Claims Act. The relator may share in a
portion of the recovery. The FCA allows reduced penalties if the person in
violation self-discloses under specified conditions, including furnishing all
information within 30 days, fully cooperating, and no additional criminal or civil
action being pursued.
Question 6. The FCA allows for reduced penalties if the person in violation self-
discloses if which conditions exist?
A) The person furnishes all information about the violation within 30 days
B) The person fully cooperates with the investigation
C) There is no additional criminal prosecution or civil action with respect to the
violation
D) All of the above
Rationale: The False Claims Act provides reduced penalties for self-disclosure
when the person furnishes all information within 30 days of obtaining it, fully
cooperates with the investigation, and no additional criminal or civil action is
pursued for the same violation.
Question 7. Which of the following is NOT one of the four OIG risk areas
affecting physician practices?
A) HIPAA violations
B) Coding and billing
C) Documentation
D) Improper inducements, kickbacks, and self-referrals
, Rationale: The four OIG risk areas are coding and billing, reasonable and
necessary services, documentation, and improper inducements/kickbacks/self-
referrals. HIPAA violations are addressed by OCR and are not included in the
OIG's four risk areas for physician practices.
Question 8. What does the MUE table tell?
A) The maximum number of diagnoses that can be reported per encounter
B) The maximum number of units a procedure can be reported on the same
date of service
C) The maximum allowable charge for a procedure
D) The minimum documentation required for a procedure
Rationale: MUE stands for Medically Unlikely Edits. The MUE table tells the
maximum number of units a procedure can be reported on the same date of service.
MUEs are applied by Medicare Administrative Contractors (MACs) and are based
on anatomical considerations and coding guidelines.
Question 9. What does MUE stand for?
A) Medical Utilization Edits
B) Medically Unlikely Edits
C) Maximum Unbundling Edits
D) Mandatory Unit Evaluation
Rationale: MUE stands for Medically Unlikely Edits. These edits are set by
Medicare to prevent payment for an excessive number of units of a service that
would be medically improbable on a single date of service.
Question 10. When a provider is excluded under the Exclusions statute, what must
he or she do at the end of the exclusionary period?
A) The provider is automatically reinstated
B) The provider must apply for reinstatement
C) The provider cannot be reinstated once excluded
D) The provider must apply for a group provider number
Questions with Answer Rationales Coding
Audits | Documentation Compliance | Risk
Assessment | Evaluation | Healthcare
Regulations Review
SECTION 1: COMPLIANCE & REGULATORY GUIDELINES (Questions
1–30)
Question 1. Which option is NOT part of the seven elements that should be
included in a compliance plan based on the OIG's recommendations?
A) Responding promptly to detected offenses and developing corrective action
B) Conducting effective training and education
C) Identifying employees on the exclusions list
D) Developing effective lines of communication
Rationale: The seven OIG-recommended elements of a compliance plan 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, and (7) responding promptly to detected offenses and developing
corrective action. Identifying employees on the exclusions list is an operational
task, not one of the seven structural elements.
Question 2. The OIG's Compliance Program Guidance for Individual and Small
Physician Group Practices identifies four risk areas affecting physician practices.
What are the four risk areas?
A) Claims submission; background checks; HIPAA violations; audit compliance
B) Coding and billing; reasonable and necessary services; documentation;
improper inducements, kickbacks, and self-referrals
,C) Unbundling; upcoding; downcoding; modifier misuse
D) Stark Law; Anti-Kickback Statute; False Claims Act; Exclusion Statute
Rationale: The OIG's Compliance Program Guidance for Individual and Small
Physician Group Practices specifically identifies four risk areas: coding and billing,
reasonable and necessary services, documentation, and improper
inducements/kickbacks/self-referrals.
Question 3. A provider consistently charges a higher level E/M service than is
documented to help cover the cost of his declining practice. Would this be fraud or
abuse, and why?
A) Abuse; charging one level higher on each visit does not show intent
B) Abuse; the provider's practice is common and therefore would not be
considered fraudulent
C) Fraud; any over-coding of services would be considered fraudulent
D) Fraud; the provider intentionally over-coded to gain financially
Rationale: Fraud requires intent. The provider's deliberate over-coding to gain
financially demonstrates the intent element required for fraud. Abuse, by contrast,
involves billing practices that are inconsistent with accepted medical or business
practices but lack intentional deception.
Question 4. When non-compliance is identified, what does the OIG recommend?
A) Continue to watch the employee in non-compliance until the incidents meet a
federal level before taking action
B) Take disciplinary action and document the date of the incident, name of
the reporting party, name of the person responsible for taking action, and the
follow-up action taken
C) Immediately terminate employment for the party found in non-compliance,
regardless of the severity of the offense
D) Take no action unless the non-compliance is reported externally
Rationale: The OIG recommends taking disciplinary action and documenting the
incident date, reporting party, person responsible for action, and follow-up action
taken. This documentation is essential for demonstrating an effective compliance
program.
,Question 5. What is a Qui Tam Relator?
A) A person who is prosecuted under the False Claims Act
B) The defendant in a Stark Law case
C) A person listed on the OIG exclusions list
D) A person who brings civil action for violation under the False Claims Act
for themselves and the government
Rationale: A Qui Tam Relator is a private individual who brings a civil action on
behalf of the government under the False Claims Act. The relator may share in a
portion of the recovery. The FCA allows reduced penalties if the person in
violation self-discloses under specified conditions, including furnishing all
information within 30 days, fully cooperating, and no additional criminal or civil
action being pursued.
Question 6. The FCA allows for reduced penalties if the person in violation self-
discloses if which conditions exist?
A) The person furnishes all information about the violation within 30 days
B) The person fully cooperates with the investigation
C) There is no additional criminal prosecution or civil action with respect to the
violation
D) All of the above
Rationale: The False Claims Act provides reduced penalties for self-disclosure
when the person furnishes all information within 30 days of obtaining it, fully
cooperates with the investigation, and no additional criminal or civil action is
pursued for the same violation.
Question 7. Which of the following is NOT one of the four OIG risk areas
affecting physician practices?
A) HIPAA violations
B) Coding and billing
C) Documentation
D) Improper inducements, kickbacks, and self-referrals
, Rationale: The four OIG risk areas are coding and billing, reasonable and
necessary services, documentation, and improper inducements/kickbacks/self-
referrals. HIPAA violations are addressed by OCR and are not included in the
OIG's four risk areas for physician practices.
Question 8. What does the MUE table tell?
A) The maximum number of diagnoses that can be reported per encounter
B) The maximum number of units a procedure can be reported on the same
date of service
C) The maximum allowable charge for a procedure
D) The minimum documentation required for a procedure
Rationale: MUE stands for Medically Unlikely Edits. The MUE table tells the
maximum number of units a procedure can be reported on the same date of service.
MUEs are applied by Medicare Administrative Contractors (MACs) and are based
on anatomical considerations and coding guidelines.
Question 9. What does MUE stand for?
A) Medical Utilization Edits
B) Medically Unlikely Edits
C) Maximum Unbundling Edits
D) Mandatory Unit Evaluation
Rationale: MUE stands for Medically Unlikely Edits. These edits are set by
Medicare to prevent payment for an excessive number of units of a service that
would be medically improbable on a single date of service.
Question 10. When a provider is excluded under the Exclusions statute, what must
he or she do at the end of the exclusionary period?
A) The provider is automatically reinstated
B) The provider must apply for reinstatement
C) The provider cannot be reinstated once excluded
D) The provider must apply for a group provider number
