CPMA Top Exam Questions and answers, 100% Accurate, Approved.

CPMA Top Exam Questions and answers, 100% Accurate, Approved. The Joint Commission (JC) requires the Factors that Affect Learning must be assessed for a hospital or hospital owned physician practice as well as other health care facilities. When assessing this element what does this include? A. The patient's ability to read, method of learning and understanding. B. Any language or physical disabilities. C. Cultural beliefs. D. All the above - -D. All the above Report copies and printouts, films, scans, and other radio logic service image records must be retained for how long according to Federal Regulations? A. 10 years B. 7 years C. 5 years D. 3 years - -C. 5 years At which point should a provider repay over payments reported by self-disclosure to the office of Inspector General? A. Make the payment to your carrier immediately. B. Make the payment at the conclusion of the OIG injury. C. Make the payment to the carrier prior to the self disclosure. D. Make the payment to the OIG with a self disclosure report. - -B. Make the payment at the conclusion of the OIG injury Which of the following may be considered essential element (s) of an operative report and will allow for accurate coding? A. The approach B. The type of anesthesia required C. The location and severity of wounds repaired D. All of the above - -D. All of the above Which of the following is NOT a covered entity under HIPPA? A. Physician B. Health Plan C. Health Care Consultant D. Physician Assistant - -C. Health Care Consultant When referring to the authentication of a medical record entry, what does this entail? A. Legible signature of author and date signed B. A physician's order for ancillary services C. An original document filed in the record D. The patient's personal information - -A. Legible signature of author and date signed What is the time limit mandated by CMS for adding a late entry to the medical record? A. One Week B. One Month C. One Year D. No time limit - -D. No time limit When should a ABN be signed? A. Prior to performing a statutorily excluded procedure for a Medicare beneficiary. B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. C. Prior to submitting a claim to Medicaid for a non- service. D. After performing a procedure and finding it is denied. - -B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary. Under a Corporate Integrity Agreement (CIA), how many claims must be randomly selected to review to determine the financial error rate? A. 15 B. 50 C. 75 D. 100 - -B. 50 When using LCDs and CMS program Guidance as a resource for an audit, what should the auditor keep in mind? A. QICs are bound by NCDs, LMRPs, and CMS Program guidance, but ALJs and MACs are not. B. Local carriers and QICs are bound by LCDs and LMRPs C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. D. Local Carriers, QICs, ALJs, and MACs are all bound by NCDs and CMS program guidance. - -C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. When reporting the claims review findings under a CIA audit, the Independent Review Organization (IRO) must provide: A. A detailed analysis listing the patient files reviewed and findings and previous audit disclosures for all services B. A detailed report with a narrative explanation of finding and supporting rationale approved by the providers attorney. C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. D. A list of data reviewed and findings in a narrative form - -C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. Which statement is most accurate regarding NCCI? A. NCCI are national coding guidelines and must be followed regardless of the insurance carrier. B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. C. Each individual carrier will have its own bundling edits and will not use NCCI. D. NCCI edits are suggested ways to bundle procedure codes, but are not necessary to review during an audit. - -B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. A provider request you to perform an audit of claims that have been denied payment by XYZ insurance. Since the physician contracted with XYZ insurance, all claims submitted that include the E/M service and EKG interpretation on the same day have been denied for the EKG interpretation. You review the medical record and the EOB and determine the services are documented and coded correctly. Which of the following items will you need to complete your audit? A. Provider contract with XYZ insurance. B. Provider internal billing polices. C. RAC statement of work D. OIG work plan for the current year. - -A. Provider contract with XYZ insurance. According to the "OIG Compliance Program for Individual and Small Group Physician Practices," There are essential elements for a compliance plan. These elements included: A. Mandatory employment of an internal auditor B. Conduct appropriate training and education C. Disciplinary action for employees who file a qui tam suit D. Develop an effective E/M Audit Tool with reproducible results. - -B. Conduct appropriate training and education John presents today for his yearly physical and during the encounter he alerts his physician to some abdominal issues he has been having including sharp pains that come and go and have been increasing in severity especially after eating. After examination the doctor orders an ultrasound which is performed in the office and medications and schedules a follow-up for two weeks. What is the appropriate modifier for this encounter? A. No modifier necessary B. 25 C. 57 D. 24 - -B. 25 Which of the following accurately describes the financial impact for appending modifier 24 to an E/M service performed during the global period of a major surgery? A. The E/M service will not be paid when performed during the global period. B. The E/M service will be paid at 20% of the physician fee schedule C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. D. The E/M service will not be paid and a ABN should be signed since the service provided is unrelated to the surgery. - -C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility. Select the scenario that would support medical necessity for observation services. A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. B. A patient who is recovering from abdominal surgery who requires observation until awake from anesthesia. C. A patient who is receiving infusion chemotherapy for the first time and is anxious about that procedure D. A patient who is dependent on a ventilator and requires pulse oximetry to monitor 02 staturation - -A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. When may a focused audit be initiated? A. After a prepayment or retrospective audit has identified a specific problem B. When the auditor first decides to conduct an audit C. To compare coding and billing patterns for the entire practice D. To ensure compliance with all coding guidelines - -A. After a prepayment or retrospective audit has identified a specific problem Which of the following represents the most logical initial step in the audit process? A. Develop an audit tool and tally form B. Determine the objective(s), the type, and the scope of the audit C. Gather the medical records to be audited. D. Analyze the audit and compare the documentation to the procedure and diagnosis code(s) billed. - -B. Determine the objective(s), the type, and the scope of the audit What are the the Seven Elements defined by the OIG? - -The Seven Elements defined by the OIG 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 7. Responding promptly to detected problems and undertaking corrective action The office of Inspector General (OIG) - -The mission of the Office of Inspector General is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs Fraud - -Fraud is an intention deception made for personal gain. Fraud is a crime and a civil law violation Abuse - -Abuse is an act that directly or indirectly results in unnecessary reimbursement without defined intent. A qui tam suit - -(Whistle blower) One in which an action that will grant the plaintiff a portion of the recovered penalty and gives the rest of it to the state. How often does the Compliance program Guidance for Individual and Small Group Physician Practices recommends employees be trained on compliance programs? - -As soon as possible after their start date and receive refresher training on an annual basis or as appropriate. Improper Payments - -The discovery of billing errors does not man that the provider should freeze billing of all services. At Minimum, the provider should hold billing services with noted deficiencies until the appropriate corrective action plan is implemented. Federal Anti-Kickback Law - -Prohibits the knowing and willful solicitation, offer, payment, or receipt of any remuneration (broadly interpreted to encompass anything of value), whether direct or indirect, in cash or in like kind, to induce or in return for referring an individual, or purchasing or arranging for an item of service for which payment may be mad under the Medicare, Medicaid, or other government health program. Safe Harbor Provisions - -Describes various payment and business practices that, although they potentially implicate the Federal Anti-Kickback Statute, are not reated as offenses under the statute. The Safe Harbor provisions are updated by the OIG and maintained on their website. False Claims - -A false Claim includes a claim that does not conform to Medicare's (or other programs) requirements for reimbursement. The Civil False Claim Acts - -Imposes civil monetary penalties of between $5,500 and $11,000 plus three times the value of each claim. It prohibits the knowing submission of a false or fraudulent claim for payment to the United States, the knowing use of a false record or statement to obtain payment on a false or fraudulent claim, or a conspiracy to defraud the United States by having a false or fraudulent claim allowed or paid The Criminal False Claim Act: - -Prohibits knowingly and willfully making or causing to be made any false statement or representation of material fact in any claims or application for benefits under federally funded health plans as well as commercial carriers. Violations are felonies and are punishable by up to five years imprisonment and/or $25,000 in fines. The Civil Monetary Penalties Law: - -Provides for the imposition of civil monetary penalties up to $10,000 per false service claimed, plus assessments equal to three times the amount claimed, for services that the provider knows or should know were not provided as claimed or for claims the provider knows or should know are false or fraudulent. Other federal criminal laws: - -Also may be used to prosecute the submission of false claims, including prohibitions on making false statements to the government and engaging in mail fraud. Felony convictions will result in exclusion from Medicare for a minimum of a five-year period. Option for Providers - -Self Disclosure: Fines may be less if a practice self-disclosed its knowledge of the violation. Appeal Rights: A practice has the right to an appeal process, and may choose to request a hearing before an administration law judge (ALJ). The OIG and the respondent have the right to present evidence and make arguments to the ALJ, who issues a written decision. Additional Appeal: The ALJ's decision may be appealed administratively and to federal court. OIG Work Plan - -OIG Work Plan The OIG Work Plan is released annually and identifies priority areas for OIG review/ investigation, which the agency believes are HHS' most vulnerable programs and activities, with the goal to improve HHS agency efficiency and effectiveness Corporate Integrity Agreement (CIA) What is a Corporate Integrity Agreement? - -It is an agreement between the OIG and a health care provider or other entity. CIA agreements are detailed and restrictive agreements imposed on providers when serious misconduct (fraudulent or abusive type action) is discovered through an audit or self-disclosure. The government may enter into a CIA with an entity instead of seeking to exclude the entity from Medicare, Medicaid, and other federal health care programs. The typical term of a comprehensive CIA is five years