CHC Study Guide UPDATED ACTUAL
Exam Questions and CORRECT Answers
Federal Sentencing Guidelines - Culpability Score Aggravating Factors - CORRECT
ANSWER - 1. upper-level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sentencing Guidelines - Culpability Score Mitigating Factors - CORRECT
ANSWER - 1. effective compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program -
CORRECT ANSWER - 1. written standards of conduct
2. Chief Compliance Officer
3. effective education and training
4. audits and evaluations to monitor compliance
5. reporting processes and procedures for complaints
6. appropriate disciplinary mechanisms
7. investigation and remediation of systematic problems
The only thing worse than not having a policy is... - CORRECT ANSWER - ...having a
policy and not following it.
Medicare reimbursement - hospital inpatient codes - CORRECT ANSWER - International
Classification of Diseases (ICD)
,Medicare reimbursement - physician codes - CORRECT ANSWER - Current Procedural
Technology (CPT)
Questions to guide the scope of an internal investigation. - CORRECT ANSWER - 1.
What is the origin of the issue?
2. When did the issue originate?
3. How far back should the investigation go?
4. Can extrapolation of a statistical sample be used?
It is in the best interest of the organization to have the board _______. - CORRECT
ANSWER - ...take an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance. - CORRECT ANSWER - 1. embed
quality into existing processes
2. centralize common processes and controls
3. improve human resources infrastructures
4. improve information systems processes
5. emphasize training
6. monitor marketing and compensation
Baseline Audit Process - CORRECT ANSWER - 1. outline the current operational
standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness - CORRECT ANSWER - 1. staff
knowledge
2. all 7 elements included
3. comparing issues year to year
,4. tracking and trending complaints
5. tracking corrective actions
6. reviewing current audits
7. educational session pre and post tests
8. tracking bill denials
9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
Modifier - CORRECT ANSWER - a two digit alpha/numeric code used in conjunction
with CPT or HCPCS codes that may increase or decrease reimbursement
gives new meaning to the code
International Classification of Diseases (ICD) - CORRECT ANSWER - a statistical
classification system that arranges diseases and injuries into groups according to established
criteria (signs and symptoms)
Current Procedural Terminology (CPT) - CORRECT ANSWER - American Medical
Association publishes and maintains this coding system
Organized Health Care Arrangements (OHCA) - CORRECT ANSWER - HIPAA
arrangement between clinically integrated setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) - CORRECT ANSWER - an inpatient classification
system based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and
discharge status
Healthcare Common Procedure Coding System (HCPCS) - CORRECT ANSWER - for
medication, maintained by CMS
, CMS contracts with American Medical Association to use CPT coding for the Medicare program
using this expanded version
Upcoding - CORRECT ANSWER - providers use a billing code that reflects a higher
payment rate for a device or service provided than the actual device or service furnished to the
patient
Unbundling - CORRECT ANSWER - submitting bills by piecemeal or in fragmented
fashion to maximize reimbursement
Outlier - CORRECT ANSWER - additional payment for patients with long hospital length
of stay
Billing and Coding Concerns (*) - CORRECT ANSWER - 1. coding advice (if not in book
- get in writing)
2. significant increases in volume (*) (find out why increase)
3. hiring external consultants (need BAA, if provide patient care - check OIG sanction list)
4. number of auditors for Part B audits
5. teaching physicians (*) (physician must be physically present and involved in managing care)
6. co-pay waivers (cannot routinely waive)
7. record does not support code
8. research payments (cannot bill Medicare for costs covered by sponsor)
9. disagreements (get 3rd party opinion)
10. DOCUMENTATION
"Incident To" services - CORRECT ANSWER - services commonly furnished in a
physician's office by a nurse practitioner in which there is direct physician personal supervision
and are billed under the physician's provider number (does not apply in hospital setting)
Exam Questions and CORRECT Answers
Federal Sentencing Guidelines - Culpability Score Aggravating Factors - CORRECT
ANSWER - 1. upper-level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sentencing Guidelines - Culpability Score Mitigating Factors - CORRECT
ANSWER - 1. effective compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program -
CORRECT ANSWER - 1. written standards of conduct
2. Chief Compliance Officer
3. effective education and training
4. audits and evaluations to monitor compliance
5. reporting processes and procedures for complaints
6. appropriate disciplinary mechanisms
7. investigation and remediation of systematic problems
The only thing worse than not having a policy is... - CORRECT ANSWER - ...having a
policy and not following it.
Medicare reimbursement - hospital inpatient codes - CORRECT ANSWER - International
Classification of Diseases (ICD)
,Medicare reimbursement - physician codes - CORRECT ANSWER - Current Procedural
Technology (CPT)
Questions to guide the scope of an internal investigation. - CORRECT ANSWER - 1.
What is the origin of the issue?
2. When did the issue originate?
3. How far back should the investigation go?
4. Can extrapolation of a statistical sample be used?
It is in the best interest of the organization to have the board _______. - CORRECT
ANSWER - ...take an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance. - CORRECT ANSWER - 1. embed
quality into existing processes
2. centralize common processes and controls
3. improve human resources infrastructures
4. improve information systems processes
5. emphasize training
6. monitor marketing and compensation
Baseline Audit Process - CORRECT ANSWER - 1. outline the current operational
standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness - CORRECT ANSWER - 1. staff
knowledge
2. all 7 elements included
3. comparing issues year to year
,4. tracking and trending complaints
5. tracking corrective actions
6. reviewing current audits
7. educational session pre and post tests
8. tracking bill denials
9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
Modifier - CORRECT ANSWER - a two digit alpha/numeric code used in conjunction
with CPT or HCPCS codes that may increase or decrease reimbursement
gives new meaning to the code
International Classification of Diseases (ICD) - CORRECT ANSWER - a statistical
classification system that arranges diseases and injuries into groups according to established
criteria (signs and symptoms)
Current Procedural Terminology (CPT) - CORRECT ANSWER - American Medical
Association publishes and maintains this coding system
Organized Health Care Arrangements (OHCA) - CORRECT ANSWER - HIPAA
arrangement between clinically integrated setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) - CORRECT ANSWER - an inpatient classification
system based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and
discharge status
Healthcare Common Procedure Coding System (HCPCS) - CORRECT ANSWER - for
medication, maintained by CMS
, CMS contracts with American Medical Association to use CPT coding for the Medicare program
using this expanded version
Upcoding - CORRECT ANSWER - providers use a billing code that reflects a higher
payment rate for a device or service provided than the actual device or service furnished to the
patient
Unbundling - CORRECT ANSWER - submitting bills by piecemeal or in fragmented
fashion to maximize reimbursement
Outlier - CORRECT ANSWER - additional payment for patients with long hospital length
of stay
Billing and Coding Concerns (*) - CORRECT ANSWER - 1. coding advice (if not in book
- get in writing)
2. significant increases in volume (*) (find out why increase)
3. hiring external consultants (need BAA, if provide patient care - check OIG sanction list)
4. number of auditors for Part B audits
5. teaching physicians (*) (physician must be physically present and involved in managing care)
6. co-pay waivers (cannot routinely waive)
7. record does not support code
8. research payments (cannot bill Medicare for costs covered by sponsor)
9. disagreements (get 3rd party opinion)
10. DOCUMENTATION
"Incident To" services - CORRECT ANSWER - services commonly furnished in a
physician's office by a nurse practitioner in which there is direct physician personal supervision
and are billed under the physician's provider number (does not apply in hospital setting)
