CHC STUDY GUIDE – ALL DOMAINS,
REGULATIONS & GUIDELINES
COVERED
1. upper-level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive - correct answers ✔✔Federal
Sentencing Guidelines - Culpability Score Aggravating Factors
1. effective compliance program
2. reported promptly
,3. cooperation with investigation
4. accept responsibility - correct answers ✔✔Federal Sentencing Guidelines -
Culpability Score Mitigating Factors
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 - correct answers ✔✔Federal
Sentencing Guidelines - Seven Elements of an Effective Compliance Program
...having a policy and not following it. - correct answers ✔✔The only thing worse than
not having a policy is...
International Classification of Diseases (ICD) - correct answers ✔✔Medicare
reimbursement - hospital inpatient codes
Current Procedural Technology (CPT) - correct answers ✔✔Medicare reimbursement -
physician codes
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? - correct answers ✔✔Questions to
guide the scope of an internal investigation.
...take an active rather than a passive role in compliance. - correct answers ✔✔It is in
the best interest of the organization to have the board _______.
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 - correct answers ✔✔Six tips for saving on
future costs of compliance.
1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations - correct answers ✔✔Baseline Audit Process
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 - correct answers
✔✔Compliance Program - Measures of Effectiveness
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 - correct answers ✔✔Modifier
a statistical classification system that arranges diseases and injuries into groups
according to established criteria (signs and symptoms) - correct answers
✔✔International Classification of Diseases (ICD)
American Medical Association publishes and maintains this coding system - correct
answers ✔✔Current Procedural Terminology (CPT)
HIPAA arrangement between clinically integrated setting (ex: hospitals and medical
staff) - correct answers ✔✔Organized Health Care Arrangements (OHCA)
an inpatient classification system based on: principal diagnosis, secondary diagnosis,
surgical factors, age, sex, and discharge status - correct answers ✔✔Diagnosis Related
Group (DRG)
for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version - correct answers ✔✔Healthcare Common
Procedure Coding System (HCPCS)
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 - correct answers
✔✔Upcoding
submitting bills by piecemeal or in fragmented fashion to maximize reimbursement -
correct answers ✔✔Unbundling
additional payment for patients with long hospital length of stay - correct answers
✔✔Outlier
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 - correct answers ✔✔Billing and Coding Concerns (*)
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)
physician must be present to bill (*) - correct answers ✔✔"Incident To" services
CMS will consider a claim as inpatient if the patient in hospital bed over two midnights -
correct answers ✔✔Two-Midnight Rule
all diagnostic outpatient charges and other related outpatient charges within 72 hours
prior to an inpatient admission are bundled into inpatient stay reimbursement - correct
answers ✔✔72 Hour Rule/3 Day Window Project (*)
submission of charges to Medicare which are unrelated to medical care, such as
administrative overhead - correct answers ✔✔False Cost Reports (*)
provider has 60 days to refund credit balances (*) - correct answers ✔✔Credit Balances
- Failure to Refund (*)
PPS transfer of patient (rather than discharge) and receiving payment - correct answers
✔✔PPS Transfer Project
a written form that a provider gives to a Medicare beneficiary that informs the
beneficiary that Medicare may not pay for an item or service
must be provided and signed by patient before services are provided (or provider
cannot bill patient if Medicare denies) - correct answers ✔✔Advance Beneficiary Notice
(ABN)
used to identify the correct insurance company that must pay health care bills first when
Medicare pays second - correct answers ✔✔Medicare Secondary Payer Questionnaire
physician must be present during treatment - correct answers ✔✔Hospital Outpatient
Cardiac Rehabilitation
REGULATIONS & GUIDELINES
COVERED
1. upper-level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive - correct answers ✔✔Federal
Sentencing Guidelines - Culpability Score Aggravating Factors
1. effective compliance program
2. reported promptly
,3. cooperation with investigation
4. accept responsibility - correct answers ✔✔Federal Sentencing Guidelines -
Culpability Score Mitigating Factors
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 - correct answers ✔✔Federal
Sentencing Guidelines - Seven Elements of an Effective Compliance Program
...having a policy and not following it. - correct answers ✔✔The only thing worse than
not having a policy is...
International Classification of Diseases (ICD) - correct answers ✔✔Medicare
reimbursement - hospital inpatient codes
Current Procedural Technology (CPT) - correct answers ✔✔Medicare reimbursement -
physician codes
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? - correct answers ✔✔Questions to
guide the scope of an internal investigation.
...take an active rather than a passive role in compliance. - correct answers ✔✔It is in
the best interest of the organization to have the board _______.
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 - correct answers ✔✔Six tips for saving on
future costs of compliance.
1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations - correct answers ✔✔Baseline Audit Process
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 - correct answers
✔✔Compliance Program - Measures of Effectiveness
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 - correct answers ✔✔Modifier
a statistical classification system that arranges diseases and injuries into groups
according to established criteria (signs and symptoms) - correct answers
✔✔International Classification of Diseases (ICD)
American Medical Association publishes and maintains this coding system - correct
answers ✔✔Current Procedural Terminology (CPT)
HIPAA arrangement between clinically integrated setting (ex: hospitals and medical
staff) - correct answers ✔✔Organized Health Care Arrangements (OHCA)
an inpatient classification system based on: principal diagnosis, secondary diagnosis,
surgical factors, age, sex, and discharge status - correct answers ✔✔Diagnosis Related
Group (DRG)
for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version - correct answers ✔✔Healthcare Common
Procedure Coding System (HCPCS)
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 - correct answers
✔✔Upcoding
submitting bills by piecemeal or in fragmented fashion to maximize reimbursement -
correct answers ✔✔Unbundling
additional payment for patients with long hospital length of stay - correct answers
✔✔Outlier
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 - correct answers ✔✔Billing and Coding Concerns (*)
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)
physician must be present to bill (*) - correct answers ✔✔"Incident To" services
CMS will consider a claim as inpatient if the patient in hospital bed over two midnights -
correct answers ✔✔Two-Midnight Rule
all diagnostic outpatient charges and other related outpatient charges within 72 hours
prior to an inpatient admission are bundled into inpatient stay reimbursement - correct
answers ✔✔72 Hour Rule/3 Day Window Project (*)
submission of charges to Medicare which are unrelated to medical care, such as
administrative overhead - correct answers ✔✔False Cost Reports (*)
provider has 60 days to refund credit balances (*) - correct answers ✔✔Credit Balances
- Failure to Refund (*)
PPS transfer of patient (rather than discharge) and receiving payment - correct answers
✔✔PPS Transfer Project
a written form that a provider gives to a Medicare beneficiary that informs the
beneficiary that Medicare may not pay for an item or service
must be provided and signed by patient before services are provided (or provider
cannot bill patient if Medicare denies) - correct answers ✔✔Advance Beneficiary Notice
(ABN)
used to identify the correct insurance company that must pay health care bills first when
Medicare pays second - correct answers ✔✔Medicare Secondary Payer Questionnaire
physician must be present during treatment - correct answers ✔✔Hospital Outpatient
Cardiac Rehabilitation
