chc study guide| 350 questions| 45 pages| with complete solution
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CHC Study Guide| 350 QUESTIONS| 45
PAGES| WITH COMPLETE SOLUTION
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)
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)
physician must be present to bill (*)
Two-Midnight Rule Correct Answer: CMS will consider a claim as inpatient if the patient in
hospital bed over two midnights
72 Hour Rule/3 Day Window Project (*) Correct Answer: all diagnostic outpatient charges and
other related outpatient charges within 72 hours prior to an inpatient admission are bundled into
inpatient stay reimbursement
False Cost Reports (*) Correct Answer: submission of charges to Medicare which are unrelated
to medical care, such as administrative overhead
Credit Balances - Failure to Refund (*) Correct Answer: provider has 60 days to refund credit
balances (*)
PPS Transfer Project Correct Answer: PPS transfer of patient (rather than discharge) and
receiving payment
Advance Beneficiary Notice (ABN) Correct Answer: 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)
Medicare Secondary Payer Questionnaire Correct Answer: used to identify the correct insurance
company that must pay health care bills first when Medicare pays second
Hospital Outpatient Cardiac Rehabilitation Correct Answer: physician must be present during
treatment
DRG Utilization (*) Correct Answer: DRG utilization should be reviewed when the number of
uses of a particular DRG is outside of the norm or average
The three components of Evaluation and Management (E&M) services (*) Correct Answer: 1.
History
2. Examination
3. Medical Decision Making
Evaluation & Management Codes Correct Answer: 1. subset of CPT codes
2. privileged providers
3. describe complexity of care, place of services, and type of service
Types of History or Examination Correct Answer: 1. Problem Focused (CC & brief history)
2. Expanded Problem Focus
3. Detailed
4. Comprehensive
Complexities of Medical Decision Making Correct Answer: 1. Straight-forward (simple, 1
problem)
2. Low complexity
3. Moderate complexity (may have some complications)
4. High complexity
Initial patient visit (*) Correct Answer: 3 out of 3 key elements of E&M services must be met or
exceeded in order to bill for this type of visit
Established patient visit (*) Correct Answer: 2 out of 3 key elements of E&M services must be
met or exceeded in order to bill for this type of visit
Inpatient Documentation Requirements Correct Answer: 1. sufficient documentation to
demonstrate signs/symptoms were sever enough to warrant inpatient care
2. preexisting medical problems or extenuating circumstances
Factors to Consider When Making the Decision to Admit as Inpatient Correct Answer: 1.
severity of signs and symptoms
2. medical predictability of something adverse happening to the patient
3. need for diagnostic studies
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