Certified Medical Coding Specialist Quality Control & Assurance 2 — Questions and Answers
Question 1: A coding audit reveals that a coder consistently upcodes evaluation and management services. What is the MOST appropriate corrective action?
- Terminate the coder immediately
- Provide targeted education and reaudit within 90 days (Correct answer)
- Report the coder to the OIG
- Suspend all claims submitted by the coder
Correct answer: Provide targeted education and reaudit within 90 days
Targeted education followed by a reaudit is the standard corrective action for identified coding errors, allowing the coder to improve while confirming the issue is resolved.
Question 2: Which statistical sampling method selects every nth record from a list to create a representative audit sample?
- Random sampling
- Stratified sampling
- Systematic sampling (Correct answer)
- Convenience sampling
Correct answer: Systematic sampling
Systematic sampling selects every nth record from a population, providing an even distribution across the dataset.
Question 3: A hospital's compliance program identifies a pattern of billing for services not documented. Under the False Claims Act, what is the potential penalty per false claim?
- $500 to $1,000
- $2,587 to $25,868 (Correct answer)
- $10,000 to $50,000
- $100,000 to $500,000
Correct answer: $2,587 to $25,868
The False Claims Act imposes civil monetary penalties of $2,587 to $25,868 per false claim (adjusted annually for inflation), plus treble damages.
Question 4: Which document outlines the standards and expectations for coding accuracy and serves as the benchmark during internal audits?
- Chargemaster
- Compliance plan
- Coding policies and procedures manual (Correct answer)
- Remittance advice
Correct answer: Coding policies and procedures manual
The coding policies and procedures manual establishes the standards against which coding accuracy is measured during internal audits.
Question 5: A quality review finds that 8 out of 40 audited records contain coding errors. What is the error rate?
- 10%
- 15%
- 20% (Correct answer)
- 25%
Correct answer: 20%
8 errors divided by 40 records equals 0.20, or a 20% error rate.
Question 6: Which type of audit is performed BEFORE claims are submitted to payers to prevent billing errors?
- Retrospective audit
- Prospective audit (Correct answer)
- Concurrent audit
- Post-payment audit
Correct answer: Prospective audit
A prospective audit reviews claims before submission to identify and correct errors, preventing overpayments and denials.
Question 7: When a coder queries a physician about an unclear diagnosis, the query must be:
- Leading, to guide the physician to the most specific code
- Non-leading, presenting clinical indicators without suggesting a specific answer (Correct answer)
- Verbal only to avoid documentation
- Submitted only after the claim is billed
Correct answer: Non-leading, presenting clinical indicators without suggesting a specific answer
AHIMA and ACDIS guidelines require physician queries to be non-leading, presenting clinical indicators and allowing the physician to respond without bias.
Certified Medical Coding Specialist Quality Control & Assurance 2
A coding audit reveals that a coder consistently upcodes evaluation and management services.
What is the MOST appropriate corrective action?