Certified Medical Coding Specialist Quality Control & Assurance 4 — Questions and Answers
Question 1: Which of the following best describes 'unbundling' in the context of coding quality?
- Assigning a single comprehensive code when multiple codes are required
- Billing component procedures separately when a comprehensive code exists (Correct answer)
- Using an unspecified code when a more specific one is available
- Reporting the same service twice on the same date
Correct answer: Billing component procedures separately when a comprehensive code exists
Unbundling involves billing component parts of a procedure individually rather than using the single comprehensive code, resulting in higher reimbursement.
Question 2: A quality assurance program should include which of the following to be compliant with OIG guidelines?
- Coding audits limited to high-risk areas only
- Written standards, training, internal auditing, and a mechanism to report concerns (Correct answer)
- Audits performed only by external contractors
- Policies that prohibit self-reporting of errors
Correct answer: Written standards, training, internal auditing, and a mechanism to report concerns
The OIG's seven elements of an effective compliance program include written standards, education and training, internal auditing, and a confidential reporting mechanism.
Question 3: What is the primary purpose of a charge capture audit?
- To ensure all services rendered are accurately billed and not missed or duplicated (Correct answer)
- To verify patient demographic information
- To check payer contract terms
- To review physician credentialing files
Correct answer: To ensure all services rendered are accurately billed and not missed or duplicated
A charge capture audit ensures that all services provided are documented, coded, and billed accurately, preventing revenue leakage or overbilling.
Question 4: When an outpatient facility reports a diagnosis 'confirmed' during a visit that was only suspected, this violates which coding guideline?
- UHDDS guidelines
- Outpatient coding guidelines (OGCR) Section IV (Correct answer)
- DRG grouping logic
- Medicare's inpatient-only policy
Correct answer: Outpatient coding guidelines (OGCR) Section IV
OGCR Section IV states that outpatient coders should report the condition to the highest degree of certainty, coding signs/symptoms rather than unconfirmed diagnoses.
Question 5: A concurrent coding audit differs from a retrospective audit in that it:
- Occurs after the patient is discharged and the claim is submitted
- Reviews records and codes while the patient is still receiving care (Correct answer)
- Is performed only by external auditors
- Focuses exclusively on physician documentation
Correct answer: Reviews records and codes while the patient is still receiving care
A concurrent audit reviews coding while the patient is still admitted, allowing real-time corrections before the claim is submitted.
Question 6: Which coding quality indicator measures the percentage of records where the principal diagnosis was coded correctly?
- Clean claim rate
- Principal diagnosis accuracy rate (Correct answer)
- Case mix index
- Denial rate
Correct answer: Principal diagnosis accuracy rate
The principal diagnosis accuracy rate measures how often coders correctly identify and code the principal diagnosis, a key quality metric in inpatient coding.
Question 7: A self-disclosure to the OIG through the Provider Self-Disclosure Protocol typically results in:
- Automatic exclusion from Medicare
- A reduced multiplier (typically 1.5x) compared to the standard treble damages under FCA (Correct answer)
- No financial penalty if submitted voluntarily
- Mandatory criminal prosecution
Correct answer: A reduced multiplier (typically 1.5x) compared to the standard treble damages under FCA
Providers who self-disclose to the OIG typically receive a reduced settlement multiplier of approximately 1.5 times the overpayment rather than the FCA's treble damages.
Certified Medical Coding Specialist Quality Control & Assurance 4
Which of the following best describes 'unbundling' in the context of coding quality?