Certified Medical Coding Specialist Regulatory Frameworks & Compliance 3 — Questions and Answers
Question 1: The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring patients for designated health services to entities in which they have a financial relationship UNLESS:
- The physician has malpractice insurance
- A valid Stark Law exception applies (Correct answer)
- The patient provides written consent
- The service is covered by Medicaid
Correct answer: A valid Stark Law exception applies
Stark Law is a strict liability statute, meaning intent is irrelevant, but numerous statutory and regulatory exceptions permit otherwise-prohibited arrangements.
Question 2: Which compliance program element requires organizations to establish mechanisms for employees to report suspected violations confidentially?
- Written policies and procedures
- Open lines of communication (hotlines) (Correct answer)
- Compliance officer designation
- Training and education programs
Correct answer: Open lines of communication (hotlines)
The OIG's seven compliance program elements include open lines of communication, such as anonymous hotlines, so employees can report concerns without fear of retaliation.
Question 3: A coder assigns a code for a higher-complexity procedure than what was actually performed to increase reimbursement. This is an example of:
- Unbundling
- Upcoding (Correct answer)
- Phantom billing
- Clustering
Correct answer: Upcoding
Upcoding involves billing for a more expensive service or higher-level code than what was actually provided or documented.
Question 4: Under the OIG's Corporate Integrity Agreement (CIA), a healthcare organization typically must do all of the following EXCEPT:
- Submit to annual independent reviews
- Hire a compliance officer
- Cease all Medicare/Medicaid billing for 5 years (Correct answer)
- Provide compliance training to employees
Correct answer: Cease all Medicare/Medicaid billing for 5 years
A CIA allows organizations to continue participating in federal healthcare programs while implementing specific compliance obligations; it does not require cessation of billing.
Question 5: Which type of Medicare audit involves a statistical sample of claims and extrapolates the error rate to a universe of claims to calculate an overpayment?
- Targeted Probe and Educate (TPE)
- Comprehensive Error Rate Testing (CERT)
- Statistical sampling extrapolation audit (Correct answer)
- Prepayment review
Correct answer: Statistical sampling extrapolation audit
Statistical sampling extrapolation is used by CMS and its contractors to estimate total overpayments based on a statistically valid sample of claims.
Question 6: Which regulation requires Medicare providers to report and return identified overpayments within 60 days of identification?
- The False Claims Act
- The 60-Day Rule (42 CFR Part 401) (Correct answer)
- The Anti-Kickback Statute
- HIPAA Security Rule
Correct answer: The 60-Day Rule (42 CFR Part 401)
The 60-Day Rule, codified at 42 CFR Part 401, requires Medicare and Medicaid providers to report and return identified overpayments within 60 days, or they may face FCA liability.
Question 7: A provider bills for 10 units of a service but only delivered 6 units. This billing practice is known as:
- Upcoding
- Unbundling
- Billing for services not rendered (Correct answer)
- Misrepresentation of diagnosis
Correct answer: Billing for services not rendered
Billing for more units or services than were actually provided constitutes billing for services not rendered, a form of healthcare fraud.
Certified Medical Coding Specialist Regulatory Frameworks & Compliance 3
The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring patients for designated health services to entities in which they have a financial relationship UNLESS: