Certified Medical Coding Specialist Regulatory Frameworks & Compliance 4 — Questions and Answers
Question 1: The Exclusion Database maintained by the OIG lists individuals and entities that are excluded from participation in federal healthcare programs. How often should providers check this database for employees and contractors?
- Only at initial hire
- Annually
- Monthly (Correct answer)
- Every five years
Correct answer: Monthly
OIG recommends monthly checks of the exclusion database (LEIE) to ensure employees and contractors have not become excluded after initial hire.
Question 2: Which federal agency is primarily responsible for investigating healthcare fraud and abuse under the False Claims Act?
- Centers for Medicare & Medicaid Services (CMS)
- Department of Justice (DOJ) (Correct answer)
- Office of Inspector General (OIG)
- Health Resources and Services Administration (HRSA)
Correct answer: Department of Justice (DOJ)
The Department of Justice (DOJ) has primary authority to litigate civil False Claims Act cases, often working in partnership with the OIG and FBI.
Question 3: A coder separately bills CPT code 36000 (IV catheter placement) when it is included in the procedure code for a more complex service. This is an example of:
- Upcoding
- Unbundling (Correct answer)
- Phantom billing
- Double billing
Correct answer: Unbundling
Unbundling is the practice of billing separately for services that should be bundled into a single comprehensive code, violating NCCI edit policies.
Question 4: Under HIPAA's Minimum Necessary Standard, a medical coder accessing PHI should:
- Access all patient records for quality review purposes
- Access only the information needed to perform their job duties (Correct answer)
- Obtain patient authorization before accessing any records
- Share information freely within the covered entity
Correct answer: Access only the information needed to perform their job duties
The Minimum Necessary Standard requires covered entities to limit PHI access to the minimum needed to accomplish the intended purpose.
Question 5: Which of the following is the primary purpose of the Medicare Integrity Program (MIP)?
- To educate providers on correct coding
- To identify and recover improper Medicare payments through audits and investigations (Correct answer)
- To set Medicare reimbursement rates
- To process Medicare claims
Correct answer: To identify and recover improper Medicare payments through audits and investigations
The Medicare Integrity Program authorizes CMS to enter into contracts with entities to perform audits, cost report reviews, and investigations to protect Medicare Trust Fund integrity.
Question 6: A patient is billed for a brand-name drug but received a generic equivalent. From a compliance perspective, this is an example of:
- Upcoding
- Misrepresentation of services (Correct answer)
- Unbundling
- Clustering
Correct answer: Misrepresentation of services
Billing for a brand-name drug when a generic was dispensed misrepresents what was actually provided and constitutes healthcare fraud.
Question 7: Which penalty can the OIG impose on a provider who submits false claims to Medicare without criminal prosecution, through civil monetary penalties?
- Up to $1,000 per false claim
- Up to $10,000 per false claim plus three times the overpayment (Correct answer)
- Up to $50,000 per false claim
- Only exclusion from Medicare, no monetary penalty
Correct answer: Up to $10,000 per false claim plus three times the overpayment
Under the Civil Monetary Penalties Law, providers can face penalties of up to $10,000 per false claim plus treble (three times) damages for each fraudulent claim.
Certified Medical Coding Specialist Regulatory Frameworks & Compliance 4
The Exclusion Database maintained by the OIG lists individuals and entities that are excluded from participation in federal healthcare programs.
How often should providers check this database for employees and contractors?