CPC - Certified Professional Coder Compliance and Regulatory Guidelines Questions and Answers 1 — Questions and Answers
Question 1: A Medicare patient is scheduled for a procedure that is often covered, but due to the patient's specific diagnosis, it is likely to be denied as not medically necessary. To ensure the provider can bill the patient if Medicare denies the claim, which of the following must be completed and signed by the patient BEFORE the service is rendered?
- A Medicare Summary Notice (MSN)
- A Remittance Advice (RA)
- An Advance Beneficiary Notice of Noncoverage (ABN) (Correct answer)
- A standard Consent for Treatment form
Correct answer: An Advance Beneficiary Notice of Noncoverage (ABN)
An Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a notice given to beneficiaries in Original Medicare to convey that Medicare is not expected to pay for a specific item or service. It must be issued before providing the item or service, allowing the beneficiary to make an informed decision and accept financial responsibility if they choose to proceed. The MSN is sent to the patient after a claim is processed, and an RA is sent to the provider.
Question 2: What is the primary purpose of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan?
- To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit. (Correct answer)
- To publish the annual updates to the CPT and ICD-10-CM code sets.
- To establish the relative value units (RVUs) and reimbursement rates for Medicare services.
- To provide clinical guidelines for the treatment of common diseases and conditions.
Correct answer: To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit.
The OIG Work Plan outlines the audits, evaluations, and inspections the OIG plans to conduct during the fiscal year. Its purpose is to publicly identify high-risk areas in HHS programs, such as Medicare and Medicaid, to combat fraud, waste, and abuse.
Question 3: An established Medicare patient with stable, chronic hypertension is seen by a Nurse Practitioner (NP) for a scheduled follow-up. The supervising physician is in the office suite and immediately available but does not personally see the patient. The service was integral to the physician's established plan of care. Under which provision can this service be billed under the physician's NPI to receive 100% of the physician fee schedule rate?
- New patient visit rules
- Shared/split visit guidelines
- Locum tenens arrangement
- "Incident-to" billing guidelines (Correct answer)
Correct answer: "Incident-to" billing guidelines
"Incident-to" billing allows services provided by a non-physician practitioner (NPP) to be billed under the physician's National Provider Identifier (NPI) as if the physician performed them, resulting in 100% reimbursement. This requires that the service be an integral part of a physician's established plan of care for an existing problem and that the physician provides direct supervision (is physically present in the office suite).
Question 4: According to the HIPAA Privacy Rule, which of the following is a permissible use or disclosure of Protected Health Information (PHI) that does NOT require a specific written authorization from the patient?
- Releasing a patient's entire medical record to their employer for a pre-employment screening.
- Disclosing a patient's diagnosis to another physician for treatment consultation. (Correct answer)
- Providing a list of diabetic patients' names and addresses to a pharmaceutical company for marketing purposes.
- Sharing a patient's interesting case details, including name and date of birth, with a colleague in the breakroom.
Correct answer: Disclosing a patient's diagnosis to another physician for treatment consultation.
The HIPAA Privacy Rule permits covered entities to use and disclose PHI without a patient's written authorization for Treatment, Payment, and Health Care Operations (TPO). Disclosing information to another healthcare provider for the purpose of treating the patient falls directly under the 'Treatment' category. The other options are clear violations or would require specific patient authorization.
Question 5: A physician has a significant ownership interest in a local diagnostic imaging center. The physician consistently refers their Medicare and Medicaid patients to this specific center for MRI and CT scans. This practice could be a violation of which federal law?
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Emergency Medical Treatment and Active Labor Act (EMTALA)
- The Physician Self-Referral Law (Stark Law) (Correct answer)
- The Clinical Laboratory Improvement Amendments (CLIA)
Correct answer: The Physician Self-Referral Law (Stark Law)
The Physician Self-Referral Law, commonly known as the Stark Law, prohibits physicians from referring Medicare or Medicaid patients for designated health services (DHS), such as imaging, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. This is intended to prevent financial incentives from influencing medical decision-making.
Question 6: A coder is determining Medicare coverage for a new procedure. After searching, the coder confirms that no National Coverage Determination (NCD) exists for the service. What is the next official source the coder should consult to determine if the service is covered in their specific geographic area?
- Local Coverage Determinations (LCDs) from their Medicare Administrative Contractor (MAC). (Correct answer)
- The American Medical Association's CPT® Assistant newsletter.
- The most recent OIG Work Plan.
- Medical policies from a major commercial insurance payer.
Correct answer: Local Coverage Determinations (LCDs) from their Medicare Administrative Contractor (MAC).
In the absence of a National Coverage Determination (NCD), which applies nationwide, coverage is determined at the regional level by Medicare Administrative Contractors (MACs). These MACs publish Local Coverage Determinations (LCDs) that specify which items and services are considered reasonable and necessary within their specific jurisdiction.
CPC - Certified Professional Coder Compliance and Regulatory Guidelines Questions and Answers 1
A Medicare patient is scheduled for a procedure that is often covered, but due to the patient's specific diagnosis, it is likely to be denied as not medically necessary.
To ensure the provider can bill the patient if Medicare denies the claim, which of the following must be completed and signed by the patient BEFORE the service is rendered?