CPC - Certified Professional Coder Compliance and Regulatory Rules Questions and Answers — Questions and Answers
Question 1: A primary care physician is a part-owner of a local imaging center. The physician refers her Medicare patients who need radiology services exclusively to this facility. Under which federal regulation is this financial arrangement most likely to be scrutinized?
- Emergency Medical Treatment and Active Labor Act (EMTALA)
- Health Insurance Portability and Accountability Act (HIPAA)
- The Stark Law (Correct answer)
- The Anti-Kickback Statute (AKS)
Correct answer: The Stark Law
The Stark Law, also known as the Physician Self-Referral Law, prohibits physicians from referring Medicare or Medicaid patients for specific 'designated health services' (DHS), such as radiology, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception is met.
Question 2: According to the Office of Inspector General (OIG), which of the following is considered one of the seven fundamental elements of an effective compliance program for a physician practice?
- Outsourcing all billing and coding functions to a third-party vendor.
- Conducting appropriate training and education for employees. (Correct answer)
- Purchasing the most expensive Electronic Health Record (EHR) system available.
- Guaranteeing a 10% annual increase in practice revenue.
Correct answer: Conducting appropriate training and education for employees.
The OIG has outlined seven core elements for an effective compliance program. These include: (1) Implementing written policies, procedures, and standards of conduct; (2) Designating a compliance officer or contact; (3) Conducting effective training and education; (4) Developing effective lines of communication; (5) Conducting internal monitoring and auditing; (6) Enforcing standards through well-publicized disciplinary guidelines; and (7) Responding promptly to detected offenses and undertaking corrective action.
Question 3: In which of the following situations must a provider issue a mandatory Advance Beneficiary Notice of Noncoverage (ABN) to an Original Medicare beneficiary?
- When providing a service that is statutorily excluded from Medicare, such as cosmetic surgery.
- Prior to delivering a service that is typically covered but may not be considered medically necessary for this specific patient. (Correct answer)
- After a service has been provided and the claim has been denied by Medicare.
- When the patient is enrolled in a Medicare Advantage (Part C) plan.
Correct answer: Prior to delivering a service that is typically covered but may not be considered medically necessary for this specific patient.
A mandatory ABN is required when a provider believes that a service or item, which is usually covered by Medicare, may be denied for this particular patient because it is not considered medically reasonable and necessary. This allows the patient to make an informed decision about receiving and paying for the service. ABNs are not used for services that are never covered by Medicare or for patients in Medicare Advantage plans.
Question 4: A billing department audit reveals that due to a coding error, a physician's practice has received overpayments from Medicare for the past six months. What is the practice's primary legal obligation according to federal law?
- To report and return the overpayment within 60 days of its identification. (Correct answer)
- To keep the funds, as the error was unintentional.
- To wait until Medicare performs an audit and requests the money back.
- To correct the error for future claims but take no action on past payments.
Correct answer: To report and return the overpayment within 60 days of its identification.
The Affordable Care Act established the 60-day rule, which requires providers to report and return any identified overpayments from Medicare or Medicaid within 60 days of the date the overpayment was identified. Failure to do so can result in significant penalties under the False Claims Act.
Question 5: What is the primary focus of the federal Anti-Kickback Statute (AKS)?
- To prevent improper billing for services not rendered.
- To protect the privacy and security of patient health information.
- To prohibit offering or receiving remuneration to induce referrals for items or services covered by federal healthcare programs. (Correct answer)
- To ensure all patients receive stabilizing treatment in an emergency, regardless of ability to pay.
Correct answer: To prohibit offering or receiving remuneration to induce referrals for items or services covered by federal healthcare programs.
The Anti-Kickback Statute (AKS) is a criminal law that prohibits knowingly and willfully offering, paying, soliciting, or receiving anything of value (remuneration) to induce or reward referrals for items or services payable by federal healthcare programs like Medicare. It is intended to prevent medical decisions from being compromised by improper financial incentives.
Question 6: Which of the following is a critical requirement for billing a service performed by a non-physician practitioner (NPP) as 'incident-to' a physician's service in an office setting?
- The service must be for a new patient to establish care.
- The supervising physician must be in the same room while the NPP performs the service.
- The service must be part of an established plan of care initiated by a physician. (Correct answer)
- The NPP must bill the service under their own National Provider Identifier (NPI).
Correct answer: The service must be part of an established plan of care initiated by a physician.
'Incident-to' billing requires that the service be an integral, although incidental, part of the physician's professional service. This means a physician must have personally performed an initial service and established a plan of care. The NPP's service is a follow-up part of that plan. Additionally, direct supervision is required, meaning the physician must be in the office suite and immediately available.
CPC - Certified Professional Coder Compliance and Regulatory Rules Questions and Answers
A primary care physician is a part-owner of a local imaging center.
The physician refers her Medicare patients who need radiology services exclusively to this facility.
Under which federal regulation is this financial arrangement most likely to be scrutinized?