CPCA Compliance and Auditing Questions and Answers — Questions and Answers
Question 1: A Medicare patient is scheduled for a blepharoplasty. The physician's documentation indicates the primary reason is to improve the patient's appearance, but there is also a minor note about "heavy eyelids." The practice is concerned Medicare will deny the claim as cosmetic. What is the most appropriate compliance step to take BEFORE the procedure?
- Code the procedure as medically necessary using a diagnosis for visual field impairment, even if not fully documented.
- Refuse to perform the procedure since it might be denied by Medicare.
- Have the patient sign an Advance Beneficiary Notice (ABN) explaining they will be financially responsible if Medicare denies the service. (Correct answer)
- Bill the procedure with a -GA modifier without discussing it with the patient.
Correct answer: Have the patient sign an Advance Beneficiary Notice (ABN) explaining they will be financially responsible if Medicare denies the service.
An Advance Beneficiary Notice (ABN) is the proper tool to inform a Medicare beneficiary that a service may not be covered because it is not considered reasonable and necessary. Signing the ABN before the service confirms the patient understands they will be financially responsible if Medicare denies payment. This allows the patient to make an informed decision about proceeding with the treatment.
Question 2: A compliance officer for a large dermatology and aesthetics practice is proactively reviewing potential areas of risk. Which government publication should be reviewed annually to identify specific services and billing practices that are targeted for scrutiny by federal auditors?
- The HIPAA Privacy Rule Summary
- The OIG (Office of Inspector General) Work Plan (Correct answer)
- The CMS Internet-Only Manuals (IOMs)
- The CPT® Codebook Professional Edition
Correct answer: The OIG (Office of Inspector General) Work Plan
The OIG Work Plan outlines the new and ongoing audit and enforcement priorities for the Department of Health & Human Services (HHS). It is a critical resource for compliance professionals to understand potential areas of federal scrutiny and to proactively address risks related to fraud, waste, and abuse.
Question 3: When auditing a patient chart for a botulinum toxin injection to treat blepharospasm (a medically necessary condition), which of the following documentation elements is most crucial for supporting medical necessity and differentiating it from a cosmetic service?
- A detailed description of the patient's functional impairment and failure of previous treatments. (Correct answer)
- The brand name and units of the neurotoxin used.
- Before-and-after photos showing cosmetic improvement.
- A patient-signed consent form acknowledging the procedure's risks.
Correct answer: A detailed description of the patient's functional impairment and failure of previous treatments.
To establish medical necessity for a service that could also be cosmetic, the documentation must clearly detail the patient's functional impairment, symptoms, and why the treatment is required to alleviate a medical condition. Documenting the failure of more conservative, previous treatments is also a key supporting point for payers. The other options are important parts of the medical record but do not, by themselves, establish medical necessity.
Question 4: An internal audit at an aesthetic practice reveals a pattern of routinely billing for E/M services with minor cosmetic procedures without supporting documentation for a significant, separately identifiable service. What is the most appropriate INITIAL action for the compliance officer to take?
- Immediately terminate the provider responsible for the billing pattern.
- Report the finding to the Office of Inspector General (OIG) immediately.
- Ignore the finding, as the reimbursement for the E/M codes is minimal.
- Implement a corrective action plan that includes provider education and a focused follow-up audit. (Correct answer)
Correct answer: Implement a corrective action plan that includes provider education and a focused follow-up audit.
The standard process for handling an internal audit finding is to first investigate the root cause, then develop and implement a corrective action plan (CAP). A CAP should include education to prevent recurrence, and a follow-up audit is necessary to ensure the problem has been resolved. Reporting to the OIG or terminating the provider are premature steps without first attempting internal correction and education.
Question 5: An aesthetic practice wants to use patient "before and after" photos on its social media page for marketing. According to HIPAA, what is the most critical compliance requirement before posting these images?
- The practice must have a general consent-to-treat form on file for the patient.
- A specific, written authorization must be obtained from the patient that allows for the use and disclosure of their images for marketing purposes. (Correct answer)
- The photos must be de-identified by blurring the patient's eyes and any distinct tattoos.
- The patient must be over 18 years old and have given verbal consent.
Correct answer: A specific, written authorization must be obtained from the patient that allows for the use and disclosure of their images for marketing purposes.
Using patient photos for marketing is a use and disclosure of Protected Health Information (PHI) that is not for treatment, payment, or healthcare operations. Therefore, HIPAA requires a specific, written authorization from the patient that details how and where the images will be used before they can be posted. A general consent form is insufficient, and verbal consent is not valid for this purpose.
Question 6: Which of the following represents a significant compliance risk related to compensation and sales within an aesthetic practice that accepts federal payers?
- Offering a discount to patients who purchase a package of multiple treatments.
- Any arrangement that provides a commission or "kickback" to staff for selling certain products or services, potentially violating the Anti-Kickback Statute. (Correct answer)
- Displaying the price list for all cosmetic services and products in the waiting room.
- Paying a physician-employee a fixed annual salary that is consistent with fair market value.
Correct answer: Any arrangement that provides a commission or "kickback" to staff for selling certain products or services, potentially violating the Anti-Kickback Statute.
The federal Anti-Kickback Statute (AKS) is a criminal law that prohibits offering, paying, soliciting, or receiving remuneration to induce or reward referrals for items or services reimbursable by federal healthcare programs. Commission-based payments to staff for selling specific services or products could be seen as an illegal kickback if they influence decisions about federally covered services.
CPCA Compliance and Auditing Questions and Answers
A Medicare patient is scheduled for a blepharoplasty.
The physician's documentation indicates the primary reason is to improve the patient's appearance, but there is also a minor note about "heavy eyelids." The practice is concerned Medicare will deny the claim as cosmetic.
What is the most appropriate compliance step to take BEFORE the procedure?