Billing and Coding Compliance Flashcards
7 cards from real CCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Billing and Coding Compliance flashcards as text
What is a chargemaster (charge description master) in a hospital setting?
Answer: A comprehensive listing of all services, procedures, and items a facility may bill for along with their standard charges
A chargemaster is the hospital's internal master price list containing every billable item and service with its associated standard charge, serving as the starting point for all billing.
What is 'downcoding' in medical billing?
Answer: Billing for a lower level of service than was actually provided, often due to insufficient documentation
Downcoding occurs when a provider bills for a lower level of service than was actually provided, typically because the documentation does not adequately support the higher-level service.
Which of the following best describes 'medical necessity' in the context of billing compliance?
Answer: Services that are reasonable and necessary for the diagnosis or treatment of illness or injury, meeting accepted standards of care
Medical necessity refers to services or supplies that are appropriate and needed for diagnosing or treating a medical condition, consistent with accepted standards of good medical practice and not primarily for the patient's convenience.
What is a 'remittance advice' (RA) in medical billing?
Answer: A notice from a payer explaining how a claim was processed, including payment amounts or denial reasons
A remittance advice is issued by a payer to a provider after claim adjudication, detailing any payment made, contractual adjustments applied, patient responsibility amounts, and the reason codes for any denials.
Why is the routine waiver of patient copayments considered a compliance risk?
Answer: It is fraudulent because it artificially inflates effective reimbursement and may induce overutilization, potentially violating anti-kickback statutes
Routinely waiving copayments is considered fraudulent because it removes a cost-sharing incentive, can induce patients to overuse services, and may constitute an illegal inducement under the Anti-Kickback Statute.
What is a 'credit balance' in healthcare billing and how does it relate to compliance?
Answer: An amount a provider owes back to Medicare because they received more payment than they were entitled to
A credit balance arises when a provider has been overpaid, and Medicare requires providers to report and return credit balances within 30 days of the end of each fiscal quarter or face potential fraud liability.
What is 'place of service' (POS) coding in medical billing?
Answer: A two-digit code on a claim that identifies the setting where the medical service was actually provided
Place of service codes are two-digit codes on claims that identify where a service was rendered (e.g., office, inpatient hospital, nursing facility), which can directly affect the applicable reimbursement rate.