Healthcare Billing and Coding Compliance Questions and Answers Flashcards
6 cards from real CHC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Healthcare Billing and Coding Compliance Questions and Answers flashcards as text
The 'two-midnight rule' in Medicare billing primarily governs which type of admission?
Answer: Inpatient hospital admissions and whether they meet criteria for Part A payment
CMS's two-midnight rule states that inpatient admission is generally appropriate if the physician expects the patient to require hospital care spanning at least two midnights, qualifying for Part A reimbursement.
When a provider receives an overpayment from Medicare, within how many days must it be reported and returned under the ACA's 60-day rule?
Answer: 60 days
The Affordable Care Act requires that identified Medicare/Medicaid overpayments be reported and returned within 60 days of identification, after which retention of the overpayment becomes a False Claims Act violation.
What is the primary purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?
Answer: To notify a Medicare patient in advance that a service may not be covered and shift financial liability to the patient
An ABN informs a Medicare beneficiary that a specific service may be denied as not medically necessary, allowing the patient to decide whether to proceed and accept financial responsibility.
Which coding system is primarily used for inpatient hospital diagnoses and procedures for Medicare billing under the MS-DRG system?
Answer: ICD-10-CM/PCS (International Classification of Diseases)
ICD-10-CM is used for diagnosis coding and ICD-10-PCS for inpatient procedure coding, which together drive the MS-DRG assignment and corresponding Medicare payment.
What does 'clawback' mean in the context of healthcare billing compliance?
Answer: The recovery by a payer of previously paid funds determined to be improper or overpaid
A clawback occurs when a payer (such as Medicare) recovers funds from a provider due to identified overpayments, billing errors, or compliance violations.
In healthcare compliance, what is the significance of the '3-day payment window rule' for hospital outpatient services?
Answer: Outpatient services provided within 3 days before an inpatient admission must be bundled into the inpatient claim
Under the 3-day payment window rule, diagnostic and certain other outpatient services provided within 3 days prior to an inpatient admission are bundled into the DRG payment and cannot be billed separately.