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
Which federal statute prohibits submitting claims for services that were not actually rendered to Medicare or Medicaid?
Answer: False Claims Act
The False Claims Act prohibits knowingly submitting false or fraudulent claims for payment to any federal program, including Medicare and Medicaid.
What is 'upcoding' in the context of healthcare billing compliance?
Answer: Billing for a service with a higher-value code than the service actually performed
Upcoding involves intentionally billing a more expensive procedure code than the one actually performed to receive higher reimbursement.
What does 'unbundling' refer to in healthcare billing?
Answer: Billing component services separately when a bundled code should be used to reduce reimbursement inflation
Unbundling means billing individual components of a procedure separately when a single bundled CPT code should be used, resulting in higher total reimbursement than intended.
Which organization publishes the National Correct Coding Initiative (NCCI) edits used to prevent improper Medicare billing?
Answer: CMS
CMS developed and publishes the NCCI to promote national correct coding methodologies and prevent improper payment of Part B claims.
In medical documentation for billing, what does the principle of 'if it wasn't documented, it wasn't done' mean for compliance?
Answer: Services billed must be supported by clinical documentation in the medical record
Medicare and Medicaid require that all billed services be supported by clinical documentation in the medical record; absent documentation, claims may be denied or subject to recoupment.
What is a 'Comparative Billing Report' (CBR) issued by CMS used for in compliance?
Answer: To show a provider how their billing patterns compare to peers, flagging potential outliers
CBRs provide providers with data comparing their billing patterns to those of similar providers, helping them identify and correct potential anomalies before they become enforcement targets.