Compliance & Regulatory Knowledge Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliance & Regulatory Knowledge flashcards as text
Under the Stark Law, which of the following financial relationships between a physician and a hospital would be EXEMPT from the prohibition on referrals?
Answer: A physician employed by the hospital at fair market value compensation
The Stark Law's bona fide employment exception permits physician-hospital employment arrangements when compensation is at fair market value and not contingent on referrals.
The National Correct Coding Initiative (NCCI) edits are designed to prevent which type of billing abuse?
Answer: Unbundling procedures that should be billed together
NCCI edits identify pairs of CPT codes that should not be billed together because one code's work is included in the other, preventing unbundling.
A provider knowingly submits claims using a deceased physician's NPI number. This action most directly violates which law?
Answer: The False Claims Act
Knowingly submitting false or fraudulent claims to a federal healthcare program violates the False Claims Act and can result in treble damages and per-claim penalties.
Which CMS program uses Risk Adjustment Data Validation (RADV) audits to ensure coding accuracy?
Answer: Medicare Advantage (Part C)
CMS conducts RADV audits for Medicare Advantage plans to verify that submitted diagnosis codes are supported by medical record documentation and accurate risk scores.
What is the statute of limitations for the government to bring a False Claims Act lawsuit if the violation was NOT known to the government?
Answer: 6 years from the date of the violation
Under the FCA, the government has 6 years from the violation date, or 3 years from when it knew (or should have known), whichever is later, up to 10 years maximum.
A compliance audit reveals that coders consistently assign diagnosis codes that are not fully supported by physician documentation. This is an example of:
Answer: Upcoding
Upcoding occurs when codes representing a higher level of service or more severe condition than documented are submitted, resulting in inflated reimbursement.
Under HIPAA's Minimum Necessary Standard, which scenario is compliant?
Answer: A coder accesses only the operative report needed to assign the surgical code
The Minimum Necessary Standard requires that access to PHI be limited to only what is needed for a specific job function, such as a coder reviewing only the relevant operative report.