Compliance and Documentation Flashcards

Under HIPAA, which minimum necessary standard applies when a billing staff member requests a patient's OB record for claim submission?

Answer: Only the information reasonably necessary to accomplish the billing purpose should be disclosed

HIPAA's minimum necessary rule requires that only the PHI needed for the specific purpose—here, billing—be disclosed or accessed.

A gynecology coder queries a physician about an unspecified diagnosis code. Which element is required for a compliant physician query?

Answer: The query must present all clinically reasonable options including 'clinically undetermined'

AHIMA and ACDIS guidelines require that queries offer all reasonable clinical options, including 'clinically undetermined,' to avoid leading the physician.

Which federal law establishes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?

Answer: The False Claims Act

The False Claims Act (31 U.S.C. §§ 3729–3733) imposes civil and criminal liability on individuals and entities that submit fraudulent claims to federal health programs.

In OB/GYN documentation, the phrase 'as above' used to describe a physical examination finding is considered:

Answer: Incomplete documentation that may not support the code billed

Payers and auditors generally reject 'as above' or 'see above' as insufficient documentation because the specific findings must be recorded to support level of service coding.

A practice bills a global OB package but the patient's prenatal care was provided by a different physician group. How should this be handled?

Answer: Bill only the delivery and postpartum services actually provided by the billing physician

When a physician does not provide the full antepartum care included in the global OB package, only the delivery and postpartum components actually rendered should be billed.

Which document serves as the primary compliance roadmap outlining an OB/GYN practice's commitment to ethical billing and coding standards?

Answer: The compliance plan

A written compliance plan describes the practice's policies, procedures, and training commitments to prevent, detect, and correct fraudulent or erroneous billing.

A coder notices that a physician consistently documents a comprehensive history and exam for straightforward OB follow-up visits. This pattern most likely warrants:

Answer: An internal audit and potential education on medical necessity and upcoding risk

A pattern of over-documentation inconsistent with the clinical scenario suggests upcoding risk and should trigger internal review and provider education before any external action.