Compliance & Regulatory Guidelines Flashcards
7 cards from real CPC 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 Guidelines flashcards as text
A hospital submits claims for services that were never provided to collect Medicare reimbursement. Under the False Claims Act, the government may recover up to how many times the actual damages, plus penalties?
Answer: Three times (treble damages)
The False Claims Act provides for treble (triple) damages plus civil monetary penalties per false claim, making it the government's most powerful tool against healthcare fraud.
In medical coding compliance, 'query fatigue' refers to the risk that:
Answer: Physicians begin agreeing to queries without carefully reviewing them to avoid repeated requests
Query fatigue occurs when physicians, overwhelmed by frequent queries, begin rubber-stamping responses without proper review, potentially leading to inaccurate documentation.
Which type of Medicare audit focuses on reviewing claims from providers with aberrant billing patterns identified through data analysis, using both prepayment and post-payment review?
Answer: ZPIC/UPICreview
Zone Program Integrity Contractors (ZPICs), now called Unified Program Integrity Contractors (UPICs), conduct investigations targeting suspected fraud through both pre- and post-payment review based on data analysis.
Under Medicare's teaching physician rules, what is required for a resident to bill an E/M service at the level documented by the resident?
Answer: Teaching physician must be present during key portions and document their presence
Teaching physicians must be present during the key or critical portions of the service and must document their presence and participation for billing at the level documented.
A coder separates a bundled procedure into its component parts and bills each separately to increase reimbursement. This is called:
Answer: Unbundling
Unbundling involves billing separately for procedure components that should be included in a single, comprehensive code, violating NCCI edits and constituting fraudulent billing.
The minimum standard for a compliant healthcare compliance program, as outlined by the OIG, includes how many core elements?
Answer: 7 elements
The OIG's Compliance Program Guidance identifies 7 core elements of an effective compliance program, including written policies, a compliance officer, training, auditing, and disciplinary standards.
A Local Coverage Determination (LCD) differs from a National Coverage Determination (NCD) in that an LCD:
Answer: Is developed by a Medicare Administrative Contractor for its jurisdiction
LCDs are coverage policies developed by Medicare Administrative Contractors (MACs) that apply only within their specific geographic jurisdiction, unlike NCDs which apply nationally.