Compliance and Regulatory Rules 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 and Regulatory Rules flashcards as text
Which federal law establishes the Anti-Kickback Statute (AKS) that prohibits offering, paying, soliciting, or receiving anything of value to induce referrals for federal healthcare programs?
Answer: Social Security Act Section 1128B
The Anti-Kickback Statute is codified at 42 U.S.C. § 1320a-7b(b), which is Section 1128B of the Social Security Act.
A medical practice bills Medicare for a service using a CPT code that represents a higher level of service than what was actually performed. This is an example of:
Answer: Upcoding
Upcoding occurs when a provider bills for a higher-level or more expensive service than was actually rendered.
Under the OIG Compliance Program Guidance, which element is considered the foundation of an effective compliance program?
Answer: Designation of a compliance officer
The OIG identifies the designation of a compliance officer as the foundational element because this person oversees all other compliance activities.
Which statute imposes civil monetary penalties on any person who knowingly presents a false or fraudulent claim to a federal health care program?
Answer: False Claims Act
The False Claims Act (31 U.S.C. § 3729) imposes civil liability for submitting false or fraudulent claims to the federal government.
A coder assigns separate CPT codes for each component of a procedure that should be reported with a single comprehensive code. This practice is known as:
Answer: Unbundling
Unbundling is the practice of billing separately for services that should be reported together under one comprehensive CPT code.
The National Correct Coding Initiative (NCCI) edits are used by CMS to prevent improper billing of which type?
Answer: Unbundling of CPT codes
NCCI edits are CMS policy guidelines that prevent unbundling by identifying code pairs that should not be billed together.
Which of the following is a safe harbor under the Anti-Kickback Statute?
Answer: Personal services and management contracts that meet specific criteria
Personal services and management contracts meeting specific criteria are recognized safe harbors under the AKS regulations.