CPCA Compliance and Auditing Questions and Answers

Question 1

A Medicare patient is scheduled for a blepharoplasty.
The physician's documentation indicates the primary reason is to improve the patient's appearance, but there is also a minor note about "heavy eyelids." The practice is concerned Medicare will deny the claim as cosmetic.
What is the most appropriate compliance step to take BEFORE the procedure?

Accepted Answer

Have the patient sign an Advance Beneficiary Notice (ABN) explaining they will be financially responsible if Medicare denies the service.

Answer

Code the procedure as medically necessary using a diagnosis for visual field impairment, even if not fully documented.

Answer

Refuse to perform the procedure since it might be denied by Medicare.

Answer

Bill the procedure with a -GA modifier without discussing it with the patient.

Question 2

A compliance officer for a large dermatology and aesthetics practice is proactively reviewing potential areas of risk. Which government publication should be reviewed annually to identify specific services and billing practices that are targeted for scrutiny by federal auditors?

Accepted Answer

The OIG (Office of Inspector General) Work Plan

Answer

The HIPAA Privacy Rule Summary

Answer

The CMS Internet-Only Manuals (IOMs)

Answer

The CPT® Codebook Professional Edition

Question 3

When auditing a patient chart for a botulinum toxin injection to treat blepharospasm (a medically necessary condition), which of the following documentation elements is most crucial for supporting medical necessity and differentiating it from a cosmetic service?

Accepted Answer

A detailed description of the patient's functional impairment and failure of previous treatments.

Answer

The brand name and units of the neurotoxin used.

Answer

Before-and-after photos showing cosmetic improvement.

Answer

A patient-signed consent form acknowledging the procedure's risks.

Question 4

An internal audit at an aesthetic practice reveals a pattern of routinely billing for E/M services with minor cosmetic procedures without supporting documentation for a significant, separately identifiable service. What is the most appropriate INITIAL action for the compliance officer to take?

Accepted Answer

Implement a corrective action plan that includes provider education and a focused follow-up audit.

Answer

Immediately terminate the provider responsible for the billing pattern.

Answer

Report the finding to the Office of Inspector General (OIG) immediately.

Answer

Ignore the finding, as the reimbursement for the E/M codes is minimal.

Question 5

An aesthetic practice wants to use patient "before and after" photos on its social media page for marketing. According to HIPAA, what is the most critical compliance requirement before posting these images?

Accepted Answer

A specific, written authorization must be obtained from the patient that allows for the use and disclosure of their images for marketing purposes.

Answer

The practice must have a general consent-to-treat form on file for the patient.

Answer

The photos must be de-identified by blurring the patient's eyes and any distinct tattoos.

Answer

The patient must be over 18 years old and have given verbal consent.

Question 6

Which of the following represents a significant compliance risk related to compensation and sales within an aesthetic practice that accepts federal payers?

Accepted Answer

Any arrangement that provides a commission or "kickback" to staff for selling certain products or services, potentially violating the Anti-Kickback Statute.

Answer

Offering a discount to patients who purchase a package of multiple treatments.

Answer

Displaying the price list for all cosmetic services and products in the waiting room.

Answer

Paying a physician-employee a fixed annual salary that is consistent with fair market value.