CHC Study Guide Questions And Answers
2024-2025 Rated A+.
Federal Sentencing Guidelines - Culpability Score Aggravating Factors - correct
answer. 1. upper-level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sentencing Guidelines - Culpability Score Mitigating Factors - correct answer.
1. effective compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program -
correct answer. 1. written standards of conduct
2. Chief Compliance Officer
3. effective education and training
4. audits and evaluations to monitor compliance
5. reporting processes and procedures for complaints
6. appropriate disciplinary mechanisms
7. investigation and remediation of systematic problems
The only thing worse than not having a policy is... - correct answer. ...having a policy
and not following it.
Medicare reimbursement - hospital inpatient codes - correct answer. International
Classification of Diseases (ICD)
Questions to guide the scope of an internal investigation. - correct answer. 1. What is
the origin of the issue?
2. When did the issue originate?
3. How far back should the investigation go?
4. Can extrapolation of a statistical sample be used?
It is in the best interest of the organization to have the board _______. - correct answer.
...take an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance. - correct answer. 1. embed quality
into existing processes
2. centralize common processes and controls
3. improve human resources infrastructures
4. improve information systems processes
5. emphasize training
6. monitor marketing and compensation
Baseline Audit Process - correct answer. 1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness - correct answer. 1. staff knowledge
2. all 7 elements included
3. comparing issues year to year
4. tracking and trending complaints
5. tracking corrective actions
6. reviewing current audits
7. educational session pre and post tests
8. tracking bill denials
9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
Modifier - correct answer. a two digit alpha/numeric code used in conjunction with
CPT or HCPCS codes that may increase or decrease reimbursement
gives new meaning to the code
International Classification of Diseases (ICD) - correct answer. a statistical
classification system that arranges diseases and injuries into groups according to
established criteria (signs and symptoms)
,Current Procedural Terminology (CPT) - correct answer. American Medical
Association publishes and maintains this coding system
Organized Health Care Arrangements (OHCA) - correct answer. HIPAA arrangement
between clinically integrated setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) - correct answer. an inpatient classification system
based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and
discharge status
Healthcare Common Procedure Coding System (HCPCS) - correct answer. for
medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version
Upcoding - correct answer. providers use a billing code that reflects a higher payment
rate for a device or service provided than the actual device or service furnished to the
patient
Unbundling - correct answer. submitting bills by piecemeal or in fragmented fashion to
maximize reimbursement
Outlier - correct answer. additional payment for patients with long hospital length of
stay
Billing and Coding Concerns (*) - correct answer. 1. coding advice (if not in book - get
in writing)
2. significant increases in volume (*) (find out why increase)
3. hiring external consultants (need BAA, if provide patient care - check OIG sanction
list)
4. number of auditors for Part B audits
5. teaching physicians (*) (physician must be physically present and involved in
managing care)
6. co-pay waivers (cannot routinely waive)
7. record does not support code
8. research payments (cannot bill Medicare for costs covered by sponsor)
9. disagreements (get 3rd party opinion)
10. DOCUMENTATION
"Incident To" services - correct answer. services commonly furnished in a physician's
office by a nurse practitioner in which there is direct physician personal supervision and
are billed under the physician's provider number (does not apply in hospital setting)
physician must be present to bill (*)
, Two-Midnight Rule - correct answer. CMS will consider a claim as inpatient if the
patient in hospital bed over two midnights
72 Hour Rule/3 Day Window Project (*) - correct answer. all diagnostic outpatient
charges and other related outpatient charges within 72 hours prior to an inpatient
admission are bundled into inpatient stay reimbursement
False Cost Reports (*) - correct answer. submission of charges to Medicare which are
unrelated to medical care, such as administrative overhead
Credit Balances - Failure to Refund (*) - correct answer. provider has 60 days to
refund credit balances (*)
PPS Transfer Project - correct answer. PPS transfer of patient (rather than discharge)
and receiving payment
Advance Beneficiary Notice (ABN) - correct answer. a written form that a provider
gives to a Medicare beneficiary that informs the beneficiary that Medicare may not pay
for an item or service
must be provided and signed by patient before services are provided (or provider
cannot bill patient if Medicare denies)
Medicare Secondary Payer Questionnaire - correct answer. used to identify the
correct insurance company that must pay health care bills first when Medicare pays
second
Hospital Outpatient Cardiac Rehabilitation - correct answer. physician must be
present during treatment
DRG Utilization (*) - correct answer. DRG utilization should be reviewed when the
number of uses of a particular DRG is outside of the norm or average
The three components of Evaluation and Management (E&M) services (*) - correct
answer. 1. History
2. Examination
3. Medical Decision Making
Evaluation & Management Codes - correct answer. 1. subset of CPT codes
2. privileged providers
3. describe complexity of care, place of services, and type of service
Types of History or Examination - correct answer. 1. Problem Focused (CC & brief
history)
2. Expanded Problem Focus
3. Detailed
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