Certified Healthcare Constructor Exam Study Guide
Questions | Consisting Of 348 Questions With Verified
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Federal Sentencing Guidelines - Culpability Score Aggravating Factors
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
1. effective compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance
Program
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...
...having a policy and not following it.
Medicare reimbursement - hospital inpatient codes
International Classification of Diseases (ICD)
Medicare reimbursement - physician codes
Current Procedural Technology (CPT)
Questions to guide the scope of an internal investigation.
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 _______.
...take an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance.
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
,1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness
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
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)
a statistical classification system that arranges diseases and injuries into groups
according to established criteria (signs and symptoms)
Current Procedural Terminology (CPT)
American Medical Association publishes and maintains this coding system
Organized Health Care Arrangements (OHCA)
HIPAA arrangement between clinically integrated setting (ex: hospitals and medical
staff)
Diagnosis Related Group (DRG)
an inpatient classification system based on: principal diagnosis, secondary diagnosis,
surgical factors, age, sex, and discharge status
Healthcare Common Procedure Coding System (HCPCS)
for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare
program using this expanded version
Upcoding
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
submitting bills by piecemeal or in fragmented fashion to maximize reimbursement
Outlier
additional payment for patients with long hospital length of stay
Billing and Coding Concerns (*)
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
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
CMS will consider a claim as inpatient if the patient in hospital bed over two midnights
72 Hour Rule/3 Day Window Project (*)
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 (*)
submission of charges to Medicare which are unrelated to medical care, such as
administrative overhead
Credit Balances - Failure to Refund (*)
provider has 60 days to refund credit balances (*)
PPS Transfer Project
PPS transfer of patient (rather than discharge) and receiving payment
Advance Beneficiary Notice (ABN)
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
used to identify the correct insurance company that must pay health care bills first when
Medicare pays second
Hospital Outpatient Cardiac Rehabilitation
physician must be present during treatment
DRG Utilization (*)
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 (*)
1. History
2. Examination
3. Medical Decision Making
, Evaluation & Management Codes
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
1. Problem Focused (CC & brief history)
2. Expanded Problem Focus
3. Detailed
4. Comprehensive
Complexities of Medical Decision Making
1. Straight-forward (simple, 1 problem)
2. Low complexity
3. Moderate complexity (may have some complications)
4. High complexity
Initial patient visit (*)
3 out of 3 key elements of E&M services must be met or exceeded in order to bill for this
type of visit
Established patient visit (*)
2 out of 3 key elements of E&M services must be met or exceeded in order to bill for this
type of visit
Inpatient Documentation Requirements
1. sufficient documentation to demonstrate signs/symptoms were sever enough to
warrant inpatient care
2. preexisting medical problems or extenuating circumstances
Factors to Consider When Making the Decision to Admit as Inpatient
1. severity of signs and symptoms
2. medical predictability of something adverse happening to the patient
3. need for diagnostic studies
4. availability of diagnostic procedures at the time and location where patient presents
Medicare Part A
Part of Medicare that reimburses primarily for inpatient services provided by institutions
such as hospitals and skilled nursing facilities
Medicare Part B
Part of the Medicare program that reimburses covered physician and supplier services
Medicare Part C (Medicare Advantage)
Formerly known as Medicare + Choice, government managed care program, must have
Part B
Medicare Part D
part of Medicare that reimburses for outpatient prescription drugs
Medicare Administrative Contractor (MAC)
Processes Part A and Part B claims
Focused Medical Review (FMR)
1. determine if documentation supports claim
2. reviews guidelines
Medicaid
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