CHC Study Guide All Answers Correct
2023
Federal Sentencing Guidelines - Culpability Score Aggravating Factors Ans- 1. upper-level employee
participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sent...
CHC Study Guide All Answers Correct
2023
Federal Sentencing Guidelines - Culpability Score Aggravating Factors Ans- 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 Ans- 1. effective compliance
program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program Ans- 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... Ans- ...having a policy and not following it.
Medicare reimbursement - hospital inpatient codes Ans- International Classification of Diseases (ICD)
Medicare reimbursement - physician codes Ans- Current Procedural Technology (CPT)
,Questions to guide the scope of an internal investigation. Ans- 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 _______. Ans- ...take an active rather than
a passive role in compliance.
Six tips for saving on future costs of compliance. Ans- 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 Ans- 1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness Ans- 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 Ans- 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) Ans- a statistical classification system that arranges diseases
and injuries into groups according to established criteria (signs and symptoms)
Current Procedural Terminology (CPT) Ans- American Medical Association publishes and maintains this
coding system
Organized Health Care Arrangements (OHCA) Ans- HIPAA arrangement between clinically integrated
setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) Ans- an inpatient classification system based on: principal diagnosis,
secondary diagnosis, surgical factors, age, sex, and discharge status
Healthcare Common Procedure Coding System (HCPCS) Ans- for medication, maintained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare program using
this expanded version
Upcoding Ans- 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 Ans- submitting bills by piecemeal or in fragmented fashion to maximize reimbursement
Outlier Ans- additional payment for patients with long hospital length of stay
, Billing and Coding Concerns (*) Ans- 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 Ans- 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 Ans- CMS will consider a claim as inpatient if the patient in hospital bed over two
midnights
72 Hour Rule/3 Day Window Project (*) Ans- 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 (*) Ans- submission of charges to Medicare which are unrelated to medical care, such
as administrative overhead
Credit Balances - Failure to Refund (*) Ans- provider has 60 days to refund credit balances (*)
PPS Transfer Project Ans- PPS transfer of patient (rather than discharge) and receiving payment
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