Test Bank Solution Manual for Coding Compliance Programs, Clinical Documentation Improvement,
and Coding Medical Necessity Chapter 10-11
coding compliance - Answers is the conformity to established coding guidelines and regulations.
●Written policies and procedures, which are updated at least annually, and address clinical
documentation improvement, downcoding/unbundling/upcoding, ethical coding, physician queries,
using code editing software, and so on.
●Routine coding audits and monitoring, both internal (performed by coding manager) and external
(conducted by outside consulting agency), identify coding errors and at-risk coding practices.
Benchmarking is a helpful practice that allows the coding manager to establish criteria (e.g., coding error
rates, coding productivity rates), which are used during coding assessment.
●Compliance-based education and training, which results from routine coding audits and monitoring.
Education and training programs are developed to assist coders improve accuracy (e.g., decrease coding
error rates) and the proper use of software (e.g., outpatient code editor).An effective coding compliance
program requires adhe - Answers Health information management departments (and similar areas, such
as the coding and billing section of a physician's practice) develop coding compliance programs to
ensure coding accuracy and conformance with guidelines and regulations. Coding compliance programs
include:
●Hospitals (1998 and 2005)
●Home health agencies (1998)
●Clinical laboratories (1998)
●Third-party medical billing companies (1998)
●Durable medical equipment, prosthetic, orthotic, and supply industry (1999)
●Hospices (1999)
●Medicare+Choice organizations (1999)
●Nursing facilities (2000 and 2008)
●Individual and small group physician practices (2000)
●Ambulance suppliers (2003)
●Pharmaceutical manufacturers (2003)
●Recipients of Public Health Service biomedical and behavioral research awards (2005) - Answers The
Department of Health and Human Services' Office of the Inspector General (OIG) developed voluntary
compliance program guidance documents for the following segments of the health care industry to
,encourage the development and use of internal controls to monitor adherence to applicable regulations,
statutes, and program requirements. Health care organizations implemented compliance programs
under the management of a designated compliance officer
voluntary compliance efforts - Answers foster an environment that promotes detection, prevention, and
resolution of conduct that does not conform to facility or provider ethical business policies, federal and
state laws (statutes) and regulations, and government and private third-party payer health care program
requirements
compliance program - Answers A successful ________ reduces fraud and abuse, enhances provider
operations, improves quality of patient care, and reduces overall costs of providing health care services
benchmarks - Answers Health care facilities establish _______ (e.g., points of reference) to demonstrate
implementation of a compliance program and document achievements and action plans to address
deficiencies
comprehensive error rate testing (CERT) program - Answers the _______ was implemented as a result of
the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012, and its purpose is
to annually review programs to improve efforts to reduce and recover improper payments.
improper payments - Answers are those that should not have been made or included an incorrect
amount
●Duplicate payments
●Payments for an incorrect amount
●Payments for an ineligible service
●Payments for services not received
●Payments to an ineligible recipient - Answers Improper payments are those that should not have been
made or included an incorrect amount. They are both overpayments and underpayments, and include:
CERT program - Answers The objective of the ______ is to estimate the accuracy of the Medicare fee-
for-service (FFS) by calculating improper payment rate through evaluation of a statistically valid random
sample of claims (e.g., 50,000 claims each year). The evaluation determines whether they were properly
paid under Medicare billing, coding, and coverage rules
1.Claim selection from Medicare Part A, Part B, and DMEPOS
2.Medical record requests from providers and suppliers that submitted the selected claims
3.Review of claims by medical review professionals (coders, nurses, physicians) and submitted
documentation (medical records) to determine whether claim was paid properly
4.Assignment of improper payment categories
, a.No documentation (e.g., provider or supplier fails to respond to request for medical records)
b.Insufficient documentation (e.g., medical records do not support payment for services billed)
c.Medical necessity (e.g., submitted medical records either support or do not support services billed)
d.Incorrect coding (e.g., erroneous codes, unbundled codes)
e.Other (e.g., duplicate payment error, noncovered or unallowable service)
5.Calculation of improper payment rate by statistical contractor
6.Centers for Medicare and Medicaid Services (CMS) and Medicare admin - Answers The CERT program
process includes the following steps:
Medicare medical review (MR) program - Answers The goal of the ________ is to reduce payment errors
by identifying and addressing provider billing errors that involve coverage and coding issues
●Proactively identify patterns of potential billing errors concerning Medicare coverage and coding made
by providers through data analysis and evaluation of other information (e.g., submission of complaints).
●Review CERT program data, RAC program vulnerabilities, and Office of Inspector General (OIG) and
Government Accountability Office (GAO) reports.
●Take action to prevent and address identified errors.
●Publish local coverage determination (LCDs) to provide guidance about items and services that will be
eligible for Medicare payment.
●Publish Medicare Learning Network (MLN) educational articles related to the MR process - Answers To
achieve the goal, Medicare administrative contractors:
progressive correct action (PCA) - Answers All medical review activities are based on the operational
principle of __________, which involves data analysis, error detection, validation of errors, provider
education, determination of review type, sampling claims, and payment recovery. _________ serves as
an approach to performing medical review, and it assists Medicare administrative contractors in
deciding how to deploy medical review resources and tools appropriately. The Medicare administrative
contractor may use any relevant information deemed necessary to generate a prepayment or post-
payment claim review determination
additional documentation request (ADR) - Answers a process called _____ is initiated when the
Medicare administrative contractor has reviewed documentation submitted with a claim and then
requests additional documentation from the provider when deemed necessary and in accordance with
Medicare program manuals
●Reviewing and approving MAC annual medical review strategies
