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CHC Study Guide Exam – 348 Questions and Answers
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CHC Study Guide Exam – 348 Questionsand Answers
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
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