CMCA PRACTICE EXAM 136 Questions with Verified Answers
The Joint Commission (JC) requires the Factors that Affect Learning must be assessed for a
... [Show More] hospital or hospital owned physician practice as well as other health care facilities. When assessing this element what does this include?
A. The patient's ability to read, method of learning and understanding.
B. Any language or physical disabilities.
C. Cultural beliefs.
D. All the above - CORRECT ANSWER D. All the above
Report copies and printouts, films, scans, and other radio logic service image records must be retained for how long according to Federal Regulations?
A. 10 years
B. 7 years
C. 5 years
D. 3 years - CORRECT ANSWER C. 5 years
At which point should a provider repay over payments reported by self-disclosure to the office of Inspector General?
A. Make the payment to your carrier immediately.
B. Make the payment at the conclusion of the OIG injury.
C. Make the payment to the carrier prior to the self disclosure.
D. Make the payment to the OIG with a self disclosure report. - CORRECT ANSWER B. Make the payment at the conclusion of the OIG injury
Which of the following may be considered essential element (s) of an operative report and will allow for accurate coding?
A. The approach
B. The type of anesthesia required
C. The location and severity of wounds repaired
D. All of the above - CORRECT ANSWER D. All of the above
Which of the following is NOT a covered entity under HIPPA?
A. Physician
B. Health Plan
C. Health Care Consultant
D. Physician Assistant - CORRECT ANSWER C. Health Care Consultant
When referring to the authentication of a medical record entry, what does this entail?
A. Legible signature of author and date signed
B. A physician's order for ancillary services
C. An original document filed in the record
D. The patient's personal information - CORRECT ANSWER A. Legible signature of author and date signed
What is the time limit mandated by CMS for adding a late entry to the medical record?
A. One Week
B. One Month
C. One Year
D. No time limit - CORRECT ANSWER D. No time limit
When should a ABN be signed?
A. Prior to performing a statutorily excluded procedure for a Medicare beneficiary.
B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary.
C. Prior to submitting a claim to Medicaid for a non- service.
D. After performing a procedure and finding it is denied. - CORRECT ANSWER B. Prior to performing a procedure that may be denied due to medical necessity for a Medicare beneficiary.
Under a Corporate Integrity Agreement (CIA), how many claims must be randomly selected to review to determine the financial error rate?
A. 15
B. 50
C. 75
D. 100 - CORRECT ANSWER B. 50
When using LCDs and CMS program Guidance as a resource for an audit, what should the auditor keep in mind?
A. QICs are bound by NCDs, LMRPs, and CMS Program guidance, but ALJs and MACs are not.
B. Local carriers and QICs are bound by LCDs and LMRPs
C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them.
D. Local Carriers, QICs, ALJs, and MACs are all bound by NCDs and CMS program guidance. - CORRECT ANSWER C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them.
When reporting the claims review findings under a CIA audit, the Independent Review Organization (IRO) must provide:
A. A detailed analysis listing the patient files reviewed and findings and previous audit disclosures for all services
B. A detailed report with a narrative explanation of finding and supporting rationale approved by the providers attorney.
C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample.
D. A list of data reviewed and findings in a narrative form - CORRECT ANSWER C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample.
Which statement is most accurate regarding NCCI?
A. NCCI are national coding guidelines and must be followed regardless of the insurance carrier.
B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits.
C. Each individual carrier will have its own bundling edits and will not use NCCI.
D. NCCI edits are suggested ways to bundle procedure codes, but are not necessary to review during an audit. - CORRECT ANSWER B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits.
A provider request you to perform an audit of claims that have been denied payment by XYZ insurance. Since the physician contracted with XYZ insurance, all claims submitted that include the E/M service and EKG interpretation on the same day have been denied for the EKG interpretation. You review the medical record and the EOB and determine the services are documented and coded correctly. Which of the following items will you need to complete your audit?
A. Provider contract with XYZ insurance.
B. Provider internal billing polices.
C. RAC statement of work
D. OIG work plan for the current year. - CORRECT ANSWER A. Provider contract with XYZ insurance.
According to the "OIG Compliance Program for Individual and Small Group Physician Practices," There are essential elements for a compliance plan. These elements included:
A. Mandatory employment of an internal auditor
B. Conduct appropriate training and education
C. Disciplinary action for employees who file a qui tam suit
D. Develop an effective E/M Audit Tool with reproducible results. - CORRECT ANSWER B. Conduct appropriate training and education
John presents today for his yearly physical and during the encounter he alerts his physician to some abdominal issues he has been having including sharp pains that come and go and have been increasing in severity especially after eating. After examination the doctor orders an ultrasound which is performed in the office and medications and schedules a follow-up for two weeks. What is the appropriate modifier for this encounter?
A. No modifier necessary
B. 25
C. 57
D. 24 - CORRECT ANSWER B. 25
Which of the following accurately describes the financial impact for appending modifier 24 to an E/M service performed during the global period of a major surgery?
A. The E/M service will not be paid when performed during the global period.
B. The E/M service will be paid at 20% of the physician fee schedule
C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility.
D. The E/M service will not be paid and a ABN should be signed since the service provided is unrelated to the surgery. - CORRECT ANSWER C. The E/M service will be paid at 100% of the physician fee schedule minus the patients responsibility.
Select the scenario that would support medical necessity for observation services.
A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs.
B. A patient who is recovering from abdominal surgery who requires observation until awake from anesthesia.
C. A patient who is receiving infusion chemotherapy for the first time and is anxious about that procedure
D. A patient who is dependent on a ventilator and requires pulse oximetry to monitor 02 staturation - CORRECT ANSWER A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs.
When may a focused audit be initiated?
A. After a prepayment or retrospective audit has identified a specific problem
B. When the auditor first decides to conduct an audit
C. To compare coding and billing patterns for the entire practice
D. To ensure compliance with all coding guidelines - CORRECT ANSWER A. After a prepayment or retrospective audit has identified a specific problem
Which of the following represents the most logical initial step in the audit process?
A. Develop an audit tool and tally form
B. Determine the objective(s), the type, and the scope of the audit
C. Gather the medical records to be audited.
D. Analyze the audit and compare the documentation to the procedure and diagnosis code(s) billed. - CORRECT ANSWER B. Determine the objective(s), the type, and the scope of the audit
What are the the Seven Elements defined by the OIG? - CORRECT ANSWER The Seven Elements defined by the OIG are:
1. Implementing written policies and procedures
2. Designating a compliance officer and compliance committee
3. Conducting effective training and education
4. Developing effective lines of communication
5. Conducting internal monitoring and auditing
6. Enforcing standards through well-publicized disciplinary guidelines
7. Responding promptly to detected problems and undertaking corrective action
The office of Inspector General (OIG) - CORRECT ANSWER The mission of the Office of Inspector General is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs
Fraud - CORRECT ANSWER Fraud is an intention deception made for personal gain. Fraud is a crime and a civil law violation
Abuse - CORRECT ANSWER Abuse is an act that directly or indirectly results in unnecessary reimbursement without defined intent.
A qui tam suit - CORRECT ANSWER (Whistle blower) One in which an action that will grant the plaintiff a portion of the recovered penalty and gives the rest of it to the state.
How often does the Compliance program Guidance for Individual and Small Group Physician Practices recommends employees be trained on compliance programs? - CORRECT ANSWER As soon as possible after their start date and receive refresher training on an annual basis or as appropriate.
Improper Payments - CORRECT ANSWER The discovery of billing errors does not man that the provider should freeze billing of all services. At Minimum, the provider should hold billing services with noted deficiencies until the appropriate corrective action plan is implemented.
Federal Anti-Kickback Law - CORRECT ANSWER Prohibits the knowing and willful solicitation, offer, payment, or receipt of any remuneration (broadly interpreted to encompass anything of value), whether direct or indirect, in cash or in like kind, to induce or in return for referring an individual, or purchasing or arranging for an item of service for which payment may be mad under the Medicare, Medicaid, or other government health program.
Safe Harbor Provisions - CORRECT ANSWER Describes various payment and business practices that, although they potentially implicate the Federal Anti-Kickback Statute, are not reated as offenses under the statute. The Safe Harbor provisions are updated by the OIG and maintained on their website.
False Claims - CORRECT ANSWER A false Claim includes a claim that does not conform to Medicare's (or other programs) requirements for reimbursement.
The Civil False Claim Acts - CORRECT ANSWER Imposes civil monetary penalties of between $5,500 and $11,000 plus three times the value of each claim. It prohibits the knowing submission
of a false or fraudulent claim for payment to
the United States, the knowing use of a false record or statement to obtain payment on a
false or fraudulent claim, or a conspiracy to
defraud the United States by having a false or
fraudulent claim allowed or paid
The Criminal False Claim Act: - CORRECT ANSWER Prohibits
knowingly and willfully making or
causing to be made any false statement or
representation of material fact in any claims
or application for benefits under federally
funded health plans as well as commercial
carriers. Violations are felonies and are
punishable by up to five years imprisonment
and/or $25,000 in fines.
The Civil Monetary Penalties Law: - CORRECT ANSWER Provides
for the imposition of civil monetary penalties
up to $10,000 per false service claimed, plus
assessments equal to three times the amount
claimed, for services that the provider knows
or should know were not provided as claimed
or for claims the provider knows or should
know are false or fraudulent.
Other federal criminal laws: - CORRECT ANSWER Also may be
used to prosecute the submission of false
claims, including prohibitions on making
false statements to the government and
engaging in mail fraud. Felony convictions
will result in exclusion from Medicare for a
minimum of a five-year period.
Option for Providers - CORRECT ANSWER Self Disclosure: Fines may be less if a practice
self-disclosed its knowledge of the violation.
Appeal Rights: A practice has the right to an
appeal process, and may choose to request
a hearing before an administration law
judge (ALJ). The OIG and the respondent
have the right to present evidence and make
arguments to the ALJ, who issues a written
decision.
Additional Appeal: The ALJ's decision may
be appealed administratively and to federal
court.
OIG Work Plan - CORRECT ANSWER OIG Work Plan
The OIG Work Plan is released annually
and identifies priority areas for OIG review/
investigation, which the agency believes are HHS'
most vulnerable programs and activities, with
the goal to improve HHS agency efficiency and
effectiveness
Corporate Integrity Agreement (CIA)
What is a Corporate Integrity Agreement? - CORRECT ANSWER It is an agreement between the OIG and a health
care provider or other entity. CIA agreements are
detailed and restrictive agreements imposed on
providers when serious misconduct (fraudulent or
abusive type action) is discovered through an audit
or self-disclosure.
The government may enter into a CIA with an
entity instead of seeking to exclude the entity from
Medicare, Medicaid, and other federal health care
programs.
The typical term of a comprehensive CIA is five
years
Discovery Sample - CORRECT ANSWER The claims review procedures require a Discovery
Sample. A Discovery Sample is used to determine
the financial error rate. The Discovery Sample is a
review of 50 units to be randomly selected.
The purpose of conducting a Discovery Sample as
part of the claims review is to determine the net
financial error rate of the sample that is selected.
If the net financial error rate equals or exceeds
5 percent, the results of the Discovery Sample
are used to determine the Full Sample size. The
Full Sample size is based on an estimate of the
variability of the overpayment amount in the
population from which the sample was drawn. The
results of the Discovery Sample allow the reviewer
to estimate how many sample units need to be
reviewed in order to estimate the overpayment
in the population within certain confidence
and precision levels (eg, generally, a 90 percent
confidence and 25 percent precision level
Stark Law - CORRECT ANSWER The Stark Law is primarily defined as a physician
self-referral law, 42 USC 1395nn. Physician
self-referral is defined by the Stark Laws as:
the practice of a physician referring a patient
to a medical facility in which he has a financial
interest, be it ownership, investment, or a
structured compensation arrangement. The Stark
Law was sponsored by Congressman Pete Stark
(Calif.). Individuals such as Stark contend such
arrangements may encourage over-utilization of
services, in turn driving up health care costs. This
law prohibits a physician from making a referral
to an entity with which the physician or his or her
immediate family has a financial relationship if the
referral is for the furnishing of designated health
services, unless the financial relationship fits into
an exception set forth in the statute or impending
regulations.
What services are not targeted by the Stark Law? - CORRECT ANSWER Services such as sleep studies, EKGs, NCVs,
and Holter monitoring, or services personally
performed or provided by the referring physician
are, however, not targeted by the Stark Law.
Referral for services provided by non-physician
providers is exempt as well. The exceptions to
the Stark Law covered relationships internal to
a physician group include items such as those
involving in-office ancillary services or certain
compensation/ownership arrangements.
The Joint Commission - CORRECT ANSWER The Joint Commission (JC), formerly the Joint
Commission on Accreditation of Health Care
Organizations (better known as JCAHO), is a
private sector United States-based, not-for-profit
organization. The Joint Commission operates
voluntary accreditation programs for hospitals
and other health care organizations.
RAC Audits
CMS Recovery Audit Contractor (RAC) Program - CORRECT ANSWER CMS has implemented a system to identify
improper payments, fraud, and abuse in the
Medicare system.
When should a Self disclosure occur? - CORRECT ANSWER Self disclosure should occur within 30
days of knowing about the violation, and does not
require any form of legal assistance. Payments
relating to the disclosed matter should not be
made until the conclusion of the OIG inquiry
to allow the OIG time to verify the information
disclosed
How often are records requested from RAC auditors and how many? - CORRECT ANSWER Each 45 days, records may
be requested based on the entity's size:
less than 5 providers—10 records
6-24 providers—25 records
25-49 providers—40 records
50 or more providers—50 records
RAC Audit Appeals Process - CORRECT ANSWER Providers who choose to
appeal must send a rebuttal of the findings directly
to the RAC within 15 days of receiving the RAC's
letter identifying an overpayment. Note, however,
this does not stop the clock on the 120 day time
period during which a request for redetermination
(first level appeal) from the Medicare contractor
must be submitted. Additionally, the clock is
still running with regard to the interest accrued
when money is not refunded within 30 days of the
request. Providers who choose to send a rebuttal
to the RAC will want to either simultaneously
file a request for redetermination to the Medicare
contractor or carefully track the status of the
rebuttal and be prepared to file the request for
redetermination within the 120-day time period,
if needed. Medicaid appeals processes will vary
from state to state as well as Medicare Advantage
appeals will vary by MCO
PATH Audits - CORRECT ANSWER Another HIPAA mandated audit process
under the jurisdiction of the OIG operation is
the Physicians at Teaching Hospitals (PATH)
Audit. This audit process has two forms: purely
government-conducted audits (PATH I), and a
self-audit alternative (PATH II). This self-audit
process implies through the OIG interpretation as
having more lenient penalties for self disclosure of
deficiencies, but does not guarantee this initiative.
PATH II - CORRECT ANSWER PATH II gives teaching institutions the
opportunity to designate a third-party auditor of
their choice to be approved by the OIG prior to
any government-initiated audit. Some advantages
of the PATH II process are the ability to select
an institution's own auditor, with the approval of
OIG, and the ability to control the audit process
in a way that minimizes disruption of ordinary
operation. The auditor must be an independent
organization, and may not have a pre-existing
relationship with the facility. There is no provision
for credit of the cost of the audit against any
repayment to Medicare. The cost of the self-audit
must be weighed against the potential savings
in repayment obligations and the waiver of
confidentiality
Conditions of Participation (CoP) - CORRECT ANSWER Conditions of Participation (CoPs) and Conditions
for Coverage (CfCs) are rules and guidelines set
forth by CMS to ensure health care organizations
meet minimum standards when providing services
under the Medicare and Medicaid programs. CMS
considers the health and safety standards of their
requirements to be the foundation for improving
not only the quality of their participant's health
care but also protecting the patient's health and
safety. These standards are expected to be the
minimum and accrediting organizations should
seek to exceed the Medicare standards set forth in
the CoPs/CfCs [Show Less]