CPMA Exam with correct answers, Exams of Nursing

Download CPMA Exam with correct answers and more Exams Nursing in PDF only on Docsity! CPMA Exam with correct answers CMS Fraud Definition - ANSWERS✔✔ Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Abuse Definition - ANSWERS✔✔ An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Examples of Fraud - ANSWERS✔✔ Billing for services and/or supplies that you know were not furnished or provided, altering claim forms and/or receipts to receive a higher payment amount, billing a Medicare patient above the allowed amount for services, billing for services at a higher level than provided or necessary, misrepresenting the diagnosis to justify payment CMS Examples of Abuse - ANSWERS✔✔ Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, billing Medicare patients a higher fee schedule than non-Medicare patients False Claims Act - ANSWERS✔✔ Any person is liable if they knowingly present or cause to be presented a false or fraudulent claim for payment or approval; knowingly makes, uses, or causes to be made or used, a false record or material to a false or fraudulent claims Current False Claims Act penalties - ANSWERS✔✔ $5,500-$11,000 per claim When does the False Claims Act allow for reduced penalties? - ANSWERS✔✔ If the person committing the violation self-discloses and provides all known info within 30 days, fully cooperates with the investigation, and there is no criminal prosecution, civil action, or administrative action regarding the violation Qui Tam or "Whistleblower" provision - ANSWERS✔✔ If an individual (known as a "relator") knows of a violation of the False Claims Act, he or she may bring a civil action on behalf of him or herself and on behalf of the U.S. government; the relator may be awarded 15-25% of the dollar amount recovered Stark or Physician Self-Referral Law - ANSWERS✔✔ Bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationship; bans the entity from billing Medicare or Medicaid for the services provided as a result of the self-referral Anti-Kickback Law - ANSWERS✔✔ Similar to the Stark Law but imposes more severe penalties; states that whoever knowingly or willfully solicits or receives any remuneration in return for referring an individual to a person for the furnishing or arranging of any item or service for which payment may be made in whole or in part under a federal healthcare program or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for whichpayment may be made in whole or in part under a federal healthcare program is guilty of a felony Penalty for violating the Anti-Kickback Law - ANSWERS✔✔ Up to $25,000 fine and/or imprisonment of up to 5 years Stark Law vs. Anti-Kickback Law - ANSWERS✔✔ Anti-Kickback applies to anyone, not just physicians; the Anti-Kickback Law requires proof of intention and states that the person must "knowingly and willfully" violate the law. may be helpful in forming the scope of an audit for a provider or facility or may influence recommendations given to a practice Corporate Integrity Agreements - ANSWERS✔✔ Required by the OIG s a condition of not seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases; typically last 5 yrs but canbe longer; most have the same core requirements along with specific steps for the individual or entity that are related to the conduct that led to the settlement Core requirements in CIAs - ANSWERS✔✔ Hiring a compliance officer/appointing a compliance committee; developing written standards and policies; implementing a comprehensive employee training program; retaining an independent review organization (IRO) to conduct annual reviews; establishing a confidential disclosure program; restricting employment of ineligible persons; reporting overpayments, reportable events, and ongoing investigations/legal proceedings; providing an implementation report and annual reports to the OIG on the status of the entity's compliance activities Independent review organization (IRO) - ANSWERS✔✔ Acts as a 3rd party medical review resource that provides objective, unbiased audits and reports How many sampling units are selected for review in a Discovery Sample under a CIA? - ANSWERS✔✔ 50 Purpose of a Discovery Sample - ANSWERS✔✔ Used to determine the net financial error rate; if the error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review What is the name of the statistical sampling program provided by the OIG torandomly select and determine the size of the Discovery Sample? - ANSWERS✔✔ RAT-STATS What percent of precision and confidence are required to estimate the overpayment? - ANSWERS✔✔ 90% confidence and 25% precision level Certificate of Compliance Agreement (CCA) - ANSWERS✔✔ Require the provider to certify that is will continue to operate its existing compliance programs and to report to OIG for a lesser period of time (usually 3 years); introduced in Inspector General Janet Rehnquist's An Open Letter to Healthcare Providers in November 2011 Compliance Plan - ANSWERS✔✔ Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it Voluntary compliance plan guidance (CPG) documents - ANSWERS✔✔ Developed by the OIG for a variety of healthcare settings; indicate the comprehensive framework, standards, and principles by which an effective internal compliance program may be established and maintained Are compliance plans mandatory? - ANSWERS✔✔ No, they are currently voluntary. The Affordable Care Act makes compliance programs mandatory for providers and other healthcare providers but there is not yet an implementation date How many elements has the OIG identified that should be present in every compliance plan? - ANSWERS✔✔ 7 Elements identified by the OIG that should be present in every compliance plan (except for individual or small group practices) - ANSWERS✔✔ Implementing written policies, procedures and standards of conduct; designating a compliance officer and/or compliance committee; conducting effective training and education; developing effective lines of communication; enforcing standards through well-publicized disciplinary guidelines; conducting internal monitoring and auditing; and responding promptly to detected offenses and developing corrective action What should be included in the documentation of a finding of non-compliant conduct? - ANSWERS✔✔ Date of incident, name of reporting party, name of the person responsible for taking action, and the follow-up action taken When was the CPG for individual and small group physician practices issued? - ANSWERS✔✔ October 5, 2000 in the Federal Register What components of the compliance plan should be adopted by the practice? - ANSWERS✔✔ Based on the practice's specific history with billing problems and other issues, the practice should begin by adopting only those components most likely to provide an identifiable benefit Potential benefits of a compliance program for individual and small group practices - ANSWERS✔✔ Increasing accuracy of documentation; increasing the speed and optimization of proper payment of claims; minimizing billing mistakes; reducing the chances that an audit will be conducted by CMS or the OIG; and avoiding conflicts with the self-referral and anti-kickback statutes Potential risk areas for individual and small group practices indicated by theOIG in the CPG - ANSWERS✔✔ Coding and billing, reasonable and necessary services, documentation, and improper inducements, kickbacks, and self-referrals Additional risk area for physicians listed in the appendix at the end of the CPG - ANSWERS✔✔ Reasonable and necessary services; physician relationships with hospitals; physician billing practices; and other risk areas(rental of space in physician offices by persons or entities to which physicians refer and unlawful advertising) reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of 1-5 elements identified by a bullet, whether in a box with a shaded or unshaded border; Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet, whether in a box with a shaded or unshaded border; Detailed Examination-examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, whether in a box or unshaded border. Eye and psychiatric examinations should include the performance and documentation of at least 9 elements identified by a bullet, whether in a box with a shaded or unshaded border; Comprehensive Examination-should include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. Can a provider choose from either 1995 or 1997 guidelines for each E/M service? - ANSWERS✔✔ Yes Why is it important for an auditor to be familiar with both sets of guidelines? - ANSWERS✔✔ A provider can choose either the 1995 or the 1997 guidelines and they must determine which will be more advantageous to the provider Purpose of the National Correct Coding Initiative (NCCI) - ANSWERS✔✔ Topromote correct coding methodologies and to control improper assignment of codes that results in inappropriate reimbursement; identifies Column I/Column 2 edits that are edits for code pairs that should not be billed together because one service inherently includes the other, unless an appropriate modifier is used and allowed Correct Coding Modifier (CCM) indicator - ANSWERS✔✔ Determines whether a CCM causes the code pair to bypass the edit; will be either "0", "1", or "9" CCM indicator 0 - ANSWERS✔✔ A CCM is not allowed and will not bypass the edits CCM indicator 1 - ANSWERS✔✔ A CCM is allowed and will bypass the edits CCM indicator 9 - ANSWERS✔✔ The used of modifiers is not specified; this indicator is used for all code pairs that have a deletion date that is the same as the effective date; created so that no blank spaces would be in the indicator field Medically Unlikely Edits - ANSWERS✔✔ Define the maximum units of service that a provider would report, under most circumstances, for a singlebeneficiary, on a single date of service, for a specific HCPCS/CPT code Purpose of the medically unlikely edits - ANSWERS✔✔ To help reduce the paid claims error rate for Medicare Part B claims Medicare Modernization Act - ANSWERS✔✔ Required a 3-year Recovery Audit demonstration, which ran between 2005 and 2008; during the demonstration, Medicare employed Recovery Auditors to identify overpayments and underpayments made to healthcare providers and suppliers in randomly selected states Tax Relief and Healthcare Act of 2006 - ANSWERS✔✔ Requires a permanent and nationwide Recovery Audit program by 2010 How many Recovery Audit Contractors does Medicare currently have? - ANSWERS✔✔ 4, divided by region Recovery Audit Contractors (RACs) - ANSWERS✔✔ Review claims on a post-payment basis and use the same CMS regulations that providers are required to follow Fee-For-Service (FFS) Recovery Auditors - ANSWERS✔✔ Contract with CMS to identify Medicare FFS improper payments; if an improper payment is identified, a review results letter is sent to the provider that includes the decision and rationale for that decision How long can FFS Recovery Auditors go back and request claims after the date the claim is paid? - ANSWERS✔✔ 3 years 3 types of review performed by FFS Recovery Auditors - ANSWERS✔✔ Automated, semi-automated, and complex Automated review - ANSWERS✔✔ no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals Semi-automated review - ANSWERS✔✔ claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claimidentified by data analysis as an improper payment Complex review - ANSWERS✔✔ medical record required Medicare Administrative Contractor (MAC) - ANSWERS✔✔ Adjusts a claim and sends a demand letter to the provider for the amount of the overpayment What happens after the provider receives the demand letter during a RAC audit? - ANSWERS✔✔ If the provider agrees with the letter, he/she may submit payment; ask for a recoupment of future payments; or ask for an extended payment plan. If the provider disagrees with the demand letter, he/she may submit a discussion period request to the Recovery Auditor SOAP and CHEDDAR are two formats of medical record documentation. Which section of each format would you find the patient's history? - ANSWERS✔✔ S in SOAP and H in CHEDDAR Patients can request copies of disclosure of PHI under HIPAA: - ANSWERS✔✔ For a six (6) year period of time In preparation for a high volume of patients coming in for chemotherapy, the nurse documents the chemotherapy treatments in advance. The purposeis to speed up the treatment process so that patients do not have to wait long. Would this cause concern in an audit? - ANSWERS✔✔ Yes, chart entry should not be made in advance of the treatment. A provider knows that an evaluation and management service they provide on the same date as a major procedure will be bundled, so submits the claimfor the E/M with a different date of service. This is an example of: - ANSWERS✔✔ Fraud What are the civil monetary penalties for false or fraudulent claims? - ANSWERS✔✔ Up to $11,000 per claim and three times the amount improperly claimed Which type of case is not prosecuted under the federal false claims act? - ANSWERS✔✔ Physician tax issues A full sample must be reviewed and a systems review must be conducted when the net financial error rate of the sampling equals or exceeds what percent? - ANSWERS✔✔ 5% What falls under the responsibility or oversight of an organization's compliance committee? - ANSWERS✔✔ Regularly reviewing and updating policies and procedures, assisting with the development of standards of conduct and policies and procedures, and determining the appropriate strategy to promote compliance What will be one of the focuses of OIG audits in 2014? - ANSWERS✔✔ Evaluation and Management New Patient Visits An infectious disease provider has been notified by the MAC (Medicare Administrative Contractor) in his region that their data shows he is billing level 99214 more frequent than any other provider in the same specialty and same geographic region. The provider requests that you audit a sample of his claims that were coded as 99214 to determine if he is coding appropriately. What supporting references will you need to conduct the audit? - ANSWERS✔✔ 1995 and 1997 CMS Documentation Guidelines The Stark Statute applies to: - ANSWERS✔✔ Only physicians who refer Medicare and Medicaid patients to entities for designated health care services with which the provider or immediate family member has a financial relationship When can a RAC extrapolate the overpayment(s) on claims? - ANSWERS✔✔ If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund. Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier -59 is: - ANSWERS✔✔ Only appropriate if the two procedures are performed on separate lesions orat separate patient encounters. Dr. Jones performed a femoral-femoral bypass graft in the morning on June 1, 20xx. Later that day, the graft clotted and the entire procedure was repeated. Dr. Jones was not available so Dr. Martin who is with a different group repeated the procedure in the evening. The auditor reviewed the documentation for Dr. Martin. The following was reported by Dr. Martin: Date of Service Procedure 06/01/20xx 35556-76 What procedure should Dr.Martin report? - ANSWERS✔✔ 35558-77 A family physician requests that you perform a post payment audit on claimsfrom a particular commercial payer he is receiving denials from. Whenever the provider performs a minor procedure with an E/M service, the minor surgery is reimbursed but the E/M service is denied. You review 10 charts and all cases are documented and coded correctly. What could be the reason for the denial? - ANSWERS✔✔ The payer contract may bundle the E/M service when performed on the same day as the minor surgery. A provider receives a denial on a Medicare claim due to lack of medical necessity. What resource is a valuable tool for providers to limit denials for medical necessity? - ANSWERS✔✔ LCDs A comprehensive audit is: - ANSWERS✔✔ A large number of claims are selected for review that might be focused on specific procedure and/or diagnosis codes. What is RAT-STATS used for by an auditor? - ANSWERS✔✔ Software used in performing statistical random samples and evaluating results What are the recommended number of charts to audit per provider and the minimum frequency of the audit? - ANSWERS✔✔ 10 records per provider each year Evaluation and Management documentation is often captured in SOAP format, which is the acronym for: - ANSWERS✔✔ Subjective, Objective, Assessment, Plan Failure to have which form in the medical record will result in payment being sent to the beneficiary? - ANSWERS✔✔ Assignment of benefits form findings report? - ANSWERS✔✔ Coding is incorrect, code 77002 should be reported for these cases. A provider performs two procedures that NCCI edits state should not be reported together. However if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the documentation supports and qualifies as an unusual procedure, the physician may report the column one HCPCS/CPT® procedure code of the NCCI edit with what modifier? - ANSWERS✔✔ 22 An auditor identifies a procedure that has a modifier appended. This is an indication that: - ANSWERS✔✔ the procedure performed was altered, but the definition of the code has not changed. Sarah Smith works for an emergency physician group. She has been given the responsibility to perform a baseline E/M audit for the physicians in the group. What is the first step she should take to begin this process? - ANSWERS✔✔ Run a utilization report of E/M services An audit performed on one provider would be considered a: - ANSWERS✔✔ Focused audit When performing a retrospective audit, the auditor will need to have what materials? - ANSWERS✔✔ Medical record, audit form, coding manuals, EOBor Medicare RA, payer policies and CMS-1500 form. A sample is gathered of the CPT®/HCPCS codes that have the highest dollar charges. This would be considered which type of sampling? - ANSWERS✔✔ Proportional Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose? - ANSWERS✔✔ Identify the financial error rate of the selected sample A provider receives denials from a private payer for E/M services performedon the same date as a minor procedure. You review documentation for 25 records and the payer contract which states the provider must follow CMS coding guidelines. You determine that 20 of the records have appropriate documentation to support both E/M and the procedure and were coded correctly when the claim was originally submitted. You submit an appeal forthe 20 dates of service that are supported by documentation. To support youfindings, you will include in the appeal a letter reporting your findings, claim forms, copies of documentation, EOB copies and: - ANSWERS✔✔ NCCI policy manual for modifier 25. Nancy prepares to begin a focused audit for Dr. Jacobsen, a general surgeon.The resources that she will gather in addition to the CPT®, HCPCS Level II and ICD-9-CM codebooks, that will be needed to accurately complete the audit will be: - ANSWERS✔✔ Medical terminology book, surgical package definition, global days, surgery audit tool, insurance carrier rules and NCCI edits. In reviewing claims for an ENT provider, you identify that he is consistently billing Medicaid for four units of 69641. Which of the following resources would support your findings that this provider is billing too many units? - ANSWERS✔✔ Medically Unlikely Edits An annual audit is the minimum requirement an IRO must conduct under what agreement? - ANSWERS✔✔ Corporate Integrity Agreement When conducting a compliance audit your findings identify that one of the providers is signing chart entries in the EMR three days after seeing patients. What steps should be taken to address this finding? - ANSWERS✔✔ Prepare a summary of findings that include number or percentages of compliant vs. non-compliant charting; discuss with the provider, including recommendations for improvement; re-audit according to criteria established by the practice. Audit findings are of little value unless the findings are shared with the provider to: - ANSWERS✔✔ Offer recommendations for improvement, illustrate compliant documentation, and address problem areas. According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an outside auditor must sign which of the following agreements prior to reviewing and auditing any medical records? - ANSWERS✔✔ Business Associate Agreement The HIPAA Privacy Rule defines "minimum necessary" as typically requiringhealthcare employees to: - ANSWERS✔✔ Follow policies and procedures developed by the covered entity which limit use and disclosure of PHI to that which is needed to accomplish the intended purpose to perform the duties of their job. When auditing an ENT practice, you discover the practice uses an EMR. Which of the following options would you look for when reviewing documents created in the electronic medical record or notes created using templates that may be indicators of misuse? - ANSWERS✔✔ Complete medical histories on each visit, diagnosis driven by clinical picture, repetitious notes not relevant to presenting problem. State law will take precedence over HIPAA under which of the following circumstances: - ANSWERS✔✔ If HIPAA is less restrictive than state law. When providing a prescription for a patient, the education of the patient, including side effects and supporting documentation in the medical record that the information was reviewed is based on which of the following standards? - ANSWERS✔✔ Joint Commission standards A deliberate misrepresentation of facts to gain unauthorized benefits is the definition of: - ANSWERS✔✔ Fraud Under the Office of the Inspector General CIA, an Independent Review Organization (IRO) reports audit results to: - ANSWERS✔✔ the compliance officer in the organization under the CIA Education and training to reinforce recommendations regarding a physician's deficiencies and problematic areas is best addressed through: - ANSWERS✔✔ Direct follow-up with the physician. The OIG CIA agreement states that the IRO's minimum requirement to perform an audit is: - ANSWERS✔✔ Annually Medical record - ANSWERS✔✔ Chronological documentation of a patient's medical history and care Entries included in a medical record - ANSWERS✔✔ Identification information, a patient's health history, medical examination documentation and findings, and test results, among other information When was HIPAA enacted? - ANSWERS✔✔ August 21, 1996 What was the original intent of HIPAA? - ANSWERS✔✔ To provide rights and protections for participants and beneficiaries of group health plans; limited exclusions for pre-existing conditions and prohibited discrimination against employees and dependents based on their health status Health Care Fraud and Abuse Control Program - ANSWERS✔✔ Established by HIPAA to combat fraud and abuse in healthcare, including both public and private health plans HIPAA Administrative Simplification provisions - ANSWERS✔✔ Required that sections of the law be publicized to explain the standards for the electronic exchange, privacy, and security of health information Privacy Rule standards - ANSWERS✔✔ Address how an individual's protected health information (PHI) may be used Purpose of the Privacy Rule - ANSWERS✔✔ To protect individual privacy, while promoting high quality healthcare and public health and well-being HIPAA covered entities - ANSWERS✔✔ Health plans, healthcare clearinghouses, and any healthcare provider who transmits health information in an electronic format Health plan covered entities - ANSWERS✔✔ Organizations that pay providers on behalf of an individual receiving medical care; exceptions include an employer who solely establishes and maintains the plan with fewer than 50 participants, food stamps, community health centers, insurersproviding only worker's compensation, automobile insurance, and property and casualty insurance Healthcare clearinghouses - ANSWERS✔✔ Billing services, repricing companies, and community health management information systems that process nonstandard information, received from another entity, into a standard (or vice versa) HIPAA electronic transaction content and format requirement - ANSWERS✔✔ ASC X12N or NCPDP (used for certain pharmacy transactions) Business Associates - ANSWERS✔✔ Perform certain functions or activities which involve the use or disclosure of individually identifiable health information on behalf of another person or organization Services provided by Business Associates - ANSWERS✔✔ Claims processingor administration, data analysis, utilization review, billing, benefit management, and re-pricing; for a covered entity, services are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services Purpose of a contract between business associates - ANSWERS✔✔ To impose specified written safeguards on the individually identifiable health information used or disclosed by the business associate What must be included in a contract between business associates? - ANSWERS✔✔ Description of the permitted and required uses of PHI by the business associate, limit the business associate from using or further disclosing the PHI (except where permitted by contract or required by law), and a requirement for the business associate to follow appropriate safeguards to prevent use or disclosure of the PHI, except as expressly defined in the contract Privacy Rule exceptions to the business associate standard - ANSWERS✔✔ Disclosures by a covered entity to a healthcare provider for the treatment ofthe individual; disclosures to a health plan sponsor, such as an employer, bya group health plan that provides the health insurance benefits or coverage for the group health plan; and the collection and sharing of PHI by a health plan that is a public benefits program, such as Medicare PHI - ANSWERS✔✔ Individually identifiable health information that includes many common identifiers such as demographic data, name, address, birth date, and social security number; also includes information that relates to an individual's past, present, or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of healthcare to the individual, which reasonably may be used to identify the individual their creation, or last effective date; fully insured group health plans have only 2 obligations: banned from retaliatory acts and waiver of individual rights and to provide documentation for the disclosure of PHI through documentation What organization is responsible for administering and enforcing the standards set forth in the Privacy Rule? - ANSWERS✔✔ The HHS OCR What is the civil monetary penalty for covered entities that fail to comply and cooperate with any investigation initiated by OCR? - ANSWERS✔✔ Between $100-$50,000 or more per violation with a calendar year cap of $1,500,000 When will a covered entity not receive a civil monetary penalty for failing to comply and cooperate with an investigation initiated by OCR? - ANSWERS✔✔ If the failure to comply was not due to willful neglect and wascorrected within 30 days of identification that the error occurred; or, if a criminal penalty was imposed by the Department of Justice When can penalties be reduced at the discretion of the OCR? - ANSWERS✔✔ If the failure to comply was due to reasonable cause and the penalty would be excessive based on the nature and extent of the noncompliance What organization is responsible for criminal prosecutions under the Privacy Rule? - ANSWERS✔✔ The Department of Justice When are criminal penalties imposed for individuals who have violated the Privacy Rule? - ANSWERS✔✔ When a person knowingly obtains or disclosesindividually identifiable health information in a way that violates the PrivacyRule; penalties may be as much as $250,000 and up to 10 years imprisonment if the conduct involves the intent to sell, transfer, or use identifiable health information for commercial advantage, personal gain, or malicious harm How are medical records requirements generally enforced? - ANSWERS✔✔ Through licensing, the certification process, or credentialing with insurancecarriers What components are commonly found in all medical records? - ANSWERS✔✔ A personal identification number specific to every individual patient; a patient's medical history; often a medical directive Purpose of the personal identification number assigned to each medical record? - ANSWERS✔✔ To ensure accuracy of the details contained within the record and it adds a layer of security to prevent unauthorized use Types of history often involved in the medical record - ANSWERS✔✔ Surgical history, obstetric history, medications and allergies, family history, social history, immunization history, developmental history Purposed of including a patient's medical history in the record - ANSWERS✔✔ So healthcare providers can make assessments about a past, current, or future state of an illness Purpose of a medical directive - ANSWERS✔✔ To allow the patient to communicate his/her wishes to the healthcare community prior to any eventin which he/she may become incapacitated to speak, or to make his/her wishes known in certain medical emergencies When are acronyms acceptable in the medical record? - ANSWERS✔✔ Whenthey are commonly recognized What must a practice do if they use abbreviations that are not industry standard? - ANSWERS✔✔ They must maintain a list of the abbreviations with definitions and how they are used, and should understand that documentation should be submitted anytime an audit is done. What organization has published a standard for the appropriate use of abbreviations as well as a "minimum list" of dangerous abbreviations, acronyms, and symbols? - ANSWERS✔✔ The Joint Commission (JC) What is the purpose of "best practice" standards relating to the contents of a medical record provided by allied health professional organizations? - ANSWERS✔✔ They are a tool to help guide health information managers, toensure accurate and compliant medical records Why are templates often adopted for medical records? - ANSWERS✔✔ To ensure consistency and accuracy What permits providers and suppliers "accredited" by an approved national accreditation organization (AO) to be exempt from routine surveys by state survey agencies to determine compliance with Medicare conditions? - ANSWERS✔✔ The Social Security Act Is accreditation by an AO mandatory? - ANSWERS✔✔ No, it is voluntary Where can you find a list of AOs online? - ANSWERS✔✔ the Medicare website for accreditation What organization is one of the most commonly known accrediting organizations? - ANSWERS✔✔ the JC Who established National Safety Goals? - ANSWERS✔✔ the JC When were National Safety Goals established? - ANSWERS✔✔ 2002 Risk areas of dictations - ANSWERS✔✔ It may take several days for the transcriptionist to transcribe the recorded information and return it to the physician, When should corrections be made to dictations? - ANSWERS✔✔ Before it becomes part of the record How much information should be included in a written summary of the services rendered on the DOS? - ANSWERS✔✔ Enough information about the patient encounter so that it could be used in place of the transcription incase of loss, misfiling, or inaccuracies According to Medicare guidelines, when must the physician sign dictated notes? - ANSWERS✔✔ Before they are placed in the patient's chart What does a signature alongside the note indicate? - ANSWERS✔✔ That theprovider has read the transcription and approved the information When providers use templates, how should abnormal findings be documented? - ANSWERS✔✔ Any findings that are abnormal must have elaboration as to what is abnormal Risk areas of EHRs - ANSWERS✔✔ Templates might cause a provider to document more than is medically necessary for that visit, EHRs allow copying or cloning medical records which can cause many records to look the same and cause information to be recorded that did not apply to that visit What element should drive the level of a visit? - ANSWERS✔✔ Medical necessity What was included in the OIG Work Plans for 2013 and 2014? - ANSWERS✔✔ Direction to review EMR/EHR systems due to concerns over system up code selection, cloning of patient data on subsequent visits, and auto population or auto fill features Why is it important to include the time of service in every medical record entry? - ANSWERS✔✔ So that the events of a patient's medical treatment may be reconstructed at a later time. If the time of the service is significantly different from the time of the chart entry, both times should be documented with an explanation for the delayed entry. Does CMS allow rubber stamps for signatures? - ANSWERS✔✔ No Why is a full signature generally the best practice? - ANSWERS✔✔ Medical records can, and often do, become legal documents How does a physician "sign" an electronic record? - ANSWERS✔✔ By entering his or her unique code into the system In what setting is the electronic signature recognized as sufficient to meet documentation requirements? - ANSWERS✔✔ In the hospital setting What systems meet the authentication requirements for medical record entries? - ANSWERS✔✔ Computerized systems that require the physician toreview the document on-line and indicate that it has been approved by entering a computer code; a system in which the physician signs off against a list of entries that must be verified in the individual record; and a mail system in which transcripts are sent to the physician for review, and the he/she signs and returns a postcard identifying the record and verifying its accuracy Patient registration form - ANSWERS✔✔ Gathers information needed to identify the patient and process claims and typically includes the date, patient demographic information (age, DOB, address, SSN), insurance and financial information, and an emergency contact Assignment of benefits - ANSWERS✔✔ Authorization form signed by the patient that allows their insurance carrier to pay the provider directly. Without this, the payment will go to the beneficiary and the provider will be required to collect payment from the beneficiary. Confirmation of Receipt of Privacy Notice - ANSWERS✔✔ Signed documentation from the patient that he/she received the entity's privacy notice Release of Information - ANSWERS✔✔ Form signed by patient allowing the release of their medical records Informed consent - ANSWERS✔✔ Signed by the patient to verify that the patient understands procedures, outcomes, and options; consists of the patient's diagnosis (if known), the nature and purpose of a proposed treatment/procedure, alternative treatments/procedures, the associated risks and benefits, and the risk and benefits of not receiving the treatment/procedure. The patient can withdraw this consent of the procedure at any time. What elements are generally included in an evaluation and management encounter? - ANSWERS✔✔ Chief complaint, history of present illness (HPI),physical examination, and assessment Chief complaint - ANSWERS✔✔ A description of why the patient is presenting for healthcare services. History of present illness (HPI) - ANSWERS✔✔ How the patient describes the symptoms he or she is experiencing, and which have prompted the patient to seek medical attention When must an operative report be dictated? - ANSWERS✔✔ Immediately after the procedure was performed What must be included in an operative report? - ANSWERS✔✔ A detailed summary of the findings throughout the surgery, the procedure performed, any specimens removed, the pre- and postoperative diagnoses, and the names of the primary performing surgeon and any assistants How many sections is the operative report divided into? - ANSWERS✔✔ 4 What is included in each section of the operative report? - ANSWERS✔✔ The header, indications for surgery, the detail or body of the procedure, andthe findings What is the header of the operative note designed to identify? - ANSWERS✔✔ Patient name, date of surgery, preoperative diagnosis, postoperative diagnosis, the procedure performed, primary surgeon, assistant surgeon(s), anesthesia administered, anesthesiologist Indication - ANSWERS✔✔ Typically gives a brief history outlining the reasons for or medical necessity for the procedure What is included in the body of the notes? - ANSWERS✔✔ Specific details ofthe surgery What determines the CPT code used to convey surgical services performed? - ANSWERS✔✔ The details in the body of the notes Why is it important to read the entire operative note slowly and carefully? - ANSWERS✔✔ The details in the body of the note do not always match the procedure that is documented in the header or indicate additional procedures not reported in the title If there are elements missing in an operative note, does it always mean that something wasn't done? - ANSWERS✔✔ No, it may be that the physician believes the missing element would be inherently "built into" the note by another physician reading that note What should happen if there are elements missing in an operative note? - ANSWERS✔✔ Training should be provided to remind physicians that the note is the only way to represent what was actually done in the operating room, and that everything must be clearly spelled out through documentation What should be included in the informed consent for treatment? - ANSWERS✔✔ The patient's diagnosis (if known), the nature and purpose of the treatment, risks and benefits of the treatment, alternative treatment options, risks and benefits of alternative treatment options, risks and benefits of not receiving any treatment How should a primary physician document the help of a surgical assistant? -ANSWERS✔✔ The primary surgeon should clearly explain in the indications section of the note why an assistant was necessary and what the assistant surgeon performed that required the assistance What requirements must radiology reports meet to accurately assign a CPT code for services performed? - ANSWERS✔✔ It is necessary to retain the actual images of radiologic services, as well as a written report, to describe the indication for the study and to summarize the findings. An order or request for the study must also be retained. Who must maintain the orders for radiologic services? - ANSWERS✔✔ The facility What is included in a complete radiology report? - ANSWERS✔✔ Patient name; referring physician; date and time of study; patient history; reason for study; diagnostic and procedural statement; extent of exam (limited, complete); number and type of views taken (bilateral, left, right); contrast material used, as appropriate, including type, amount, and method of administration; separate description of each study performed on the patient;recommendations for follow-up exam or additional studies needed; comparison of prior studies, as appropriate; indication of any limitations in study, such as poor image quality or poor patient prep; summary of conversations with other healthcare providers; findings, results, impressions, conclusions; signature of radiologist What should happen if any information within the radiology report is unclear or conflicting? - ANSWERS✔✔ The documenting provider should be queried for verification and correction, as necessary Is the number of radiological views the same as the number of digital images or films? - ANSWERS✔✔ No Anteroposterior (AP) - ANSWERS✔✔ Front to back Decubitus (DEC) - ANSWERS✔✔ Patient lying on their side Oblique (OBL) - ANSWERS✔✔ Angled view Posteroanterior (PA) - ANSWERS✔✔ Back to front Right anterior oblique (RAO) - ANSWERS✔✔ Right front angled view Right posterior oblique (RPO) - ANSWERS✔✔ Right rear angled view Left anterior oblique (LAO) - ANSWERS✔✔ Left front angled view When are outpatient therapy services covered? - ANSWERS✔✔ When services were required because the individual needed therapy services; and a plan of care has been established and is periodically reviewed; and services were furnished while under the care of a physician; and the physician or nonphysician practitioner certifies the plan of care Documentation requirements for therapy services include: - ANSWERS✔✔ Evaluation and Plan of Care; certification and recertification; progress reports which provide justification for the medical necessity of treatment information; and treatment encounter notes for each treatment day Outpatient therapy treatment encounter notes for each treatment day should include: - ANSWERS✔✔ Date of treatment; treatment, intervention, or activity; total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes); signature and professional identity of the qualified professional furnishing the treatment; and additional information may include response to treatment or changes When can outpatient therapy start? - ANSWERS✔✔ When the initial plan of care has been established What must be included in the plan of care? - ANSWERS✔✔ Diagnoses; long term treatment goals; type of rehabilitation therapy services (physical therapy, occupational therapy, or speech-language pathology) identifies each specific intervention, procedure, or modality, to support billing and verify correct coding; amount of therapy (number of treatment sessions in a day); duration of therapy (number of weeks or number of treatment sessions); and frequency of therapy (number of treatment sessions in a week) Additional optional, but recommended, elements for a plan of care include: -ANSWERS✔✔ Short term goals; goals and duration for the current episode of care; specific treatment interventions, procedures, modalities, or techniques and the amount of each; and the beginning date for the plan Who must sign the plan of care for outpatient therapy services? - ANSWERS✔✔ The person who established the plan of care (physician, NPP, clinical nurse specialist, or physician assistant) Who must also sign the certification for outpatient therapy services if a physical therapist or speech-language pathologist establishes the plan of care? - ANSWERS✔✔ A physician, NPP, clinical nurse specialist, or physician assistant Who is required to certify the care or re-certify the plan of care if significantmodifications are made? - ANSWERS✔✔ The physician or NPP Errors identified in outpatient therapy services by Medicare's Comprehensive Error Rate Testing (CERT) - ANSWERS✔✔ Missing the plan of care, missing signatures and dates, missing certification and recertification, and missing the total time for procedures and modalities If a covered entity identifies material breach of a contract agreement with a business associate and the contract is terminated the problem is reported to: - ANSWERS✔✔ The Office for Civil Rights (OCR) What is an example of an exception under the Privacy Rule that requires a written agreement to disclose protected health information? - ANSWERS✔✔A physician sending patient's treatment plan to a marketing pharmaceuticalcompany What is proper protocol for making a correction to a paper medical record? - ANSWERS✔✔ Place a single line strike through the original statement, signing and dating the revision Why is the CERT program beneficial to auditors? - ANSWERS✔✔ It identifies errors causing improper payments by the Medicare program. The errors found can identify areas for providers to improve documentation. Authentication of a report by a physician or other practitioner must take place: - ANSWERS✔✔ After the document has been transcribed and reviewed What is included in the CPT codebook? - ANSWERS✔✔ Instructions, coding guidelines, parenthetical notes, and symbols to provide guidance for proper coding Do all payers follow CPT coding guidelines? - ANSWERS✔✔ No Add-on code icon - ANSWERS✔✔ + Add-on code definition - ANSWERS✔✔ Some of the procedures listed in CPTare carried out "in addition to" the primary procedure performed. Add-on codes are never reported alone. They always accompany specific primary procedure codes. There usually is a parenthetical note following the add-on code to indicate the appropriate primary code(s) for the add-on code. Are all add-on codes exempt from the multiple procedure concept? - ANSWERS✔✔ Yes Multiple surgical procedure reduction - ANSWERS✔✔ Applied when multiple procedures are performed during the same operative session; the highest valued code is paid at 100%, the second highest valued code is paid at 50%, and each additional procedure is paid at 25%; if a claim exceeds 5 line items, payers may evaluate for special pricing; the fee schedule for add-on codes already accounts for the reduction and the payment is made at 100% provider credit for using either set that is most advantageous for the provider for the visit Both sets of guidelines are determined by what 3 key components? - ANSWERS✔✔ History, exam, and medical decision-making (MDM) The history component consists of: - ANSWERS✔✔ A chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family and social history (PFSH) Chief Complaint - ANSWERS✔✔ The reason for the encounter A chief complaint is required for every encounter except for what kind of service? - ANSWERS✔✔ A preventive service What is the only option to report an encounter without a chief complaint? - ANSWERS✔✔ Unlisted code 99499 Can you use elements of the HPI for a chief complaint? - ANSWERS✔✔ Yes. According to the CMS E/M Guide: "the CC, ROS, and PFSH may be listed asseparate elements of history or they may be included in the description of the history of present illness." If a patient is returning for a follow up, does the provider have to document the reason for the follow up? - ANSWERS✔✔ Yes History of present illness - ANSWERS✔✔ A chronological description of the development of the patient's present illness from the first sign or symptom, or from the previous encounter, to the present How many elements of HPI can be included in the documentation? - ANSWERS✔✔ 8 What are the elements of HPI that can be included in the documentation? - ANSWERS✔✔ Location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms Location - ANSWERS✔✔ The patient's statements regarding the anatomical place, position, or site of the chief complaint Quality - ANSWERS✔✔ The patient's statements regarding characteristics about the problem, such as how it looks or feels Severity - ANSWERS✔✔ The patient's statements regarding a degree or measurement of how bad it is Duration - ANSWERS✔✔ The patient's statements regarding how long the complaint has been occurring, or the time when the complaint first occurred Timing - ANSWERS✔✔ The patient's statements regarding a measurement of when or at what frequency they noticed the complaint Context - ANSWERS✔✔ The patient's statements regarding what the patientwas doing, their environmental factors, the circumstances surrounding the complaint Modifying factors - ANSWERS✔✔ The patient's statements regarding anything that makes the problem better or worse Associated signs and symptoms - ANSWERS✔✔ The patient's statements regarding associated secondary complaints What is another way to calculate the HPI besides using the 8 elements? - ANSWERS✔✔ Based on documentation of the status of 3 chronic or inactiveconditions (documented in the 1997 guidelines), or based on the documentation of three chronic or inactive conditions as an extended HPI when using the 1995 guidelines (as of September 2013) Review of systems - ANSWERS✔✔ An account of body systems obtained through a series of questions seeking to spot signs and/or symptoms that the patient may be experiencing, or has experienced; the physician and/or staff make this query verbally or via the patient intake form; may be about the systems directly related to the problems identified in the HPI and/or additional body systems; commonly interspersed with elements of the HPI How many systems are recognized for purposes of ROS? - ANSWERS✔✔ 14 What systems are recognized for purposed of ROS? - ANSWERS✔✔ Constitutional; eyes; ears, nose, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; allergic/immunologic Constitutional - ANSWERS✔✔ Patient's answers about general constitutional signs or symptoms Eyes - ANSWERS✔✔ Patient's answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spotsor floaters, blurred or doubled vision, twitching, light sensitivity, swelling around the eyes or lids, and visual disturbances Ears, nose, and throat - ANSWERS✔✔ Patient's answers about signs or symptoms including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and abnormalities. Other possible conditions include nosebleed, postnasal drip, sneezing, nasal drainage, impaired ability to smell, sinus pain, difficulty breathing, and history of sinus infection and treatment. For the throat and mouth: sore Family history - ANSWERS✔✔ Review of medical events in the patient's family, including the age of death and diseases that may be hereditary, or that place the patient at an increased risk Can the elements of the ROS and PSFH be taken from a previous encounter? - ANSWERS✔✔ Yes, if there is documentation that the provider reviewed and updated the previous information; the provider must include any new information or comment that there has been no change and indicate the date and location of the previous ROS or PFSH What are the only elements that can be recorded by someone other than theprovider performing the E/M service? - ANSWERS✔✔ ROS and PFSH; theremust be documentation in the note that the provider reviewed the information obtained by someone else How should the provider obtain a history about a patient if the patient presents unconscious or has dementia? - ANSWERS✔✔ He or she must make an effort to obtain history from another source such as a family member, EMS bringing the patient to the emergency room, or the patient's primary care physician What must the provider do is he or she cannot obtain the history from the patient or other source? - ANSWERS✔✔ He or she must document the patient's condition or other circumstance that prevented him or her from obtaining the history Is there a quantifiable number of body area(s) or organ system requirements when using the 1995 guidelines? - ANSWERS✔✔ No, because of this, some practices choose to follow the 1997 guidelines What is one of the biggest problem areas for the exam component? - ANSWERS✔✔ Differentiating an expanded problem focused exam and detailed exam using the 1995 guidelines; both levels require 2-7 body areas/organ systems and the distinction is where the exam is limited or extended Novitas Solutions guidance for distinguishing between expanded problem focused and detailed exam using the 1995 Documentation Guidelines - ANSWERS✔✔ "By providing a tool we call 4x4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity." Why should you review MAC guidance when auditing E/M services? - ANSWERS✔✔ Many have audit tools, FAQs, and online E/M education; you must review the provider based on the standard he or she will be measured against How should the provider document body areas and organ systems that are normal? - ANSWERS✔✔ By notating "normal" or "negative" Is elaboration on abnormal findings required? - ANSWERS✔✔ Yes Body areas - ANSWERS✔✔ Head and face; neck; chest including the breast and axilla; the abdomen; genitalia; groin; buttocks; back including spine; and each extremity Organ systems - ANSWERS✔✔ Constitutional; eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; hematologic; lymphatic; and immunologic Medical decision-making - ANSWERS✔✔ Takes into account the work involved to determine a diagnosis and treatment options for the patient, andthe amount of data collected and reviewed; also factored into MDM is the level of risk to the patient, either due to the diagnosis or the management options to treat the diagnosis What is the auditor's best guide regarding the number of diagnoses and management options? - ANSWERS✔✔ The nature of the presenting problemand the medical necessity of the encounter The number of diagnosis and management options is based on: - ANSWERS✔✔ The relative level of difficulty in making a diagnosis and the status of the problem, such as whether it is controlled versus worsening What are some common indicators used to measure the relative level of difficulty in making a diagnosis and the status of the problem? - ANSWERS✔✔ Problems that are new to the patient or that the physician is seeing in this patient for the first time; seeking additional workup, such as aconsultant's opinion; ordering additional workup, such as diagnostic tests toconfirm or to rule out the suspected diagnosis and/or differential diagnosis with which the patient will leave the office; and established problems for which the patient shows no improvement or for which he or she has not responded as expected What audit tool should the auditor use? - ANSWERS✔✔ The audit tool used by the MAC for the provider(s) audited, unless one is not available; the E/M tools for the MAC should be reviewed to seek clarification and availability ofaudit tools What system do the majority of audit tools follow for the number of diagnoses and treatment options? - ANSWERS✔✔ The point system Definition of workup - ANSWERS✔✔ Anything that the physician plans to make or confirm a diagnosis such as a diagnostic test Is routine blood work to monitor side effects of medication be considered anadditional workup? - ANSWERS✔✔ No How can a provider verify that a written report was provided to the requesting provider/appropriate source? - ANSWERS✔✔ By indicating who was copied on the report; if in the inpatient setting, a separate report is not needed because providers share the record What E/M code is commonly reported in error for a nurse visit? - ANSWERS✔✔ 99211 For Medicare, if the provider was out of the office, can the service be billed?- ANSWERS✔✔ No, this is based on the incident-to guidelines Top E/M coding errors - ANSWERS✔✔ Upcoding; downcoding; chief complaint or reason for the visit is missing; assessment is not documented clearly; documentation is not initialed or signed; tests ordered are not listedin the documentation, but are billed on the encounter form/superbill; a clearassessment and plan is not documented; diagnosis is not referenced correctly; documentation is missing; lost dictation; superbill/encounter formand/or charge (fee) ticket are not available; superbill/encounter is incomplete or incorrect; and documentation is illegible Audit steps for E/M - ANSWERS✔✔ 1. Determine the scope of the audit2. Make sure the documentation is complete and legible, signed properly, and the DOS is correct. When an EMR/EHR was used to create the documentation, make sure the records haven't been cloned. Look for inconsistencies in the documentation.3. Determine whether to follow CMS 1995 or 1997 Documentation Guidelines. Review MAC guidance for the provider being audited to determine if there is further guidance or an audit tool that is MAC specific. Inquire if the practice has a policy to use one set of documentation guidelines over another.4. Verify the provider of service has been appropriately reported on the claim for post payment audits or encounter form/superbill for prepayment audits.5. Review the medical record using an audit tool to capture elements that are given credit. 6. Determine the correct E/M category and level using the 3 key components or time if properly documented.7. Verify the service provided is medically necessary.8. Run a utilization comparison of the provider against peers in the same specialty to see how the provider compares.9. Compile a report to communicate the findings.10. Determine ongoing monitoring and education targeted at the provider's specific deficiencies. What must be reported on the claim when reporting anesthesia services? - ANSWERS✔✔ The anesthesia time in minutes along with modifiers to identify the anesthesia provider Why must concurrency for anesthesia cases be monitored? - ANSWERS✔✔ Because anesthesia is time based For what insurance provider must you follow the documentation rules to be properly reimbursed when an anesthesiologist performs monitored supervision? - ANSWERS✔✔ Medicare What do anesthesia modifiers report? - ANSWERS✔✔ The type of anesthesiaprovider(s) as well as type of anesthesia or special circumstances that arise during anesthesia AA modifier - ANSWERS✔✔ Anesthesia personally performed by an anesthesiologist AD modifier - ANSWERS✔✔ A physician who is medically supervising more than 4 concurrent procedures QK modifier - ANSWERS✔✔ Qualified Individual who is medically directing 2-4 concurrent procedures QY modifier - ANSWERS✔✔ An anesthesiologist that medically directed a CRNA in a single case QX modifier - ANSWERS✔✔ A medically directed CRNA QZ modifier - ANSWERS✔✔ CRNA who is performing anesthesia services without medical direction by a physician QS modifier - ANSWERS✔✔ Monitored anesthesia care service G8 modifier - ANSWERS✔✔ Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure G9 modifier - ANSWERS✔✔ Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition Modifier 23 - ANSWERS✔✔ Unusual anesthesia. This modifier is used when administering anesthesia for a service or a procedure that does not typicallyrequire anesthesia. Modifier 53 - ANSWERS✔✔ Discontinued procedure. If during a procedure, the surgeon decides to terminate the surgery due to the patient's condition, report modifier 53 for a discontinued procedure. Modifier 59 - ANSWERS✔✔ Distinct procedural service. This modifier is used to indicate that a procedure is distinct or independent from another procedure performed on the same day. The documentation must support a different session, different procedure, different site, or separate incision/excision. Medicare calculation to determine total anesthesia units - ANSWERS✔✔ Base Units + Time Units = Total Units Calculation used by all other payers to determine total anesthesia units - ANSWERS✔✔ Base Units + Time Units + Modifying Units=Total Units Are base units assigned to each anesthesia code? - ANSWERS✔✔ Yes Where can base units be found? - ANSWERS✔✔ In the Crosswalk or RVG Guide What providers usually place the central venous catheter lines percutaneously for immediate use? - ANSWERS✔✔ Anesthesia providers; they do not usually tunnel the catheter Most reported codes for insertion of a central venous line - ANSWERS✔✔ 36555 and 36556 Coding for insertion of central venous lines - ANSWERS✔✔ The anesthesia provider must perform the insertion. If the surgeon placed the line or if the line was already in place and it is not clear who placed it, the line placementshould not be reported. If more than one line is inserted into different vessels, report all of the insertions and append modifier 59 to the additional codes for the central venous catheter placement. A lines - ANSWERS✔✔ Intra-arterial catheters; allow the physician to monitor arterial blood pressure and to have easy access to collect specimens to measure arterial blood gases Codes for insertion of arterial catheters - ANSWERS✔✔ 36620 and 36625 Coding for insertion of arterial lines - ANSWERS✔✔ The anesthesia providermust perform the insertion. Do not report line placement if the surgeon placed the line, or if the line was already in place and it is not clear who placed it. If more than one line is inserted into different vessels, report all the line insertions and append modifier 59 to the additional codes for the arterial catheter placement. Coding for Swan-Ganz catheters - ANSWERS✔✔ 93503 is the CPT code and the catheter must be placed by the anesthesia provider. It is important to determine how many lines the anesthesia provider has inserted, as the provider may place multiple lines. If the Swan-Ganz catheter is threaded through a central venous line, you do not report the insertion of the central venous line. Only report the Swan-Ganz catheter because the same line is used. If 2 separate lines are inserted and 2 different vessels are used, reportthe insertion of the line and the insertion of the Swan-Ganz catheter and append modifier 59 to the central line. CPT codes for epidurals are determined based on: - ANSWERS✔✔ Whether a single injection is performed or if it is a continuous infusion, and the section of the spine in which the epidural is inserted. What code should you report when the epidural is the method for anesthesia? - ANSWERS✔✔ The appropriate anesthesia code What codes should you report when the epidural is used for pain management? - ANSWERS✔✔ 62310, 62311, 62318, or 62319 What code should you report when a nerve block is performed for regional anesthesia? - ANSWERS✔✔ The appropriate anesthesia code instead of the code for the nerve block The codes used to report a nerve block is selected based on: - ANSWERS✔✔The nerve injected Nerve blocks performed for pain management and not for anesthesia may be reported separately by: - ANSWERS✔✔ Appending modifier 59 To code for medical direction to Medicare, the anesthesiologist must meet the following requirements: - ANSWERS✔✔ Perform pre-anesthetic exam and evaluation; prescribe the anesthesia plan; personally participates in the most demanding procedures in the anesthesia plan; ensure any procedures that are not personally performed are performed by a qualified individual; monitor the course of anesthesia in frequent intervals; and remains physically present and available for emergencies; and provides indicated postoperative care Steps for anesthesia auditing - ANSWERS✔✔ 1. Determine the type of anesthesia. 2. Determine the appropriate anesthesia code for the surgical procedure(s) performed. 3. Verify the correct modifiers to identify the anesthesia provider reported. 4. Verify the physical status modifier is documented and the diagnosis supports it. 5. Verify the accuracy of any qualifying circumstances codes reported.6. Review the documentation for additional procedures performed by the anesthesia provider. When documented, report the services in addition to the anesthesia code.7. Determine anesthesia time to report total minutes on the claim form.8. In a post payment audit, use the calculation to determine the expected reimbursement to make sure the claims paid correctly. When monitored anesthesia care (MAC) is performed, what modifiers may apply? - ANSWERS✔✔ GS, G8, and G9 When multiple procedures are performed during a surgical session, how many anesthesia codes are reported? - ANSWERS✔✔ Only 1, based on the anesthesia code with the highest assigned base value Where are the status indicators found? - ANSWERS✔✔ On the National Physician Fee Schedule Relative Value File Global surgery status indicator: 000 - ANSWERS✔✔ Minor procedures with preoperative and postoperative relative values on the day of the procedure only are reimbursable. E/M services on the same day of the procedure are generally not payable. Global surgery status indicator: 010 - ANSWERS✔✔ Minor procedures with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period are reimbursable services. E/M services on the day of the procedure and during the 10-day postoperative period are not reimbursable. Global surgery status indicator: 090 - ANSWERS✔✔ Major procedures with one day preoperative period and 90-day postoperative period are consideredto be a component of global package of the major procedure. E/M services on the day prior to the procedure, the day of the procedure, and during the 90-day postoperative period are not reimbursable. Global surgery status indicator: MMM - ANSWERS✔✔ Maternity codes; the usual global period concept does not apply Global surgery status indicator: XXX - ANSWERS✔✔ The global concept does not apply to this code. Global surgery status indicator: YYY - ANSWERS✔✔ These are unlisted codes, and subject to individual pricing. Global surgery status indicator: ZZZ - ANSWERS✔✔ Represents add-on codes. They are related to another service and are always included in the global period of the primary service. Steps for surgical auditing - ANSWERS✔✔ 1. Determine the scope of the audit.2. Make sure the documentation is complete.3. Review the entire operative note.4. Verify the procedures have not been unbundled when more than 1 procedure code is reported.5. Review MUEs for the codes to prevent reporting excessive units.6. When sequencing multiple codes, make sure it is done in RVU order, fromhighest to lowest.7. Verify medical necessity.8. When coding for an assistant surgeon, make sure an assistant surgeon is approved for the surgery.9. Verify modifier use.10. Make sure all charges are captured. Common surgical coding errors - ANSWERS✔✔ Unbundling of procedures; missing charges, when multiple procedures are performed; coding from the operative note headers; failure to support medical necessity; incorrect use of modifiers; failure to report imaging guidance, when appropriate; incorrect reporting of units Radiology - ANSWERS✔✔ A branch of medicine using radiation-including ionizing radiation, radionuclides, nuclear magnetic resonance, and ultrasound-to diagnose and treat disease X-ray technology - ANSWERS✔✔ Includes a variety of advanced applications, such as computerized axial tomography (CAT or CT scan), magnetic resonance imaging (MRI), ultrasound technology, nuclear medicine, radiation oncology, and positron emission tomography (PET) Types of radiologic services - ANSWERS✔✔ Diagnostic, radiation oncology, nuclear medicine, and radiologic guidance Steps for radiology auditing - ANSWERS✔✔ 1. Determine the scope of an audit.2. For diagnostic radiology services, make sure there is an order that includes the test to be performed (including views when appropriate) and the diagnosis for ordering the test.3. Verify that there is an interpretation and report and retention of a permanent image, when required, for the radiology service. Without an interpretation and report, the service cannot be reported.4. Verify if the diagnosis meets medical necessity.5. Verify the accuracy of the coding with the detail in the written radiology report.6. Many surgical procedures include imaging guidance. The instructions for reporting imaging guidance separately are found in the coding guidelines orparenthetical note(s) PC/TC indicator: 0 - ANSWERS✔✔ Physician Service Codes: The PC/TC concept does not apply. PC/TC indicator: 1 - ANSWERS✔✔ Diagnostic Tests for Radiology Services: Modifiers 26 and TC can be reported with these codes. PC/TC indicator: 2 - ANSWERS✔✔ Professional Component Only Codes: This indicator identifies the codes describe the physician work only. Modifiers 26 and TC cannot be reported. PC/TC indicator: 3 - ANSWERS✔✔ Technical Component Only Codes: This indicator identifies the codes describe the technical component only. Modifiers 26 and TC cannot be reported. PC/TC indicator: 4 - ANSWERS✔✔ Global Test Only Codes: This indicator identifies stand-alone codes that describe selected diagnostic tests that 4. Review the analyte tested, and method for performing the test.5. Check the accuracy of the coding for panels.6. Verify the accuracy of modifier use. Standing order policy - ANSWERS✔✔ Must be written and adhere to state law requirements, must indicate the clinical condition, and must be reviewed for validity Common modifiers for pathology include: - ANSWERS✔✔ Modifier 90, modifier 91, modifier 92, and modifier QW Modifier 90 definition - ANSWERS✔✔ Reference (outside) laboratory: This modifier is reported when the laboratory procedures are performed by a provider/lab other than the treating or reporting physicians Modifier 91 definition - ANSWERS✔✔ Repeat clinical diagnostic laboratory test: This modifier is reported when laboratory tests are repeated for clinical reasons. Modifier 92 definition - ANSWERS✔✔ Alternative laboratory platform testing: This modifier is reported when the test is performed using kits and transportable instruments. Modifier QW definition - ANSWERS✔✔ CLIA waived test: This modifier is reported with any test on the CMS list of CLIA waived tests Medicine section - ANSWERS✔✔ Includes therapeutic and diagnostic services When auditing any diagnostic service: - ANSWERS✔✔ Verify that documentation supports the codes reported, medical necessity is met, an order for the service is documented, and an interpretation and report are included, when required. Diagnostic services are reviewed that have: - ANSWERS✔✔ High audit errorrates and are commonly audited by government and private payers When is a code for a vaccine not reported? - ANSWERS✔✔ If the vaccine is given to the provider for free, the patient brings the supply, or if the supply s provided as part of a clinical trial. How many sets of administration codes are there? - ANSWERS✔✔ 2 sets Administration codes 90460-60461 - ANSWERS✔✔ Auditor must verify that counseling was performed and that the patient is 18 years old, or younger; reported per component, not per vaccine administered; when combination codes are given, code for each component Psychiatric services include: - ANSWERS✔✔ Diagnostic evaluations, psychotherapy, and other procedures Auditing psychiatric diagnostic evaluations - ANSWERS✔✔ Make sure the documentation includes history, mental status, and recommendations; the service may require a discussion with the patient's family or caregiver When reporting 90762, the documentation must include: - ANSWERS✔✔ A medical assessment in addition to history, mental status, other physical exam elements as indicated, and recommendations. Psychotherapy - ANSWERS✔✔ The treatment of mental illness and behavioral disturbances; codes are time based Auditing psychotherapy codes - ANSWERS✔✔ Make sure the time documented supports the codes reported When can psychotherapy be performed as a stand-alone service or as an add-on code? - ANSWERS✔✔ When performed in addition to an E/M service; when reporting the add-on psychotherapy codes, the time spent performing the E/M service is not included in the time reported with the psychotherapy code; the documentation for each service must stand alone What codes are reported when psychotherapy is provided for a patient in crisis? - ANSWERS✔✔ 90839 and 90940, based on time Pharmacologic management includes: - ANSWERS✔✔ The review of the patient's medication, responses to the medication, management of side effects, and ongoing monitoring and maintenance. Pharmacologic management can be reported only as an add-on code when: -ANSWERS✔✔ Performed with psychotherapy; providers authorized to code E/M codes are directed to report E/M When should you see 90863 reported? - ANSWERS✔✔ Only if the state where you are auditing allows a psychologist to prescribe medication; because psychiatrists most commonly prescribe medication, this service should be reported with the appropriate E/M code, based on medical necessity and documentation Chemotherapy and therapeutic drug administration requires codes for: - ANSWERS✔✔ Both the administration and the supply What codes are used to report chemotherapy and therapeutic drug supplies? - ANSWERS✔✔ HCPCS Level II Steps to follow when billing time-based codes - ANSWERS✔✔ 1. Review each time based code to see if it is performed for at least 8 minutes, to be billable.2. Look at total time. If we have 2 codes, both performed for 8 minutes, each is billable. But, for the total time, we only have 16 units. Only one unit can be billed, based on the total time. Because both services are performed for the same amount of time, report the code with the highest RVUs. When auditing physical therapy services, the documentation must include: - ANSWERS✔✔ 1. Plan of care, including diagnoses, long-term treatment goals, type of rehab services (include the intervention and modality), amount (number of treatment sessions per day), duration (number of weeks or treatment sessions), and frequency (number of sessions in a week)2. Initial certification-the physician or other qualified healthcare professional approve, by signature and date, the care plan w/in 30 days of the initial therapy treatment3. Recertification-Not required if the duration of the certified care plan is more than the duration of the entire episode of treatment; used to documentthe need for continued/modified therapy and should be done at least every 90 days after the initiation of the care plan.4. When modalities are performed, report the specific modality and the time. Modifiers - ANSWERS✔✔ Indicate that the service or procedure performed has been altered, but the definition of the code has not changed; can affect reimbursement and, used properly, can break the global package Modifier 24 - ANSWERS✔✔ Unrelated E/M by the same physician or other qualified healthcare professional during a postoperative period Modifier 25 - ANSWERS✔✔ Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service Audit concerns with modifier 25 include: - ANSWERS✔✔ Appending the modifier on the minor procedure, instead of the E/M code; documentation does not support a separate E/M; and various interpretations/guidance frompayers regarding proper use. Review the payer policies for the services you are auditing Modifier 22 - ANSWERS✔✔ Increased procedural services; documentation must clearly indicate why the procedure was more extensive, requiring more time or effort than is typically required Modifier 58 - ANSWERS✔✔ Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period; applies when the physician planned a supplementary service during the global period of another procedure, or when the patient required the supplementary service to complete treatment begun at an earlier date You may consider modifier 58 for a procedure or service during the postoperative period if the procedure or service is: - ANSWERS✔✔ Planned prospectively at the time of the original procedure (staged); more extensive than the original procedure; or for therapy following a diagnostic surgical procedure Modifier 76 - ANSWERS✔✔ Repeat procedure or service by same physician or other qualified healthcare professional Modifier 77 - ANSWERS✔✔ Repeat procedure by another physician or otherqualified healthcare professional Modifier 76 and 77 are reported when: - ANSWERS✔✔ A service is repeatedon the same date of service Modifier 78 - ANSWERS✔✔ Unplanned return to the operating room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period; requiresa return to the operating room; does not extend the global period Modifier 79 - ANSWERS✔✔ Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period; applies to any procedure within the postoperative period; will begin a new global period for the unrelated procedure Modifiers 78 and 79 are reported during the global period to: - ANSWERS✔✔ Indicate the patient required either an unplanned procedure (usually a complication) or an unrelated procedure Anatomic modifiers may be used to: - ANSWERS✔✔ Indicate different sites Proper use of modifier 59 include: - ANSWERS✔✔ Different surgical session, different procedure or surgery, different site or organ system, separate excision or incision, and separate lesion or injury Appropriate modifier use with NCCI - ANSWERS✔✔ Documentation indicates 2 separate procedures performed on the same day, by the same physician; represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury); use modifier 59 with the secondary, additional or lesser procedure of combinations listed in NCCI edits; use modifier 59 when there is NO other appropriate modifier; use modifier 59 on the second initial injection procedure code when the IV protocol requires 2 separate IV sites, or when the patient has to come back for a separately identifiable service The NCCI manual also states that if the NCCI edit does not allow the use of an NCCI-associated modifier to bypass the edit, and the procedure qualifies as an unusual procedural service that requires additional work, the providermay: - ANSWERS✔✔ Report the column 1 code of the NCCI edit with modifier 22 to indicate additional work was required. The documentation 2. For an established diagnosis, whether the patient's condition is stable, improved, worsening, etc3. When diagnostic tests are ordered, the rationale for ordering the tests are either documented or easily inferred4. Management of the patient is documented clearly When should providers use an ABN? - ANSWERS✔✔ When a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover Advance Beneficiary Notice (ABN) - ANSWERS✔✔ A standardized form thatexplains to the patient why Medicare may deny the particular service or procedure; protects the provider's financial interest by creating a paper trail that CMS requires before the provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure Common reasons Medicare may deny a procedure or service include: - ANSWERS✔✔ Medicare does not pay for the procedure/service for the patient's condition; Medicare does not pay for the procedure/service as frequently as proposed; and Medicare does not pay for experimental procedures/services The explanation of why Medicare may deny the service or procedure should be: - ANSWERS✔✔ As specific as possible The provider must present the patient with a cost estimate for the proposed procedure or service that is within how much of the actual costs? - ANSWERS✔✔ $100 or 25 percent, whichever is greater Medicare allows that an estimate that substantially exceeds the actual costswould generally still be acceptable because: - ANSWERS✔✔ The beneficiarywould not be harmed if the actual costs were less than predicted How far in advance must the ABN be presented by the patient, according to CMS? - ANSWERS✔✔ Far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice What must happen before the patient signs the ABN? - ANSWERS✔✔ It must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered If the patient chooses to proceed with a procedure after signing an ABN, he or she may request: - ANSWERS✔✔ The charge be submitted to Medicare for consideration (with the understanding that it will probably be denied) Who must receive a copy of the completed, signed ABN? - ANSWERS✔✔ The beneficiary or representative and the provider must retain the original notice on file Is the patient's signature required for assigned claims (that is, claims submitted by and paid to a physician on behalf of the beneficiary)? - ANSWERS✔✔ No What should the provider do if the beneficiary refuses to sign a properly presented ABN but still requests the service/procedure? - ANSWERS✔✔ Document the patient's refusal and sign the form, along with a witness Is a signature required on the ABN for unassigned claims (claims submitted by the provider but the payment is sent to the patient who then reimburses the physician)? - ANSWERS✔✔ Yes, to hold the patient financially liable What are the options in the event that the patient refuses to sign an ABN foran unassigned claim? - ANSWERS✔✔ To not provide the service or procedure (which might raise potential negligence issues), or to provide theservice with the understanding the provider may not be able to recoup payment from either Medicare or the beneficiary What should providers list on the ABN? - ANSWERS✔✔ Every recommendedprocedure or service that might not be covered When does Medicare relieve beneficiaries from financial liability? - ANSWERS✔✔ When they did not know and did not have reason to know a service would not be covered Without a valid ABN: - ANSWERS✔✔ The Medicare beneficiary cannot be held responsible for denied charges When are ABNs never required? - ANSWERS✔✔ In emergency or urgent care situations; CMS policy prohibits giving an ABN to a patient who is "under duress" including patients who need Emergency Department (ED) services before stabilization Can physicians seek payment from beneficiaries when Medicare denies screening and stabilizing care as medically unnecessary? - ANSWERS✔✔ No When can services provided by teaching physicians with resident services can be billed to Medicare? - ANSWERS✔✔ If the physician is involved in the key or critical portions of the services performed by the resident, and if the physician participates in the patient's management The documentation for services provided by teaching physicians with resident services must include: - ANSWERS✔✔ The services provided by theresident, as well as the services provided by the teaching physician. If it is not clear that the physician performed a face-to-face encounter with the patient, the service cannot be billed. For E/M services, when the physician has met the teaching physician requirements: - ANSWERS✔✔ Combine the resident's note and the teaching Internal audit - ANSWERS✔✔ Performed by members of the organization External audit - ANSWERS✔✔ Performed by an individual or group not part of the organization or the practice Many practices use a combination of what 2 types of audits to maintain compliance? - ANSWERS✔✔ Internal and external Hiring a full-time internal auditor may be cost prohibitive for what types of practices? - ANSWERS✔✔ Solo or small group practices A problem is finding an auditor with: - ANSWERS✔✔ The necessary trainingand expertise in auditing medical records for coding and compliance Benefits of external audits - ANSWERS✔✔ Provide a framework for developing a remedy for isolated issues; may be more objective than internal audits; and when a practice pays for an outside service, the feedback is usually taken seriously An external audit will typically conduct what type of audit to measure the coding compliance for each practitioner? - ANSWERS✔✔ A baseline audit What should the baseline audit consist of? - ANSWERS✔✔ 10-15 records, per practitioner, and include a random sampling of E/M service levels, office, and surgical procedures How often may additional audits be performed, after the baseline audit is conducted? - ANSWERS✔✔ Quarterly, biannually, or annually, depending onthe results of the baseline audit Who may conduct periodic, internal audits? - ANSWERS✔✔ Coding staff trained in auditing medical records or by a practitioner trained to audit for coding and compliance How often should an internal audit be conducted? - ANSWERS✔✔ Annually, at minimum What is 1 issue a smaller medical office may have with conducting an internal audit? - ANSWERS✔✔ If staff conducting the audit has other responsibilities, the audit could pose productivity issues. The decision to perform the audits internally or externally is determined by: - ANSWERS✔✔ Each individual practice Focused audit - ANSWERS✔✔ Looks at one item, one type of service, or oneprovider Random audit - ANSWERS✔✔ The selection will be random and each service is as likely to be chosen for audit as any other service A focused audit may concentrate on one type of service to: - ANSWERS✔✔ Determine compliance Baseline audit - ANSWERS✔✔ An audit (usually random) of all possible services provided within a specific time frame, and is normally performed if documentation from various types of services needs to be reviewed A random audit will often identify: - ANSWERS✔✔ Areas for potential education and future focused audits to determine the effectiveness of the education Prospective audit - ANSWERS✔✔ Performed prior to claim submission so that variances in the coding may be corrected prior to claim submission; if the documentation does not support the CPT/HCPCS code or ICD-9 code that was to be billed, the coding should be corrected based on the audit findings Why must a prospective audit be completed in a timely manner? - ANSWERS✔✔ To avoid delays in claims submission Retrospective audit - ANSWERS✔✔ Performed on claims that have already been submitted for payment What happens if variances are found between the codes supported and the codes submitted? - ANSWERS✔✔ Decisions must be made concerning potential corrections, including refunding of overpayments Who may retrospectively review claims submission and payment trends to ensure correct coding and billing practices? - ANSWERS✔✔ Providers and payers To perform a retrospective audit, an auditor reviews: - ANSWERS✔✔ The medical record documentation, encounter form, claim form, explanation of benefits (EOB) or Remittance Advice (RA), and the payer policies to determine if and where there are errors in the process Peer review audit - ANSWERS✔✔ May be performed if the clinical decision-making is questioned, based on the documented exam and treatment plan; some practices use a peer review audit on a quarterly basis to provide feedback among the providers; a provider performing a peer review audit may take into account the coding accuracy as well as clinical information May various audits be combined? - ANSWERS✔✔ Yes What is a good selection size for an audit? - ANSWERS✔✔ 10-15 charts per provider Why should an auditor concentrate on visits that took place during a specific period? - ANSWERS✔✔ So that trends can be observed How many charts does the OIG recommend per physician when conducting an annual compliance audit? - ANSWERS✔✔ 5-10 random charts Audit parameters - ANSWERS✔✔ Whole chart or just 1 record from the chart, multiple patients with the same diagnosis, and multiple patients seen on same date of service Purpose of codebooks in an audit - ANSWERS✔✔ Verify correct CPT, HCPCS Level II, and ICD-9-CM use What year should an auditor use for a codebook to audit a chart? - ANSWERS✔✔ The year the services being audited were rendered Electronic audit tool - ANSWERS✔✔ Prints audit reports and analyzes the data after the detail of the E/M level is entered The electronic audit tool software does not have the capability to analyze: - ANSWERS✔✔ Medical necessity What is a drawback of using an electronic audit tool? - ANSWERS✔✔ Sometimes, the level selected by the audit software affords a higher level of service based on documentation alone and the medical necessity element cannot be incorporated into the software. A useful audit tool: - ANSWERS✔✔ Guides the auditor through all the compliance issues that should be addressed, based on the scope and objective When an auditor is seeking more information than what is available in the CPT codebook, what resource can be helpful? - ANSWERS✔✔ Specialty societies' websites and publications that provide layperson descriptions for surgical CPT codes Many payers will follow NCCI in addition to: - ANSWERS✔✔ Their own bundling edits How many sets of NCCI edits are there? - ANSWERS✔✔ 2, one for the provider and one for the facility Other helpful audit tools - ANSWERS✔✔ CPT Assistant, AHA Coding Clinic, frequency reports by physician, utilization based on specialty (can be obtained by insurance carrier), physician's fee schedule by insurance carrier, medical dictionary, medical terminology reference book, OIG work plan A sample is statistically valid if: - ANSWERS✔✔ The sample was collected using scientific sampling methods Non-statistical or judgmental sampling - ANSWERS✔✔ Can be applied to a focused audit; sample based on unique services that were defined in the objective and the scope; could be used if the audit is being performed to look only at high levels of service Proportional sampling - ANSWERS✔✔ Built around high frequency items or those items that are considered proportionally significant Numerical sampling - ANSWERS✔✔ Based on all possible services within the chosen time frame; lends itself well to a random final selection Random selection - ANSWERS✔✔ All items in the total sample have an equal chance of being selected for an audit RAT-STATS - ANSWERS✔✔ Provided by the OIG; statistical software program that is recommended and commonly used to perform a sample sizeestimate and to generate a random number printout to support its sampling methodology Utilization review and data mining provide insight into: - ANSWERS✔✔ Billing patterns and can uncover areas of risk Utilization review - ANSWERS✔✔ Provides data about how frequently certain services are billed Data mining - ANSWERS✔✔ A method that many payers use to compare billing frequencies of one provider against other, or similar, providers of thesame specialty To justify an allegation of error, auditors are limited to: - ANSWERS✔✔ The application of controlling standards If a controlling standard does not exist for the service you are evaluating, you should not declare error but can use: - ANSWERS✔✔ Persuasive standards (with appropriate citations and qualifications) to identify potential post-payment risk The most important step in any compliance audit is: - ANSWERS✔✔ Validation of the rules particular to the services being audited and the payerthat the services are being billed to