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Regarding time, what MUST the physical therapy provider include on the PT log? Time IN and Time OUT. What information should be reported to the OIG in the claims review findings as part of an entity's Annual Report? Claims review methodology, statistical sampling documentation, and claim review findings. An analysis that provides an organization an overview of the deficit areas captured by a medical record audit is called what? An aggregate analysis. Under what circumstances may providers use or disclose PHI w/o patient consent? Payment, treatment, and operations. What program was established by HIPAA to combat fraud & abuse committed against all health plans both public & private? Healthcare Fraud & Abuse Control Program What is the minimum signature requirement of the author entry in a medical record? The first initial, the last name, and credentials. As an auditor, who of the following would NOT be expected to submit operative notes? A surgical assistant. A patient can request copies of disclosure of PHI under HIPAA: For a 6-year period. Can entries for medical records ever be made in advance? NO. The medical record should NEVER be prepared in advance. Based on Joint Commission accreditation guidance for personal data, what 2 elements must be evident in the medical record? Personal biographical data and consent for treatment or authorization for treatment form. A full sample must be reviewed, and a systems review must be conducted when he net financial error rate of the sampling equals or exceeds what percent? 5% When can a RAC extrapolate the overpayment(s) on claims? If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings & request a refund. For civil monetary penalties for false or fraudulent claims, up to how many times of the amount are damages for each false claim submitted? Up to three (3) times the amount improperly claimed. The Stark Statue applies to: Only physicians who refer Medicare & Medicaid patients to entities for designated health care services with which the provider or immediate family member has a financial relationship. What standards are set by the Privacy Rule? Standards for how protected health information is used. When a laboratory report has abnormal findings, what should be documented? Circle and sign the abnormal finding and address the abnormality in the diagnosis. What section of the operative report typically contains the date of surgery, preoperative diagnosis, postoperative diagnosis, and operation performed? The HEADER. Why is it important to read the body of an operative report? To identify if the details in the documentation support the surgery listed in the header, if additional procedures have been performed, or if modifiers should be used. What should be documented in Physical Therapy modalities? Each individual modality used w/ total duration in mins. What is identified in the indications portion of an operative note? A brief history outlining the medical necessity for the procedure. When is incidental use and disclosure of PHI permitted? When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. How long is a Corporate Integrity Agreement (CIA) usually in force? Five (5) years. Which may require an auditor to identify non-standard coding & reimbursement rules? Auto & Worker's Comp Which is a TRUE statement regarding speaking with providers post-audit? Focus on what the provider(s) did well, while outlining the areas where they need to do better to achieve compliance & minimize risk. Which section of an audit report would you report consistent findings that attribute to a specific procedure code or particular provider? Issue-Oriented Findings What provides an entity the ability to self-disclose the potential instances of fraud involving federal healthcare programs for which liability arises under the Civil Monetary Penalty Law? OIG self disclosure protacol (SDP) For Medicare, which administrative agency is responsible for interpretation of the statutory requirements? Health and Human Services Persuasive Which statement is TRUE regarding NCCI? NCCI identifies code pairs and exceptions where a modifier may be used to override the code pair. What would be considered a False Claims Act (FCA) violation under what is known as the "reverse false claims provision" of the FCA? Failure to report an overpayment. What is an IRO? Independent Review Organization What is an automated review? A review based solely on the submitted claims & regulatory guidelines. No medical records are needed. Adiscovery sample is how many units? 50 A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes? 15-25 percent of the money recovered What action would be considered fraud rather than abuse? A provider requiring the coding staff to intentionally code E/M services one level higher than documented. When a discovery sample is performed, what error rate requires a Full Sample to be reviewed? An error rate that exceeds 5%. The OIG Compliance Guidance for Individual & Small Group Physician lists UNBUNDLING as a potential risk area among others. What regulation is the penalty for violating the FCA increased by? The Federal Civil Penalties Inflation Adjustment Act. What can a provider do if he disagrees with a demand letter sent as a result of a Recovery Audit? Submit a discussion period request within 30 days of the demand letter. What must be included in a business associate agreement? The permitted and required uses of PHI by the business associate. Under what circumstances may providers use or disclose PHI without patient consent? Payment, treatment, or operations. What is not a core requirement of a Corporate Integrity Agreement (CIA)? You must hire an OIG employee. The Federal False Claims Act provides the government can assess: Up to 3 times the amount of the damages which the government sustains. What is the look-back period for FFS Recovery Auditors reviewing claims? 3 years What factor is NOT considered when evaluating proposals for the OIG Work Plan? TriCare payments as a result of military war-related accidents. What references can you use to show the provider how multiple units of a CPT code are not allowed and explain how it should be reported? CPT code book and NCCI edits What risk areas are listed by the OIG for individual and small physician groups? 1. Coding & Billing (Unbundling and Upcoding) 2. Reasonable and Necessary services 3. Documentation 4, Improper inducements, kick-backs, and self-referrals When non-compliance is identified, what does the OIG recommend? Corrective action must be taken, although there can be a varying degree of disciplinary action. Any finding of non-compliant actions MUST be documented in the compliance files and should include: 1. Date of Incident 2. Name of the reporting party 3. Name of the person responsible for taking action 4. The follow-up action taken What regulation is the penalty for violating the FCA increased by? The Federal Civil Penalties Inflation Adjustment Act (FCPIA). How long does HIPAA require medical records to be maintained? Six (6) years from the date of creation, or the date for which it was last in effect, whichever is later. When a correction is made in an EHR what must exist? The amendment, correction, or delayed entry must be distinctly identified. There must also be a way to provide reliable means to clearly identify the original content and the modified content. The person altering the record and the date of the revision must also be documented. Which section of an operative report would you expect to find the reason or medical necessity for the procedure? Indication for surgery. The physician should circle the abnormal result to indicate it was seen and sign, and address the abnormality in the diagnosis and treatment plan. What are good parameters for a baseline audit? Arandom selection of 10-15 records per practitioner. What is "Incident-To"? Incident to services and supplies are those provided as an integral, although incidental, part of the physician's or nonphysician practitioner's personal professional services during diagnosis and treatment. Physicians, Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) are nonphysician practitioners who are authorized to have services provided by auxiliary personnel. What is proportional sampling? An auditing method which is based on high frequency items, or those which are considered to be proportionally significant. What is numerical sampling? Sampling based on all possible services within a chosen time frame. What is a utilization review? A technique that provides data about how frequently certain services are billed. Which procedures are exempt from modifier -51? To quickly determine if a procedure is modifier -51 exempt, refer to appendix E of the CPT book. What code combinations are NOT subject to multiple procedure payment reduction? Add-on codes are not subject to the multiple fee reduction. Examples of "DO NOT USE" list: U or u- instead write "unit" IU - instead write "international unit" QOD - instead write "every other day" Trailing 0 (X.0 mg) - instead write X mg 
