CDEO Chapter 3 Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download CDEO Chapter 3 Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! CDEO Chapter 3 Exam Questions with 100% Correct Answers | Verified | Updated 2024 Documentation states that the patient had a "Status post hysterectomy. The patient presents with a fever." Which of the following would be a compliant question to query? - Correct Answer-Do you know the cause of the fever? Operation Restore Trust - Correct Answer-3 offices were involved: OIG, Healthcare Financing Administration, AoA May 1995 Bill Clinton: 2 yr partnership of federal and state agencies, working together to protect the healthcare trust funds through shared intelligence coordinated enforcement, intended to enhance quality of care for program's beneficiaries. Program is not called Senior Medicare Patrol SMP They work to combat fraud and abuse. pg. 1 professoraxe l SMP - Correct Answer-Senior Medicare Patrol OIG - Correct Answer-Office of Inspector General AoA - Correct Answer-Administration on Aging FCA - Correct Answer-False Claims Act CMPL - Correct Answer-Civil Money Penalties Law CMS Definition of Fraud - Correct Answer-knowingly making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Definition of Abuse - Correct Answer-an action resulting in unnecessary costs to a federal healthcare program either directly or indirectly CMS Examples of Fraud - Correct Answer-Billing for Services/Supplies that you know were not furnished or provided pg. 2 professoraxe l Title 31 Statute's 7 Types of Conduct - Correct Answer-that brings liability FCA It states a person is liable who: A) Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; B) Knowingly makes , uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim Title 31 Statute's 7 Types of Conduct - Correct Answer-C) Conspires to a violation of subparagraph (A), (B), (E), (F), or (G); D) Has posession, custody, or control of property or money used, or to be used, by the government and knowingly delivers, or causes to be delivered , less than all of that money or property; Title 31 Statute's 7 Types of Conduct - Correct Answer-E) Is authorized to make or deliver a document certifying receipt of pg. 5 professoraxe l property used, or to be used, by the government, and intending to defraud the government, makes or delivers the receipt without completely knowing that the information on the receipt is true F) Knowingly buys or receives as a pledge of an obligation or debt, public property from an officer or employee of the government or a member of the Armed Forces, who lawfully may not sell or pledge property Title 31 Statute's 7 Types of Conduct - Correct Answer-G) Knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay to transmit money or property to the government FCA Fraud & Misconduct - Correct Answer--Falsifying a medical chart notation -Submitting claims for services not performed, not request, not necessary -Submitting claims for expired drugs -Upcoding and/or unbundling services pg. 6 professoraxe l -Submitting claims for physician services performed by a NPP without regard to incident to guidelines Reverse False Claims Section - Correct Answer-Section 3729a.I.G It provides liability where a person acts improperly to avoid paying money owed to the government. Requires the knowledge that it is false to be fraud. Section 3729b.1. - Correct Answer-Defines the terms Knowing and Knowingly such that a person must act in deliberate ignorance of the truth or falsity of the relevant information, or acts in reckless disregard of the truth or falsity of the information; however, the act states that a violation may occur even if there no intent to defraud The FCA is not violated merely by submitting a false claim, but rather by submitting or causing to be submitted a false claim with the knowledge that it is false. pg. 7 professoraxe l 5. Submitting claims for physician services performed by a non-physician provider NPP without regard to incident-to- guidelines Qui Tam : 3730 ss - Correct Answer-describes the civil actions for false claims. This is where this provision is described Qui Tam - Correct Answer-is an abbreviation from the latin "qui tam pro domino rege quam pro sic ipso in hoc parte sequitur" meaning who as well for the king as for himself sues in this matter Qui Tam actions were first used in 13th Center England, by citizens wishing to gain access to the king's court. The complainant received a monetary reward, called a "bounty" for bringing lawbreakers to justice. Because the US founding fathers retained English common law, Qui Tam was incorporated into many early American statutes. Qui Tam - Correct Answer-initiated and confirmed on November 22, 2010, when the Department of Justice released pg. 10 professoraxe l a statment on the record $2.5 billion health care fraud recoveries for fiscal year 2010. Of the $ total, in civil settlement and judgments for cases involving fraud against the government, over 2.3 billion was recovered in lawsuits filed under the FCA Qui Tam provisions. Qui Tam - Correct Answer-the FCA refers to the person bringing the Qui Tam as a relator, in the field the relator is more commonly referred to as a "whistleblower" NPP - Correct Answer-Non Physician Provider Physician Self-Referral Law - Correct Answer-Stark Law Bans Referrals to entities for a DHS DHS - Correct Answer-Designated Health Services Designated Health Services - Correct Answer-Clinical Laboratory Services Physical Therapy Services Occupational Therapy Services pg. 11 professoraxe l Radiology Services Radiation Services DME Equipment and Supplies Parenteral and enteral nutrients, equipment, and supplies Prosthetic and orthotic devices and supplies Home Health Services Outpatient Prescription Drugs Inpatient and outpatient hospital services Stark Law - Correct Answer-named after Peter Stark, prohibits physicians from referring patients to receive "designated health services" from entities with which the physician or an immediate family member has a financial relationship with, with a few exceptions. This law applies to services payable by Medicare or Medicaid *Proof specific intent to violate the law is not required. Penalties for physicians who violate the Stark Law include fines as well as exclusion from participation in the federal health care program pg. 12 professoraxe l -Patient abuse or neglect -Felony convictions for other health care related fraud, theft, or other financial misconduct -Felony convictions for unlawful manufacture, distribution, prescription or dispensing of controlled substances 42 U.S.C 1320a-7 - Correct Answer-The Exclusions Statute CoP/CfC - Correct Answer-Conditions of Participation and Conditions for Coverage Federal Register - Correct Answer-sets forth standards in Conditions of Participation and Conditions for Coverage that must be met to participate in Medicare and Medicaid programs. *Standards include guidelines for documentation and apply to both hospitals and ambulatory surgery centers *There are not CoPs specifically for providers, an auditor should understand the CoPs exist, and often define medical record standards for facilities pg. 15 professoraxe l 42 CFR ss482.24 - Correct Answer-outlines the CoP for medical record services *conditions include that each patient should have a medical record; medical records must be organized to allow for prompt completion, filing, and retrieval; record must be retained for at least 5 years; and, patient confidentiality should be protected Civil Monetary Penalties Law - Correct Answer-CMPL CMPL - Correct Answer-allows the OIG to seek civil monetary penalties do a wide variety of conduct CMPL - Correct Answer-the law states that any person in violation if he or she knowingly presents, or causes to be presented, a claim to any Federal or State agency that the Secretary determines Federal or State agency the Secretary may determine: - Correct Answer-* UP-CODING OR MISCODING is for a medical service or other item or service that the person KNOW or pg. 16 professoraxe l SHOULD KNOW was not provided as claimed, including any person who engages in a pattern or practice of representing or causing to be presented a claim for an item or service that is based on a code that the person knows or should know is applicable to the item or service actually provided Federal or State agency the Secretary may determine: - Correct Answer-* is for a medical or other item or service and the person KNOWS OR SHOULD KNOW the claim is false or fraudulent Federal or State agency the Secretary may determine: - Correct Answer-is presented for a physician's service, or the item or service incident to a physician's service, by a person who knows or should know that the individual who furnished or supervised the service was not a licensed physician, was a licensed a licensed physician but with a licensed obtained through a misrepresentation of material fact, or represented to the patient at the time the service was furnished that the physician was certified in a medical specialty y a medical health board when the individual was not so certified Federal or State agency the Secretary may determine: - Correct Answer-* is for a medical or other service that was furnished during a period in which the person was excluded pg. 17 professoraxe l 4) All records must document the following as appropriate i) Evidence of- A) A med hx and PE completed and doxd no more than 30 days before or 24 hours after admission or registration, but prior to surgery or procedure requiring anesthesia services. Med hx and PE must be placed in the pt's med record within 24 hours after admission or registration, but prior to surgery or procedure requiring anesthesia B) An updated exam of the pt, any changes in the pt's condition, when the med hx or PE are completed wi/30 days before admission or registration. Dox of the updated examination must be placed in the pt's med record wi/24 hours after admission or registration, but prior to surgery or procedure requiring anesthesia services. ii) Admitting Dx III) Results of all consultative evals of the pt and appropriate finding by clinical or other staff involved in the care of the pt iv) Dox'd complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia v) Properly executed informed consent forms for procedure and treatments specified by the medical staff, or by Federal or State law if applicable, to require written pt consent. pg. 20 professoraxe l vI) All practitioner's orders, nursing notes, report of treatment, medication records, radiology, and lab reports, and vital signs and other information necessary to monitor the pt's condition vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care viii) Final dx with completion of medical records wi/30 days following discharge E/M Guidelines - Correct Answer-1994 CMS published dx guidelines for E/M service to give direction on how to quantify each level of service, the type of service, and what dox was needed for each key component. 1997 CMS introduced a new dx guidelines for EM. These guidelines contained 10 organ-specific exams and general multi-system examination. (boxes, bullets, borders) Practitioners may use either guideline that fits differently assessed encounters. pg. 21 professoraxe l E/M Guidelines - Correct Answer-Either version of the documentation, not a combination of the 1995 or 1997 guideline for patient encounter. HPI - Correct Answer-1995 Elements 1997 Elements or Status of 3 Chronic or Inactive Conditions Exmination - Correct Answer-Problem Focused - a limited eaminatin of the affected body area or organ system; *Expanded Problem Focused- A LIMITED examination of the affected body area or organ system an any other symptomatic or related body areas or organ systems *Detailed - An EXTENDED examination of the affected body area or organ system an any other symptomatic or related body areas or organ systems *Comprehensive - A general multi-system examination or complete examination of a single organ system and other symptomatic or related body areas or organ systems -1997 dox guidelines pg. 22 professoraxe l * Coding Guidelines developed by national medical societies * Local and National Coverage Determinations; and * Review of Current Coding Practices NCCI Edits - Correct Answer-Used to determine bundling practices for NCCI edits RACS Audit - Correct Answer-CMS Approved Issues Examples include: Hydration Therapy- RAC - Correct Answer-Recovery Audit Contractors RACs - Correct Answer-are responsible for identifying over- payments or underpayments in approximately of the 1/4 of the country CMS requires RACS list CMS approved issues that may trigger an auditor review pg. 25 professoraxe l Example: Hydration Therapy: billing therapy with dx that do not fall within the dx approved under the local determination Add_On Codes: to ensure claims are not being over-payed for add on codes when the required primary procedure was not reported or not paid Chest X-Rays: To determine medical necessity Bronchoscopy: Should only be one unit of service per DOS per patient billed NCCI Policy Manual - Correct Answer-Chapter 1- gives introduction to the NCCI as well as standards and rationale for the code edits Ex: "If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement, incision drainage) is not separately reportable. For example, pg. 26 professoraxe l debridement of skin to repair a fx is not separately reportable." NCCI Policy Manual - Correct Answer-will also find instruction for proper use of codes and code pairs MUE - Correct Answer-edits based on units of service Lower the Medicare Fee-For-Service Paid Claims Error Rate Define maximum units of service that a provider would report: *under most cirumstances *for a single beneficiary *one a single date of service *for a specific HCPCS/CPT code * April 1, 2013 - MUEs are adjudicated either as a claim line edits or date of service edits pg. 27 professoraxe l OIG has identified seven elements - Correct Answer-1- Implementing written policies, procedures and standards of conduct; 2-Designating a compliance officer and/or compliance committee; 3-Conducting effective training and education; 4-Developing effective lines of communication; 5-Enforcing standards through well-publicized disciplinary guidelines; 6-Conducting internal monitoring and auditing; and 7-Responding promptly to detected offenses and developing corrective action What is the definition of abuse? - Correct Answer-an action that results in unnecessary costs to a Federal health care program, either directly or indirectly When a physician is banned from participating in any Federal or State health care program by the OIG under the Exclusion Statute (42 U.S.C. § 1320a-7), what is the minimum term of exclusion that can be applied? - Correct Answer-Five years pg. 30 professoraxe l When non-compliance is identified, what does the OIG recommended? - Correct Answer-Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes? - Correct Answer-15-25 percent of the money recovered According to documentation, the patient has COPD, hypertension, and CKD, and is hospitalized with a fever of 40 C. The first-listed diagnosis in the discharge summary is ARF. The query most pertinent to coding would ask: - Correct Answer-What does the acronym ARF in your documentation represent? This chart cannot be completed until the coder knows the intended meaning of ARF, commonly used to abbreviate acute respiratory failure or acute renal failure. For this patient with COPD, hypertension, and CKD, either meaning might be appropriate. A query is required before coding of this chart can be completed. pg. 31 professoraxe l The OIG Work Plan is divided into seven parts. Which option is a part of the OIG Work Plan most applicable to physician services? - Correct Answer-Medicare Part A and Part B A query may be posed for which of the following reasons? I. To improve the CPT payment II. To clarify the reason for an order for physical therapy III. To allow the coder to clarify the correct ICD-10-CM code to be reported IV. To clarify if a patient has a manifestation of a chronic illness V. To keep compliant documentation a priority for the provider VI. To resolve obscure documentation - Correct Answer-It is inappropriate to query a provider to improve reimbursement. This may be the result of the query, but the goal of a query pg. 32 professoraxe l