CPMA Question & Answers ( verified solution ) 2024, Exams of Nursing

Download CPMA Question & Answers ( verified solution ) 2024 and more Exams Nursing in PDF only on Docsity! CPMA Question & Answers ( verified solution ) 2024 The Joint Commission (JC) requires the Factors that Affect Learning must be assessed for a hospital or hospital owned physician practice as well as other health care facilities. When assessing this element what does this include? A. The patient's ability to read, method of learning and understanding. B. Any language or physical disabilities. C. Cultural beliefs. D. All the above - Correct Answers ✅D. All the above Report copies and printouts, films, scans, and other radio logic service image records must be retained for how long according to Federal Regulations? A. 10 years B. 7 years C. 5 years D. 3 years - Correct Answers ✅C. 5 years CPMA Question & Answers ( verified solution ) 2024 At which point should a provider repay over payments reported by self- disclosure to the office of Inspector General? A. Make the payment to your carrier immediately. B. Make the payment at the conclusion of the OIG injury. C. Make the payment to the carrier prior to the self disclosure. D. Make the payment to the OIG with a self disclosure report. - Correct Answers ✅B. Make the payment at the conclusion of the OIG injury Which of the following may be considered essential element (s) of an operative report and will allow for accurate coding? A. The approach B. The type of anesthesia required C. The location and severity of wounds repaired D. All of the above - Correct Answers ✅D. All of the above Which of the following is NOT a covered entity under HIPPA? CPMA Question & Answers ( verified solution ) 2024 When using LCDs and CMS program Guidance as a resource for an audit, what should the auditor keep in mind? A. QICs are bound by NCDs, LMRPs, and CMS Program guidance, but ALJs and MACs are not. B. Local carriers and QICs are bound by LCDs and LMRPs C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. D. Local Carriers, QICs, ALJs, and MACs are all bound by NCDs and CMS program guidance. - Correct Answers ✅C. Local carries follow LCDs, LMRPs, and CMS program guidance, but QICs, ALJs, and MACs are not bound by them. When reporting the claims review findings under a CIA audit, the Independent Review Organization (IRO) must provide: A. A detailed analysis listing the patient files reviewed and findings and previous audit disclosures for all services CPMA Question & Answers ( verified solution ) 2024 B. A detailed report with a narrative explanation of finding and supporting rationale approved by the providers attorney. C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. D. A list of data reviewed and findings in a narrative form - Correct Answers ✅C. A detailed report with an analysis and narrative explanation with findings and supporting rationale regarding the claim review, including the results of the discovery or full sample. Which statement is most accurate regarding NCCI? A. NCCI are national coding guidelines and must be followed regardless of the insurance carrier. B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. C. Each individual carrier will have its own bundling edits and will not use NCCI. CPMA Question & Answers ( verified solution ) 2024 D. NCCI edits are suggested ways to bundle procedure codes, but are not necessary to review during an audit. - Correct Answers ✅B. You need to check individual carriers to see if they follow NCCI or if they have their own set of bundling edits. A provider request you to perform an audit of claims that have been denied payment by XYZ insurance. Since the physician contracted with XYZ insurance, all claims submitted that include the E/M service and EKG interpretation on the same day have been denied for the EKG interpretation. You review the medical record and the EOB and determine the services are documented and coded correctly. Which of the following items will you need to complete your audit? A. Provider contract with XYZ insurance. B. Provider internal billing polices. C. RAC statement of work D. OIG work plan for the current year. - Correct Answers ✅A. Provider contract with XYZ insurance. CPMA Question & Answers ( verified solution ) 2024 A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. B. A patient who is recovering from abdominal surgery who requires observation until awake from anesthesia. C. A patient who is receiving infusion chemotherapy for the first time and is anxious about that procedure D. A patient who is dependent on a ventilator and requires pulse oximetry to monitor 02 staturation - Correct Answers ✅A. A patient with severe asthma exacerbation who requires repeated nebulizer treatments and ABGs. When may a focused audit be initiated? A. After a prepayment or retrospective audit has identified a specific problem B. When the auditor first decides to conduct an audit C. To compare coding and billing patterns for the entire practice CPMA Question & Answers ( verified solution ) 2024 D. To ensure compliance with all coding guidelines - Correct Answers ✅A. After a prepayment or retrospective audit has identified a specific problem Which of the following represents the most logical initial step in the audit process? A. Develop an audit tool and tally form B. Determine the objective(s), the type, and the scope of the audit C. Gather the medical records to be audited. D. Analyze the audit and compare the documentation to the procedure and diagnosis code(s) billed. - Correct Answers ✅B. Determine the objective(s), the type, and the scope of the audit What are the the Seven Elements defined by the OIG? - Correct Answers ✅The Seven Elements defined by the OIG are: 1. Implementing written policies and procedures 2. Designating a compliance officer and compliance committee CPMA Question & Answers ( verified solution ) 2024 3. Conducting effective training and education 4. Developing effective lines of communication 5. Conducting internal monitoring and auditing 6. Enforcing standards through well-publicized disciplinary guidelines 7. Responding promptly to detected problems and undertaking corrective action The office of Inspector General (OIG) - Correct Answers ✅The mission of the Office of Inspector General is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs Fraud - Correct Answers ✅Fraud is an intention deception made for personal gain. Fraud is a crime and a civil law violation Abuse - Correct Answers ✅Abuse is an act that directly or indirectly results in unnecessary reimbursement without defined intent. CPMA Question & Answers ( verified solution ) 2024 funded health plans as well as commercial carriers. Violations are felonies and are punishable by up to five years imprisonment and/or $25,000 in fines. The Civil Monetary Penalties Law: - Correct Answers ✅Provides for the imposition of civil monetary penalties up to $10,000 per false service claimed, plus assessments equal to three times the amount claimed, for services that the provider knows or should know were not provided as claimed or for claims the provider knows or should know are false or fraudulent. Other federal criminal laws: - Correct Answers ✅Also may be used to prosecute the submission of false claims, including prohibitions on making false statements to the government and engaging in mail fraud. Felony convictions will result in exclusion from Medicare for a minimum of a five-year period. CPMA Question & Answers ( verified solution ) 2024 Option for Providers - Correct Answers ✅Self Disclosure: Fines may be less if a practice self-disclosed its knowledge of the violation. Appeal Rights: A practice has the right to an appeal process, and may choose to request a hearing before an administration law judge (ALJ). The OIG and the respondent have the right to present evidence and make arguments to the ALJ, who issues a written decision. Additional Appeal: The ALJ's decision may be appealed administratively and to federal court. OIG Work Plan - Correct Answers ✅OIG Work Plan The OIG Work Plan is released annually and identifies priority areas for OIG review/ investigation, which the agency believes are HHS' most vulnerable programs and activities, with the goal to improve HHS agency efficiency and CPMA Question & Answers ( verified solution ) 2024 effectiveness Corporate Integrity Agreement (CIA) What is a Corporate Integrity Agreement? - Correct Answers ✅It is an agreement between the OIG and a health care provider or other entity. CIA agreements are detailed and restrictive agreements imposed on providers when serious misconduct (fraudulent or abusive type action) is discovered through an audit or self-disclosure. The government may enter into a CIA with an entity instead of seeking to exclude the entity from Medicare, Medicaid, and other federal health care programs. The typical term of a comprehensive CIA is five years Discovery Sample - Correct Answers ✅The claims review procedures require a Discovery Sample. A Discovery Sample is used to determine the financial error rate. The Discovery Sample is a review of 50 units to be randomly selected. CPMA Question & Answers ( verified solution ) 2024 providers is exempt as well. The exceptions to the Stark Law covered relationships internal to a physician group include items such as those involving in-office ancillary services or certain compensation/ownership arrangements. The Joint Commission - Correct Answers ✅The Joint Commission (JC), formerly the Joint Commission on Accreditation of Health Care Organizations (better known as JCAHO), is a private sector United States-based, not-for-profit organization. The Joint Commission operates voluntary accreditation programs for hospitals and other health care organizations. RAC Audits CMS Recovery Audit Contractor (RAC) Program - Correct Answers ✅CMS has implemented a system to identify improper payments, fraud, and abuse in the Medicare system. CPMA Question & Answers ( verified solution ) 2024 When should a Self disclosure occur? - Correct Answers ✅Self disclosure should occur within 30 days of knowing about the violation, and does not require any form of legal assistance. Payments relating to the disclosed matter should not be made until the conclusion of the OIG inquiry to allow the OIG time to verify the information disclosed How often are records requested from RAC auditors and how many? - Correct Answers ✅Each 45 days, records may be requested based on the entity's size: less than 5 providers—10 records 6-24 providers—25 records 25-49 providers—40 records 50 or more providers—50 records CPMA Question & Answers ( verified solution ) 2024 RAC Audit Appeals Process - Correct Answers ✅Providers who choose to appeal must send a rebuttal of the findings directly to the RAC within 15 days of receiving the RAC's letter identifying an overpayment. Note, however, this does not stop the clock on the 120 day time period during which a request for redetermination (first level appeal) from the Medicare contractor must be submitted. Additionally, the clock is still running with regard to the interest accrued when money is not refunded within 30 days of the request. Providers who choose to send a rebuttal to the RAC will want to either simultaneously file a request for redetermination to the Medicare contractor or carefully track the status of the rebuttal and be prepared to file the request for redetermination within the 120-day time period, if needed. Medicaid appeals processes will vary from state to state as well as Medicare Advantage appeals will vary by MCO CPMA Question & Answers ( verified solution ) 2024 CoPs and CfCs apply to the following health care organizations: - Correct Answers ✅Ambulatory Surgical Centers (ASCs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Critical Access Hospitals (CAHs) End-Stage Renal Disease Facilities Federally Qualified Health Centers Home Health Agencies Hospices Hospitals Hospital Swing Beds Intermediate Care Facilities for Persons with Mental Retardation(ICF/MR) Organ Procurement Organizations (OPOs) Portable X-Ray Suppliers Programs for All-Inclusive Care for the Elderly Organizations (PACE) Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient CPMA Question & Answers ( verified solution ) 2024 Physical Therapy and Speech-Language Pathology Services Psychiatric Hospitals Religious Nonmedical Health Care Institutions Rural Health Clinics Long Term Care Facilities Transplant Centers Medical Record should include - Correct Answers ✅Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results Assessment, clinical impression, or diagnosis Medical plan of care Date and legible identity of the observer If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. CPMA Question & Answers ( verified solution ) 2024 Past and present diagnoses should be accessible to the treating and/or consulting provider. Appropriate health risk factors should be identified The patient's progress, response to, changes in treatment, and revision of diagnosis should be documented. Current CPT® and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Record Retention - Correct Answers ✅According the CMS Conditions of Participation (CoP), providers and facilities such as Ambulatory Surgery Centers, Critical Access Hospitals, Skilled CPMA Question & Answers ( verified solution ) 2024 services normally covered by Medicare but which in a particular circumstance the provider believes will not be covered for lack of medical necessity, exceeding treatment options, or other reason. GA Modifier - Correct Answers ✅To properly notify Medicare an ABN has been signed appropriately by a Medicare beneficiary. The GA modifier is used when an item or service is expected to be denied as not reasonable or necessary for the patient and/or their current condition. When the modifier is used appropriately, Medicare will process the claim and if denied will apply the balance to the patient responsibility. If the GA modifier is not used, the claim will not be applied to patient responsibility. GX modifier - Correct Answers ✅Notice of liability issued, voluntary under payer policy. Use of this modifier indicates the services delivered are excluded from Medicare coverage by statute, and the charge is being filed on the patient's behalf. In this CPMA Question & Answers ( verified solution ) 2024 case, the service is filed to Medicare to obtain a denial, usually for a secondary insurance. The GX modifier should not be used on any services covered by Medicare GY modifier - Correct Answers ✅is used for items statutorily excluded from Medicare reimbursement. The use of the GY modifier will cause the claim automatic denial. Often these services are billed by the provider to obtain the Medicare denial for the secondary insurance purposes. GZ modifier - Correct Answers ✅is a modifier that reports to Medicare that the service may not meet medical necessity guidelines, and an ABN was NOT obtained from the patient. The GZ modifier will result in automatic claim denial Health Insurance Portability CPMA Question & Answers ( verified solution ) 2024 and Accountability Act (HIPAA) - Correct Answers ✅HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996. Title I, the first rule under HIPAA, addresses portability of insurance when employees change jobs. It regulates the availability and breadth of group health plans and some limited individual health insurance policies. State law takes precedence to HIPAA policy only when the state law is more restrictive in nature. HIPAA rules apply to "covered entities:" - Correct Answers ✅Health plans Health care clearinghouses Health care providers who conduct certain financial and administrative transactions electronically. Business Associates Agreement - Correct Answers ✅—This document spells out the requirements for business associates to disclose protected health information (PHI) CPMA Question & Answers ( verified solution ) 2024 become subject to enforcement inspections, and even to some extent monitor the covered entities with which they have the BA relationship. This means not only must covered entities monitor their business associates, but business associates also have the responsibility of monitoring covered entities with which they have a BAA. If there is a breach of PHI, covered entities and BAs must: - Correct Answers ✅Notify HHS and major media outlets if the breach involves 500 or more participants. Notify affected individuals in writing within 60 days of becoming aware of the breach. Provide in the notice to individuals at least five specific categories of information. Send a notice by first-class mail to each affected individual's last known address. If the address available is no longer applicable, the covered entity may use an alternate method such as e-mail. If there are at least 10 individuals whose PHI has been CPMA Question & Answers ( verified solution ) 2024 breached and no current address is available, the notice of the breach must be posted on the covered entity's website. Anesthesia Documentation - Correct Answers ✅Anesthesia codes are selected based on the site of surgery and in some cases the type of surgery. Anesthesia services are reimbursed based on the anesthesia code and the total units billed. On the CPMA exam, 1 unit of time is equal to 15 minutes. The calculation used to determine the total units is Base Units + Time Units + Modifying Units (BTM). The units are then multiple by the anesthesia conversion factor. The anesthesia report MUST include the anesthesia start and stop times as well as any time the anesthesia provider is not in attendance for the case. The time involved providing services such as insertion of central lines, arterial lines, and postoperative pain blocks prior to anesthesia is not included in the total anesthesia time. CPMA Question & Answers ( verified solution ) 2024 The physical status modifiers are: - Correct Answers ✅P1: A normal, healthy patient P2: A patient with mild systemic disease P3: A patient with severe systemic disease P4: A patient with severe systemic disease with a constant threat to life P5: A moribund patient who is not expected to survive without the operation P6: A declared brain-dead patient whose organs are being removed for donor purposes Anesthesia Modifiers - Correct Answers ✅AA: Anesthesia performed personally by anesthesiologist QK: Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals QS: Monitored anesthesia care service QX: CRNA service, with medical direction by a physician QY: Medical direction of one certified CPMA Question & Answers ( verified solution ) 2024 modifier 22. Services that are merely utilizing a new technique or new equipment would not support the utilization of this modifier. Modifier 24: - Correct Answers ✅This E/M modifier would be appended to E/M services provided during the global surgical period that are not routine postoperative care and are additionally reimbursable. The documentation of this type of an encounter should include components that support why the encounter was not a routine service related to the surgical encounter Modifier 51: - Correct Answers ✅The multiple procedures modifier indicates more than one stand alone procedure was performed during an operative session and the procedures were related or performed in correlation with one another. The documentation would simply need to include the details of the procedures CPMA Question & Answers ( verified solution ) 2024 Modifier 52 - Correct Answers ✅Reduced services should be reported when all components of a billable CPT® code were not performed and the service was not fully delivered according to the description. The documentation should be inclusive of the service performed and any impending reasons why the full procedure was not performed during the surgical encounter. Modifier 58: - Correct Answers ✅Staged procedures are performed when a provider is planning to do a procedure in multiple sessions. The best example of staged services in separate encounters would be skin grafts when a provider performs the first graft and he or she may be unsure if another graft will be required. Another example within the same session would be a procedure that begins as a diagnostic procedure but leads to an CPMA Question & Answers ( verified solution ) 2024 open procedural service. The documentation does not have to specifically reflect the next procedure or the date of it, but should indicate that additional services may be forthcoming. Modifier 59 - Correct Answers ✅Distinct procedural services modifier is used when the services provided were for separately specified reasons or sites of service. This modifier is an unbundling modifier and is used in instances when the procedures are typically inclusive of one another but for documented reasons should be reimbursed (eg, separate sessions or anatomic locations). The documentation should be inclusive for either the specified reason and/or the specific anatomical sites of service Modifier 78 - Correct Answers ✅This modifier is used when a provider performs a surgical service CPMA Question & Answers ( verified solution ) 2024 the specific anatomic site of service would need to be included.The number of views: Determines the code reported for the service. This affects the reimbursement of the service, and must be documented within the radiology report. The finding of the radiological encounter: Affects the diagnosis codes reported. Radiation Therapy - Correct Answers ✅Clinical Treatment Planning: This service is billable regardless of the radiation treatment performed for the patient. There are three coding choices for the planning event: simple, intermediate, and complex. Based on the documentation of the planning session, the auditor should be able to differentiate these levels by the following guidelines: Simple Planning: A session that requires no interpretation of test for the appropriate planning for therapy. Intermediate Planning: A session that CPMA Question & Answers ( verified solution ) 2024 requires a level of interpretation and analysis of the provider to develop a plan for the patient's treatment. The planning is considered to be of moderate difficulty. Complex Planning: This session requires the provider's expertise for complex interpretation and planning for therapy. Complex planning may include CT and MR localization, special lab testing, special planning and mapping to protect the normal structures and it includes three or more areas that require treatment. Treatment Parameters and Development - Correct Answers ✅The treatment parameters are established through simulation and dosimetry. Simulation sets the radiation therapy treatment target area, and dosimetry is the calculation of how much (eg, dose of radiation) to be delivered to the tumor. These codes vary based on the complexity of the treatment. CPMA Question & Answers ( verified solution ) 2024 Simulation: Simple: A single area that generally only requires one to two films Intermediate: Involves three or more areas that direct to one or two treatment areas, and require two or more films of each area with or without fluoroscopy. Complex: Performed for three or more areas of malignancy with tangential ports and complex blocking and require additional complex verifications and testing. Additionally, simulation that requires contrast material will also meet the criteria of complex setting. Dosimetry: Basic Dosimetry: May be used any time during the course of therapy when calculation of dosage is needed Treatment Management - Correct Answers ✅Radiation treatment is billed in units of five CPMA Question & Answers ( verified solution ) 2024 Documentation is required to support the medical necessity of laboratory testing, such as an ICD-9-CM code. There must be an attending/treating provider's order for each test documented in the patient's medical record. Tests performed without a supporting order should be deemed as non-billable. If the ordering provider submits an ICD-9-CM code, the laboratory must use that code unless there is a reason to question the ordering provider to change the code. The laboratory must receive and maintain the documentation to alter the claim. Some tests are Qualitative and others are Quantitative. Qualitative tells if the substance is present or absent. Quantitative tells the amount of substance present. If a drug is present (qualitative), then how much is present in the body (quantitative) is determined. CPMA Question & Answers ( verified solution ) 2024 An encounter form is not an acceptable "order" for lab services. Psychiatric Services - Correct Answers ✅Most psychiatric services are billed based on the amount of time spent with the patient. Time becomes a crucial requirement of psychiatric documentation. Additional documentation requirements are discussed below. Interactive Complexity Interactive complexity is an add on code reported for patients who communication factors complicate the delivery of psychiatric services. This code can not be reported with E/M codes. The only appropriate base codes are listed in a parenthetical note following code 90785. Psychiatric Diagnostic Interview Codes 90791-90792 are for the diagnostic evaluation of a patient and are services every psychiatric provider will likely use. This is one of the few psychiatric services that is not time-based. The code selection is based on whether medical CPMA Question & Answers ( verified solution ) 2024 services were also performed. There are, however, some specific rules that apply to this service: May be provided by Physician, Clinical Psychologist (CP), or Licensed Clinical Social Workers (LCSW) Code may be reimbursable if other family, friends, health care advisors, or other informant are seen in lieu of the patient. May only bill once per diagnosis onset. If there is a hiatus from illness and the patient is later re-admitted, billing may be approved. In this instance, the documentation of the encounter should not begin as, "the patient is here for a follow-up of..." Ophthalmological Services - Correct Answers ✅Intermediate Ophthalmology Service should be billed for a patient with a new or existing problem complicated with a new diagnostic or management problem. Codes 92002 (new patient) and 92012 (established patient). CPMA Question & Answers ( verified solution ) 2024 flush at conclusion, standard supplies, and preparation of chemotherapy agent. Hydration is typically included in chemotherapy and therapeutic infusions, unless it is called for additionally in the protocol. Two medications running through one bag/ one line are reported with one infusion administration code, not two. This is typically reported as a piggy back service or IVPB (intravenous piggy back). It is appropriate to code for each drug separately. A port flush provided with an E/M encounter additionally is billable; however, a port flush with a nursing encounter are not both supported as separate services Physical Therapy Services - Correct Answers ✅The therapist should document: The total time or the beginning and ending time for each session defined by a timed code, and CPMA Question & Answers ( verified solution ) 2024 The total time in which the patient is involved in services defined by untimed codes and unattended codes. Time spent performing each individual physical therapy technique such as manual therapy, electrical stimulation, etc. Each component utilized for an individual technique must be documented. For example, if 20 leg presses were performed as part of manual therapy, the leg presses should be documented and "labeled" as manual therapy. Treatment Documentation - Correct Answers ✅Initial Physical Therapy Evaluation Documentation (97001)—Guidelines for the Initial Evaluation are very clear on what must be included. The medical necessity must be substantiated by including the diagnoses for the services needed and the requesting provider. Each of the additional requirements is discussed below. Past Medical History—Should be obtained on CPMA Question & Answers ( verified solution ) 2024 elements that influence the Physical Therapy treatment rendered. The documentation should also include the diagnosis, information regarding the patient's functional status prior to the onset of the condition as well as the current functional status, how long the problem has existed, and any pertinent prior physical therapy treatment information. Examination—There are no specific guidelines as to how much examination information must be contained within the medical record, but examination documentation is a required component. Plan of Care Required components of a plan of care include: Plan of treatment including long-term goals Frequency and duration of treatment Diagnoses Specific modalities to be employed Rehab potential Additional optional components of a plan of care CPMA Question & Answers ( verified solution ) 2024 the visit or the next day. Surgical packages include preoperative, surgery, and postoperative services; however, sometimes surgical decisions are made during an E/M visit that requires immediate surgical intervention. Common encounter structure formats may follow the SOAP or CHEDDAR formats. - Correct Answers ✅These formats present the elements in the following style: SOAP SOAP notes refer to a particular format of recording information regarding the treatment process. S = Subjective O = Objective A = Assessment P = Plan CHEDDAR C = Chief complaint, presenting problems, subjective statements H = History; social and physical history of CPMA Question & Answers ( verified solution ) 2024 presenting problem as well as contributing information E = Examination, including extent of body system(s) examined D = Details of problem and complaints, etc. D = Drugs and dosage—a list of current medications used with dosage and frequency, etc. A = Assessment of observations, etc. R = Return visit information incident-to Auditing Rules - Correct Answers ✅Incident-to charts should first be identified and separated from other charts being audited. A chart is identified as being an incident-to service when the provider on the CMS-1500 claim form differs from the provider on the medical record. Physicians cannot bill incident-to other physicians. split/shared - Correct Answers ✅Split/ shared visits in the hospital setting do not require CPMA Question & Answers ( verified solution ) 2024 incident-to rules Compliance Audits: - Correct Answers ✅These audits are performed strictly in an effort to evaluate the provider's compliance with documentation rules and guidelines. These audits may be performed by an internal compliance team or outsourced to a third party auditor. These audits tend to focus only on the documentation content as it compares to the necessary rules and guidelines. There are many different compliance audits that could be performed and are performed for various reasons; the most common being pre- and postpayment audits. Audits are typically performed by the practice, a third party consultant, health plan, or government agency. A clear understanding of the types of audits is imperative Prepayment (prospective) Audit - Correct Answers ✅This CPMA Question & Answers ( verified solution ) 2024 most commonly through the production/ utilization report. The audit may focus on a particular service that is being over- or underutilized by the provider. This audit process should not always be the type of audit performed because a more across-the-board audit should be the standard audit approach. A focused audit should be performed when a provider is suspected of not appropriately using a particular service code. A baseline audit typically includes - Correct Answers ✅10-15 records per provider as recommended by the OIG There should be three notations of each performed audit: - Correct Answers ✅Services billed Documentation level of the services billed Medical necessity level of the services billed It is important that every encounter be scored and reported based on documentation content as well CPMA Question & Answers ( verified solution ) 2024 as the medical necessity of the service. For compliance reasons, be sure the summarization for the compliance plan includes the following information: - Correct Answers ✅Date of the audit Who requested the audit How many records were reviewed Which providers were audited A statement indicating a detailed report has been provided to each provider audited A statement indicating a one-on-one or group session was provided for each provider audited to review the findings A concise overview of the findings A statement regarding intended or needed follow up to be performed to adhere to the necessary compliance components Identification of the auditor performing the service Once the audit has been performed and all CPMA Question & Answers ( verified solution ) 2024 deficiencies have been reported and reviewed, a plan for corrective action should be implemented. The corrective action should include: - Correct Answers ✅Review with each provider regarding the findings to include appropriate actions to correct going forward. Review with the compliance officer to ensure he or she has an understanding of the level of compliance the audit identifies. Education for the provider(s) and all appropriate billing/coding/nursing staff regarding the deficiencies noted in the audit, the guidelines, and necessary requirements to meet or exceed compliance in the future. Develop, implement and then educate forthcoming policies relevant to the findings of the audit. Make restitution with any carrier for services that are not billed appropriately. Failure to reimburse a carrier for services billed inappropriately could be interpreted as fraud.