COC Chapter 5 review
An anesthesiologist is directing a resident who is providing anesthesia for an appendectomy (00840). The anesthesiologist reports
00840-AA-GC Rationale: The teaching anesthesiologist reports the AA modifier and GC modifier to report the case. The anesthesia provider modifier is always listed first, followed by GC to indicate the service was provided by a resident under the direction of a teaching physician. Modifier AA denotes anesthesia services performed personally by the anesthesiologist.
Medicare was enacted in:
1965 Rationale: Medicare was enacted in 1965.
What is Medicare's definition of a teaching hospital?
A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry Rationale: A teaching hospital is a hospital that is engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry.
What is the Freedom of Information Act (FOIA)?
A law that requires government to give out certain information to the public when it receives a written request. Rationale: The Freedom of Information Act (FOIA) is a law that requires the US government to give out certain information to the public when it receives a written request. FOIA applies only to records of the executive branch of the federal government, not to those of the congress or federal courts, and does not apply to state governments, local governments, or private groups.
IME payments are based on:
Additional costs to the facility associated with having a teaching program, such as lower productivity, more tests, etc. Rationale: IME partially compensates for higher care costs due to the presence of a teaching program such as lower productivity, more tests, etc. DGME partially compensates for residency education costs which include residents' stipends and fringe benefits, salaries and fringe benefits of the supervising faculty, other direct costs, and additional allocated overhead costs.
What healthcare regulation established privacy regulations?
Administration Simplification
The False Claims Act is also known as the:
All the above: Lincoln Act,Qui Tam statute,Informers Act Rationale: The federal False Claims Act is also known as the Lincoln Act, Informers Act, or the Qui Tam Statute. It allows a private individual or whistleblower with knowledge of any type of past or present government fraud to sue on behalf of the government to recover civil penalties, and damages.
HITECH:
Allows patients to request an audit trail showing all disclosures of their health information made through an electronic record. Rationale: HITECH allows patients to request an audit trail showing all disclosures of their health information made through an electronic record. Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information. HITECH requires an individual be notified if there is an unauthorized disclosure or use of his or her health information. HITECH provides a 30-day window during which any violation not due to willful neglect may be corrected without penalty.
What is the purpose of the Operation Restore Trust program?
An effort to restore integrity in the Medicare program and to find and stop fraud and waste in the Medicare and Medicaid programs.
How are teaching hospitals typically reimbursed
Based on a reasonable cost basis
A compliance officer for a facility will NOT:
Be an elected official. Rationale: A compliance officer will not be an elected official. The compliance officer or compliance committee will be appointed by the CEO or governing body of the facility.
What are excepted benefits?
Benefits that are offered separately and are not part of the health care plan, such as limited-scope dental or vision. In addition, benefits that are not considered health coverage such as accident only, disability insurance, and Workers' Compensation. Rationale: Excepted benefits are benefits that are not considered in health coverage such as: Accident only; Disability Income Insurance; Workers' Compensation. It also includes dental and vision. Excepted benefits are treated as a separate insurance policy and supplemental to Medicare or group health insurance.
Which statement is true regarding Clinical Laboratory Improvement Amendments (CLIA)?
CLIA regulations apply to laboratory testing in all settings. Rationale: CLIA regulations apply to laboratory testing in all settings including commercial, hospital, and physician office laboratories. CLIA standards are national and are not Medicare-exclusive. CLIA applies to all providers rendering clinical laboratory services, regardless of whether Medicare claims are filed.
Which is the correct statement regarding AAPC members per AAPC's Code of Ethics?
Conduct themselves in all professional activities in a manner consistent with ethical principles of professional conduct. - Rationale It shall be the responsibility of every AAPC member, as a condition of continued membership, to conduct themselves in all professional activities in a manner consistent with ALL of the following ethical principles of professional conduct: Integrity Respect Commitment Competence Fairness Responsibility
The OIG Work Plan is targeting payments for acute care hospitals to:
Determine the hospitals' compliance with selected billing requirements. Rationale: The OIG Work Plan is targeting acute care hospitals to determine hospitals' compliance with selected billing requirements and recommend recovery of overpayments.
Title II of HIPAA known as Administration and Simplification addresses:
Electronic standards for health care transactions and the code sets that can be used. Rationale: HIPAA is a five-part act. Title II of HIPAA is known as Administrative Simplification, which addresses national standards for the electronic transfer of health care information and the code sets used for electronic transfer. It also provided for national unique identifiers for providers, health plans and employers. The Kennedy-Kassebaum Law is also known as Title 1 of the Health Insurance Portability and Accountability Act of 1966, which protects health insurance coverage for workers and their families when they change or lose their jobs.
The Privacy Rule prohibits use or disclosure of any request of an entire medical record.
False - Rationale Only the minimum protected information required to do the job should be shared. If the entire medical record is necessary, the covered entity's policies and procedures must also state so explicitly and include a justification. In addition, under the Privacy Rule, the minimum necessary standard does not apply to the following: Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information. Uses or disclosures made pursuant to an individual's authorization. Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules. Disclosures to the U. S. Department of Health & Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes. Uses or disclosures that are required by other law.
Is the following statement True or False and why? A physician's countersignature is the only Medicare requirement for payment of diagnostic radiology services interpreted by a resident.
False; Medicare requires the teaching physician to document he has personally reviewed the image and agrees with or edits the findings. Rationale: When a resident prepares and signs the interpretation of a diagnostic test, Medicare requires the teaching physician to indicate that he has personally reviewed the image and agrees with or edits the findings.
The primary care exception rule allows billing by the teaching physician:
For low- and mid-level E/M services provided by residents whereby the teaching physician is not required to see the patient. - Rationale The primary care exception allows the teaching physician to bill Medicare for low- to mid-level E/M services, the Medicare IPPE, the initial AWV, and annual AWVs performed by residents. The teaching physicians submitting claims under this exception may not supervise more than four residents at any given time and must be immediately available. The teaching physician must not have any other responsibilities at the time service is provided and must review the care provided by the resident during or immediately after each visit, such as review of the patient's history, resident's findings, and treatment plan. The teaching physician must document the extent of participation in the review and the direction of the services furnished to each patient. The teaching physician is not required to see the patient.
Which act limits access to the patient's medical record and ensures patient confidentiality?
HIPAA Rationale: Health Insurance Portability & Accountability Act (HIPAA) specifies requirements for privacy, which limits access to the patient's medical record and ensures patient confidentiality.
Providers can be excluded from participation in Medicare or Medicaid for:
Health care fraud and controlled substance abuse. Rationale: HIPAA applied provisions for mandatory exclusion from participation in Medicare or Medicaid for any individual convicted of health care fraud or controlled substance abuse.
Medical student documentation is limited to:
History, exam, and medical decision making when the documentation is not signed and reviewed by the teaching physician.
Which practice might be considered a violation of the federal Anti-Kickback Statute?
Hospital incentives to physicians Rationale: The federal Anti-Kickback Statute prohibits anyone (a person or corporate entity) from intentionally soliciting or receiving remuneration (anything of value such as bribes, rebates, cash, etc.), directly or indirectly, to get patient referrals and additional business reimbursed under federal health care programs like Medicare and Medicaid. The OIG periodically publishes a "fraud alert" that describes the types of questionable practices that could be considered anti-kickback. Some of the alerts have included: Prescription drug marketing schemes Lab pricing arrangements, provision of phlebotomy services to physicians and other similar arrangements Routine waiver of co-payments or deductibles under Medicare Part B
Which code sets are designated for standard use by HIPAA?I. APCII. CDT®III. CPT®IV. DRGV. HCPCS Level IIVI. ICD-10-CMVII. NDCVIII. SNOMED CT®
II, III, V, VI, VII Rationale: HIPAA designates CPT®, HCPCS Level II, CDT®, ICD-10-CM, and NDC for standard use.
Why is the OIG Work Plan important to review each year by facilities?
It announces potential problem areas with claims submissions that the OIG will target for special scrutiny. Rationale: Each year, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead. Of special interest to health care, the Work Plan announces potential problem areas with claims submissions that it will target for special scrutiny.
If an entity is not a covered entity performing electronic transactions:
It does not need to comply with the HIPAA Privacy Rule or the HIPAA Security Rule. Rationale: If an entity is not a covered entity performing health care transactions electronically, it does not have to comply with the Privacy Rule or the Security Rule.
What does EMTALA mean for health care facilities?
It requires the hospital's dedicated emergency department to provide screening or stabilization services to patients regardless of the patient's insurance or ability to pay. Rationale: Section 1867(h) of the EMTALA prohibits delay in providing required screening or stabilization services to inquire about the individual's insurance or ability to pay.
The law that applies federal fraud and abuse laws to all federally funded health care programs with the exception of Federal Employees Health Benefit Program; civil monetary penalties were increased from $2,000 per claim plus two times the amount claimed to $50,000 per violation plus three times the amount claimed is called:
Kassebaum-Kennedy Act Rationale: Since passing the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Kennedy-Kassebaum Act), the fines and penalties have risen, as has the list of prosecutable offenses. HIPAA applied federal fraud and abuse laws to all federally funded health care programs, with the exception of Federal Employees Health Benefit Program. Civil monetary penalties (CMP) were increased from $2,000 per claim plus two times the amount claimed to $50,000 per violation plus three times the amount claimed.
List the seven recommended elements of an effective compliance plan based on the OIG's guidance for hospitals.
Key elements of an effective compliance program include:· Conduct internal monitoring and auditing through the performance of periodic audits.· Implement compliance and hospital standards through the development of written standards and procedures.· Designate a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards.· Conduct appropriate training and education on hospital standards and procedures.· Respond appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities.· Develop open lines of communication, such as (1) discussions at staff meetings regarding how to avoid erroneous or fraudulent conduct and (2) community bulletin boards, to keep hospital employees updated regarding compliance activities.· Enforce disciplinary standards through well-publicized guidelines
Primary Care Exception allows the teaching physician to bill Medicare for:
Low- to mid-level E/M services performed by a resident in an outpatient hospital facility such as a family medicine clinic. Rationale: The Primary Care Exception allows the teaching physician to bill Medicare for low- to mid-level E/M service, the Medicare initial preventive physical examination (IPPE), the initial annual well visit (AWV), and annual AWVs performed by residents. These services must be provided in the outpatient department of a hospital, or other ambulatory care entity in which the time spent by the residents providing patient care is included in determining the direct GME payments.
Punishment for providers convicted of false claims statements may include:
Mandatory exclusion from Medicare and Medicaid. Rationale: The Civil Monetary Penalties Inflation adjustment increases fines for False Claims Act violations annually. Provisions were incorporated for a mandatory exclusion from participation in Medicare or Medicaid for any individual convicted of health care fraud or controlled substance abuse. Also, revision to the criminal laws for false claims included fines or imprisonment for not more than five years or both.
A teaching physician is supervising a resident performing a colonoscopy. The teaching physician was called out of the colonoscopy suite for an emergency just prior to the removal of the endoscope. The colonoscopy (45378) was basically finished. What should you code?
No services are billed. Rationale: For endoscopic procedures, the teaching surgeon must be present from the time of the insertion through the time of removal. The teaching physician left before the removal of the colonoscope; therefore, the procedure cannot be billed.
Are compliance plans mandatory? Why?
No; Compliance plans are currently voluntary but will be made mandatory once an implementation date is set. Rationale: Currently, compliance plans are voluntary; however, the Affordable Care Act of 2010 has made compliance plans mandatory. There is not yet an implementation date for the mandatory compliance plans.
What is a PATH Audit?
OIG audits performed on medical schools or teaching hospitals. - Rationale Physicians engaged in teaching activities are paid for their services through education funds the medical school received from CMS, endowments, and tuition monies. The residents and interns under supervision receive salaries from the hospital. When a physician not following physician teaching rules bills for services performed by a resident or intern, the Medicare fund is getting doubly charged for that service and this practice is considered a form of fraud. The Office of the Inspector General (OIG) has been auditing medical schools nationally for this fraudulent practice. These audits are called "PATH" audits.
What program was launched in May 1995 to restore integrity to the Medicare program?
Operation Restore Trust Rationale: Former President Bill Clinton launched the Operation Restore Trust (ORT) program in May of 1995 in an effort to restore integrity in the Medicare program.
Medical student documentation needs to meet which requirement under the teaching physician?
Physical exam and medical decision making must be personally performed by the teaching physician along with verifying the student's documentation. - Rationale Medical students may document services in the medical record; however, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.
What is the Stark Law also known as and why is it important to hospitals?
Physician self-referral law: The law also covers services billed by hospitals actually provided by a physician-owned entity under contract with the hospital. Rationale: Physician self-referral law: The Stark Law governs physician self-referral for Medicare and Medicaid patients. Also known as the physician self-referral law, this statute prohibits physicians from referring patients to medical facilities in which the physician or a member of the physician's immediate family has a financial interest, whether by ownership, investment, or a compensation arrangement. It includes services billed by hospitals actually provided by a physician-owned entity under contract with the hospital.
A health care facility compliance plan will NOT:
Prevent Medicare audits. Rationale: A compliance program will show that a facility is making a good faith effort to submit claims appropriately, and is following regulatory guidance and applicable laws, which may diminish the chances of a payer audit; however, it still might be involved in an audit. A good compliance program will help with the audit and its outcome.
The FOIA applies only to:
Records of the executive branch of the federal government. Rationale: The Freedom of Information Act (FOIA) is a law that requires the US government to give out certain information to the public when it receives a written request. FOIA applies only to records of the executive branch of the federal government, not to those of the congress or federal courts, and does not apply to state governments, local governments, or private groups.
What must the teaching physician or resident be physically present for, regardless of a medical student's documentation?
Review of Systems and Past, Family, and Social History Rationale: Any contribution and participation of students to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.
Services furnished in a teaching setting are reimbursed under the Medicare Fee Schedule when:
Services performed by the resident jointly with a teaching physician present. - Rationale Physician services in a teaching setting are reimbursed under the Medicare Physician Fee Schedule only if: A physician who is not a resident personally furnishes the service; the services are furnished jointly by a teaching physician and a resident or by a resident in the presence of a teaching physician, with certain exceptions; or when certain E/M services are provided under the primary care exception.
What resources can the professional coder turn to for information? (Name at least three)
The AMA, AHA, national specialty medical societies, insurance carriers, and MACs can all serve to provide important information.
The Health Insurance Portability and Accountability Act of 1996 is also referred to as what?
The Health Insurance Portability and Accountability Act of 1996 is also referred to as the Kennedy-Kassebaum Act.
Which statement is true regarding the OIG Compliance Program Guidance for Hospitals?
The OIG Supplemental Compliance Program Guidance for Hospitals published in 2005 is to be used in addition to the OIG Compliance Program Guidance for Hospitals published in 1998 Rationale: The OIG Compliance Program Guidance for Hospitals was published in the Federal Register on February 23, 1998. January 31, 2005, the OIG published an update to this guidance, the OIG Supplemental Compliance Program Guidance for Hospitals. This is not a replacement of the guidance published in 1998, but should be used in addition to the 1998 guidance. These documents still are considered appropriate guidance for compliance in hospitals today.
A surgeon is supervising two residents in two adjoining outpatient procedure rooms. One patient has the removal of a soft tissue tumor of the shoulder. The surgeon left after the removal while the resident performed the repair. The surgeon then supervised another resident. The resident had prepped the patient for surgery. The surgeon was present for the repair of an inguinal hernia and left before the closure was complete. What procedures are billed by the surgeon?
The excision of the soft tissue tumor removal and the hernia repair Rationale: A teaching surgeon may only supervise two overlapping surgeries if the key or critical portions of the surgeries do not overlap.
A teaching physician's participation in the patient's care can be documented in the patient's medical chart by:
The physician, resident, or the nurse
What is the reason the OIG initiated the PATH audits?
To determine whether, and to what extent, Medicare payment discrepancies exist in respect to teaching physicians, at teaching hospitals throughout the country Rationale: Resident salaries are paid through Part A funds from CMS; therefore, it is considered double dipping, to bill for services performed by the residents and not by the attending physicians who submitted the claims.
Under HIPAA, covered entities may obtain consent of the individual to use or disclose protected health information for:
Treatment, Payment and Health Care Operations Rationale: The Office for Civil Rights (OCR) released a document known as HIPAA Administrative Simplification. A covered entity may obtain consent of the individual to use or disclose protected health information to carry out treatment, payment or health care operations.