Chapter 5 Review

Modifier AA

Is a HCPCS modifier- is used to report anesthesia services performed personally by anesthesiologist or when an anesthetist assists a physician ...

Administrative code sets

Non medical code sets that characterize a general business situation rather than a medical condition.

OCR

Office of Civil Rights. Enforces HIPAA privacy rule.

OCR

Office of Civil Rights. Enforces the HIPAA privacy rule

OIG

Office of Inspector General in DHHS. Monitors compliance with reimbursement laws & regulations

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? a. The excision of the soft tissue tumor removal. b. The hernia repair c. The excision of the soft tissue tumor removal and the hernia repair. d. Nothing is billed, because the teaching surgeon left before the procedures were completed.

c.

EMTALA was passed in 1986 and is part of: a. HIPAA b. The Civil Rights Act. c. The Consolidated Omnibus Budget Reconciliation Act d. OIG Supplemental Compliance Program Guidance

c.

What is a PATH audit? A. OIG audits performed on medical schools B. CMS audits performed an outpatient surgical procedures C. OIG audits focusing on outpatient surgical procedures performed at physician offices D. Physician artist performed at residential treatment facilities

A

Stark law

A federal law that places limitations of certain physician referrals. Also known as the physician self referral law. The statute prohibits physicians from referring patients to medical facilities in which the physician or a member of the physicians immediate family has a financial interest, investment, or a compensation agreement.

False Claims Act (FCA)

A federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim.

Physician services in a teaching setting I reimbursed under the Medicare physician fee schedule only F:

A physician who is not a resident personally furnishes the service The services are furnished jointly by teaching position and a resident or by resident in the presence of a teaching position with certain exceptions Certain E/M services are provided under the primary care exception

Operation restore trust

A program launched by President Clinton designed to demonstrate new partnerships and approaches in finding and stopping fraud and waste in the Medicare and Medicaid program. This is federally funded

Anti-kickback statute

A statute that establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business for which payment may be made under any federal healthcare program

How is a teaching physicians participation in the patient's care documented in the patient's medical chart? A. The physician, resident, or the nurse B. Only the teaching position C. No documentation is required D. None of the above

A. According to CMS physicians, residence, and nurses can document the teaching physicians involvement in the patient's medical chart

What healthcare regulation established privacy regulations? A. Administrative simplification B. EMTALA C. SSS D. OIG compliance guidance

A. Administrative simplification. Title two of HIPAA known as administrative simplification speaks to the increasing use of technology in the healthcare industry and addresses the need for: National standards for electronic healthcare transaction and code sets National unique identifier's providers, health plans, and employers Privacy and security of health data

According to the OIG compliance guide, how can a facility open the lines of communication? A. Use community bulletin boards to keep hospital employees updated regarding compliance activities B. Read the compliance plan for the facility to new hires C. Have each employee write a summary of the facilities compliance plan efforts D. Hold daily staff meetings to discuss the section of the compliance program each day

A. Develop open lines of communication by having scheduled staff meetings regarding how to avoid erroneous or fraudulent conduct and via community bulletin boards to keep hospital employees updated regarding compliance activities

Which of the following was HIPAA covered entities due to protect patient privacy? A. Maintain reasonable and appropriate administrative, technical, and physical safeguards to protect PHI B. Have every employee sign a nondisclosure agreement on each patient record C. Medicaid employee conflicts to avoid an employee filing a Qui tam lawsuit upon dismissal D. Maintain documentation of the privacy policies until 10 years after the date of the last effective date

A. Maintain reasonable and appropriate administrative technical and physical safeguards protect PHI

Federal register

An official document, published every weekday, which lists the new and proposed regulations of executive departments and regulatory agencies.

The health insurance portability and accountability act of 1996 is also referred to as what? A. EMTALA B. Kennedy-Kassebaum act C. HITECH D. Social Security act

B

When does the primary care exception rollout billing by the teaching physician? A. For low and mid-level E/M services Provided by residents in the presence of a teaching physician B. For low and mid-level E/M services provided by residents whereby the teaching physician is not required to see the patient C. For low and mid-level E/M services provided by residence if a teaching position also examines the patient D. For low and mid-level E/M services provided only by the teaching physician

B

What is the purpose of the operation restore trust program? A. An effort to work with other countries to have worldwide healthcare program B. An effort to restore integrity in the Medicare program and fine and stop fraud and waste in the Medicare and Medicaid programs C. An increase in payments to facilities to increase their trust in government programs and help them stay financially viable D. An act designed to increase security around medical facilities to protect employees and patients from violence

B.

Which is the correct statement regarding AAA PC members per AAA PC code of ethics? A. Attend continuing education once every two years to maintain certification B. Conduct themselves in all professional activities in a manner consistent with ethical principles of professional conduct C. Exploit professional relationships with patient, employees, clients, or employers for personal gain D. Change code assignments at the provider makes a mistake

B. Conduct themselves in a professional activities in a manner consistent with ethical principles of professional conduct. Ethical principles of professional conduct include: Integrity Respect Commitment Confidence Fairness Responsibility

When are services that are furnished in a heating setting reimbursed under the Medicare physician fee schedule? A. Services are performed by the resident with the teaching physician present for a portion of the service Be. Services performed by the resident without a teaching physician present C. Servicesis performed by the resident jointly with the teaching physician present D. Services performed by resident with the teaching physicians co signature

C

CLIA

Clinical Laboratory Improvement Amendment- ensures the accuracy and reliability of laboratory testing

What resources can a professional coder turn to for information? A. The American medical association - AMA B. The American hospital association - AHA C. Medical administrative contractors - MAC D. All of the above

D

Medical student documentation needs to meet which requirement under the teaching physician? A. Past, family, and social history must be reviewed and documented by the teaching physician B. The physical exam can be verified and does not need to be personally performed by the teaching physician C. History, exam, and medical decision making documentation by the student can be reviewed by the teaching position and verified with re-performing only the history D. Physical exam and medical decision-making must be personally performed by the teaching physician along with verifying the students documentation

D.

Which of the following is a benefit of a compliance plan? A. Zero Billing mistakes B. Eliminate the change of a payer audit C. Resolution of employee conflict D. faster, more accurate payment of claims

D. Faster, more accurate payment of claims Fewer billing mistakes Diminished chance of payer audit Last chance of running afoul of self referral and anti-kickback statute

How are teaching hospitals typically reimbursed? A. Based on a fee schedule B. Based on APC payment C. Based on the DRG system D. Based on a reasonable cost basis

D. For teaching hospitals the services at the resident are typically pay through direct graduate medical education (DGME) and indirect medical education (IME) payments or reasonable cost payments made by the part A MAC

EMTALA

Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.

The privacy rule prohibits use or disclosure of any request an entire medical record is this statement true or false?

False. If the entire medical record is necessary, The covered entities 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: Disclosures to or request by healthcare provider for treatment purposes Disclosures to the individual who is a subject of the information Uses or disclosures made pursuant to an individuals authorization Uses or disclosures required for compliance with HIPAA administrative simplification rules Disclosures today Department of Health and Human Services one disclosure information is required under privacy rule for enforcement purposes Uses or disclosures that are required by other law

FOIA

Freedom of Information Act, requires The US government to give out certain information to the public when it receives a written request. Only applies to records of the executive branch of the federal government.

HITECH

Health Information Technology for Economic and Clinical Health Act. Enacted as part of the American recovery and reinvestment act of 2009 (ARRA) to promote the adoption and meeting for use of health information technology. HITECH allows patients to request an audit trail showing all disclosures of their health information made through an electronic record.

O I G

Office of Inspector General. Mandated by public law to engage in activities to test the efficiency and economy of government programs to include investigation a suspected healthcare fraud or abuse

Modifier GC

Services reported for teaching physicians that meet the supervision requirements unless the service falls under the primary care exception rule

Qui Tam

Statute which protects the whistle blowers or informers that report violations of the false claims act (FCA). A provision of the False Claims Act that allows a private citizen to file a suit in the name of the U.S. government, charging fraud by government contractors and other entities who receive or use government funds.

How are the services of the residence typically paid at teaching hospitals?

Through direct graduate medical education (DGME) and indirect medical education (IME) payments on a reasonable cost basis made by the part a Medicare administrative contractor (MAC). DGME and IME payments are based on cost reports submitted by the hospital

Modifier GE

Used when services are furnished under the primary care exception. Primary care exception is when a teaching physician bills for E/M but the resident performed the service.

At a minimum, documentation must identify which of the following when a resident is providing an E/M service under the physical presence of the teaching physician? a. Documentation of the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present. b. The services provided and the participation of the resident in providing the service; the physical presence of the teaching physician is understood without documentation. c. The diagnosis and procedure performed for medical necessity reasons. d. The service furnished and a breakdown of tasks related to the service provided by the teaching physician and the resident.

a.

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 resident. a. False; Medicare requires the teaching physician to document he has personally reviewed the image and agrees with or edits the findings. b. False; Medicare does not require a signature indicating he has reviewed the interpretation. c. True; Medicare only requires a teaching physician's countersignature on an interpretation performed by a resident to indicate the physician has reviewed and agrees with the interpretation. d. False; Medicare requires the teaching physician to dictate his own interpretation to stand independently from that of the resident.

a.

Providers can be excluded from participation in Medicare or Medicaid for: a. Health care fraud and controlled substance abuse. b. Health care fraud c. Controlled substance abuse. d. Health care fraud and substance abuse.

a.

Which code sets are designated for standard use by HIPAA? I. APC II. CDT III. CPT IV. DRG V. HCPCS Level II VI. ICD-10-CM VII. NDC VIII. SNOMED CT a. II, III, V, VI, VII b. I, III, IV, V, VI, VIII c. I, II, III, IV, VI, VIII d. II, III, VII, VIII

a.

Which statement is true regarding the OIG Compliance Program Guidance for Hospitals? a. 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. b. A hospital can choose to follow the OIG Supplemental Compliance Program Guidance for Hospitals published in 2005 or the OIG Program Guidance for Hospitals published in 1998; it is not necessary to follow both guidance documents. c. The OIG Supplemental Compliance Program Guidance for Hospitals published in 2005, replaces the OIG Program Guidance for Hospitals published in 1998. d. Both the OIG Supplemental Compliance Program Guidance for Hospitals, published in 2005, and the OIG Compliance Program Guidance for Hospitals, published in 1998, are out of date.

a.

What program was launched in May 1995 to restore integrity to the Medicare program? a. Medicare Fraud and Abuse Act b. Operation Restore Trust c. Medicare Overpayments Act d. Operation Integrity

b.

Which law was developed to deter inducements or rewards for sending business between a provider and a hospital, a provider and a DME supplier, or a provider to provider situation? a. HIPAA b. Stark Law c. EMTALA d. CLIA

b.

Which practice might be considered a violation of the federal Anti-Kickback Statute? a. Requiring a provider to pay fair market value for renting office space in the hospital b. Hospital incentives to physicians c. Scheduling providers based on seniority d. Providing emergency services based on a severity level

b.

A resident and the teaching physician saw a young man involved in a bicycle accident complaining of a headache and a laceration of the arm. After examination by the resident and the teaching physician working together, the teaching physician determined the patient could be discharged after repair of the laceration. The resident performed a simple repair of a laceration of the arm (12032) while the teaching physician documented the ED visit (99282). What should the teaching physician report? a. 99282-25, 12032 b. 12032 c. 99282 d. The visit is not reported

c.

HITECH: a. Strengthens EMTALA rules by addressing privacy and security concerns associated with the electronic transmission of health information. b. Requires a health care entity be notified if there is an unauthorized disclosure or use of patient health information. c. Allows patients to request an audit trail showing all disclosures of their health information made through an electronic record. d. Provides a 60-day window during which any violation not due to willful neglect may be corrected without penalty.

c.

If an entity is not a covered entity performing electronic transactions: a. It must comply with the HIPAA Privacy Rule and the HIPAA Security Rule. b. It must comply with the Privacy Rule only. c. It does not need to comply with the HIPAA Privacy Rule or the HIPAA Security Rule. d. It does not need to comply with the HIPAA Privacy Rule.

c.

The FOIA applies only to: a. Records of congress or federal courts. b. Records of private groups. c. Records of the executive branch of the federal government. d. Records of the federal and state government.

c.

The intentional deception or misrepresentation that an individual knows, or should know to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s) is considered a. Abuse b. Legal c. Fraud d. Misuse

c.

What act limits access to the patient's medical record and ensures patient confidentiality? a. FOIA b. BIPA c. HIPAA d. EMTALA

c.

A compliance officer for a facility will NOT: a. Monitor compliance efforts and enforce practice standards. b. Be an individual or a committee. c. Report directly to the CEO and governing body. d. Be an elected official.

d.

A health care facility compliance plan will NOT: a. Provide a means to report erroneous or fraudulent conduct. b. Show that the facility is making a good faith effort to submit claims appropriately c. Send a signal to employees that compliance is a priority. d. Prevent Medicare audits.

d.

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? a. 45378-GC b. 45378-52. Modifier 52 is appended to indicate reduced services. c. Report an E/M service, because the colonoscopy cannot be reported. d. No services are billed.

d.

E/M services reported by the teaching physician must: a. Include documentation by the resident that the teaching physician was present. b. Must include only the services provided by the teaching physician. c. Be documented by the resident. d. Include documentation provided by the resident and the teaching physician combined to support the service.

d.

For teaching hospitals, the services of the residents are paid through: a. Direct Graduate Medical Education (DGME) payment. b. Reasonable cost payments through Part A. c. Indirect Medical Education (IME) payment. d. All the above.

d.

Under HIPAA, covered entities may obtain consent of the individual to use or disclose protected health information for: a. Payment b. Treatment c. Health Care Operations d. All of the above

d.

What are excepted benefits? a. Benefits that are offered and are not part of the health care plan, such as limited-scope dental or vision. b. Benefits that are offered as an integral part of the health plan. c. Benefits that are not considered health coverage such as accident only, disability insurance, and Workers' Compensation. d. a. and c.

d.

What is the Freedom of Information Act (FOIA)? a. A law that prohibits providers from disclosing any financial interest they have in an entity they have referred to a patient. b. A law that prohibits sharing of protected health information. c. A law that requires a hospital to send medical records at the request of the government. d. A law that requires government to give out certain information to the public when it receives a written request.

d.

What will make compliance plans mandatory? a. Medicare Fraud and Abuse Act b. HIPAA c. Operation Restore Trust d. Affordable Care Act of 2010

d.

Code set

under HIPAA, terms that provide for uniformity and simplification of health care billing and record keeping. And he said of codes used to encode a data elements, such as table of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions