AAPC-COC Certified Outpatient Coder - Set 4 - Part 1

Correct Answer: Terminally ill

To elect hospice care, an individual must be entitled to Part A and be certified as terminally ill, meaning a medical prognosis of a life expectancy of 6 months or less if the illness runs its normal course. Option b is incorrect because ESRD is one basis on which people under age 65 gain Medicare coverage; it is not the certification the hospice election requires. Option c is incorrect because confinement to the home is a qualifying condition for home health benefits under Part A or Part B, not a requirement for electing hospice care. Option d is incorrect because intermittent skilled nursing need is listed with home confinement among the home health qualifications, while hospice election turns on a certified prognosis instead.

Correct Answer: Patient contact time in 15-minute increments

For services such as anesthesia, the service count field likely shows 1 for the surgery, while the MTUS count field holds the actual time the anesthesiologist spent with the patient, in 15-minute increments or a fraction thereof. Option a is incorrect because miles apply to a different indicator value used for ambulance services, and would not describe volume on an anesthesia line. Option b is incorrect because the service count field already carries that value, likely 1 for the surgery, so the MTUS count field is meant to hold different information here. Option c is incorrect because that is the job of the MTUS indicator field, which tells what the value in the MTUS count field represents, not the count itself.

Correct Answer: Residence requirements

The statute directs the Secretary to use rules similar to the MA residence requirements. An individual may elect a plan only if the plan serves the geographic area in which the individual resides. Option a is incorrect because that rule covers the plan's obligation to accept and continue enrollment, a separate provision from the geographic-area test of eligibility. Option b is incorrect because they set when an individual may make or change an election, such as initial and annual coordinated periods, not where the individual must live. Option d is incorrect because it governs review of a plan's promotional materials and enrollment forms, which has no bearing on whether the individual's location qualifies.

Correct Answer: only in ASCs

The ASC list of covered procedures only indicates which procedures are covered and paid when done in the ASC setting. It does not require them to be performed only in ASCs; the physician chooses the setting. Option a is incorrect because acceptance of assignment is a condition in the ASC agreement for facility services, and it has no bearing on where covered procedures may be performed. Option c is incorrect because the manual leaves the choice of care setting to the physician based on the beneficiary's clinical needs, so physician involvement is not the restriction the list addresses. Option d is incorrect because general coverage rules requiring a procedure to be reasonable and necessary still apply to ASC services, just as they do to other covered services.

Correct Answer: Complete primary payer's program or plan name

Item 11c calls for the 9-digit PAYERID number of the primary insurer. When no PAYERID number exists, the complete primary payer's program or plan name is entered instead. Option a is incorrect because a retirement date preceded by RETIRED belongs with employer information in Item 11b under the 08/05 form version, not in the payer field. Option b is incorrect because same is the entry for Items 4 and 7 when the insured and patient match or addresses match, not for identifying a payer. Option d is incorrect because none is entered in Item 11 when the insured reports a terminating event for insurance that had been primary, which does not identify a payer.

Correct Answer: The group health plan or beneficiary reimburses Medicare if the plan later pays

Conditional primary Medicare benefits are paid when a proper claim is filed with the group health plan and denied in whole or in part. They are paid on condition that the plan or beneficiary reimburses Medicare if the plan later pays. Option a is incorrect because the guidance places the repayment condition on the group health plan and the beneficiary, and ties it to later plan payment, not to a deductible. Option b is incorrect because that describes the rule barring secondary payment when a provider accepts the primary payment as full payment; it is unrelated to conditional primary payments. Option c is incorrect because alleging that the plan is secondary to Medicare is itself a reason conditional payment may not be made, so it cannot be the condition.

Correct Answer: Private cause of action for double damages

The MSP enforcement provision establishes a private cause of action for damages in an amount double the amount otherwise provided, when a primary plan fails to provide primary payment or appropriate reimbursement. Option b is incorrect because this gives an applicable plan a way to contest a recovery determination, so it protects the plan instead of penalizing its failure to pay. Option c is incorrect because the statute refers to an excise tax only for nonconforming group health plans, pointing to the Internal Revenue Code rather than creating it for primary plans generally. Option d is incorrect because this is a timing provision, a 65-day period the Secretary may extend, that governs notice of settlements and has no role as a remedy against a primary plan.

Correct Answer: Knowingly presenting a false or fraudulent claim for payment

The False Claims Act prohibits knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval to the Federal Government. Knowingly includes actual knowledge, deliberate ignorance and reckless disregard. Option a is incorrect because timely repayment is what the Affordable Care Act requires of entities, and it helps them avoid False Claims Act liability rather than creating it. Option b is incorrect because self-disclosure is a CMS process, the SRDP, for reporting actual or potential violations of the PSL; it is not conduct the False Claims Act prohibits. Option c is incorrect because internal audits are a proactive compliance measure recommended for providers, so they are encouraged and carry no False Claims Act prohibition.

Correct Answer: Statutes, rulings, regulations, and national coverage, payment, and coding policies

The guidance directs the MAC to ensure that all LCDs do not conflict with statutes, rulings, regulations, and national coverage, payment, and coding policies, so local policy cannot override national authority. Option a is incorrect because the guidance addresses finalizing or retiring proposed LCDs within a rolling year, and says nothing that makes public comments the benchmark for conflict. Option b is incorrect because physician documentation is what an aggrieved party uses to show need when challenging an LCD; it is not a standard the LCD content must match. Option d is incorrect because the guidance requires consistency with national authority, not with LCDs from other contractors; the database simply houses proposed and final LCDs and related articles.

Correct Answer: An aggrieved party

Section 1869(f) of the Social Security Act creates an appeals process for an aggrieved party, defined as a Medicare beneficiary needing coverage that an LCD would deny, to challenge LCDs in effect through ALJ and DAB review. Option a is incorrect because health care professionals may submit new LCD requests, but the challenge process is built around a beneficiary who needs coverage and has treating physician documentation. Option c is incorrect because a MAC is the entity that makes the LCD determination, and the challenge process exists to review that determination rather than to let the MAC contest it. Option d is incorrect because CAC members may attend open meetings on proposed LCDs, which is a participation role in LCD development rather than a right to appeal an LCD.

Correct Answer: Does the remuneration take into account the volume or value of business generated?

OIG guidance lists the manner in which remuneration is determined as a key area, asking whether it takes into account, directly or indirectly, the volume or value of business generated. Payment that rises with patient referrals fits this question. Option b is incorrect because this question looks at the nature of the items or services provided, while the scenario describes a payment that increases with the number of patients sent. Option c is incorrect because this question concerns how participants were chosen for the arrangement; the scenario describes how payment is determined once the parties are already involved. Option d is incorrect because this question addresses how the arrangement is documented, which concerns written terms and records, not how the payment amount is calculated from patient flow.

Correct Answer: Denial of payment

The sanctions provision states that no Medicare payment may be made for a designated health service provided in violation of the referral prohibition. Denial of payment is therefore the billing consequence, with refunds required for amounts already collected. Option a is incorrect because the statute does not provide for partial payment at a reduced rate; it bars payment for the designated health service altogether. Option b is incorrect because advisory opinions are written responses from the Secretary on whether a referral is prohibited, and they do not serve as a payment holding step. Option d is incorrect because reporting of ownership and compensation arrangements is a separate duty of entities, and it does not decide whether a violating claim is paid.

Correct Answer: An HHS administrative law judge

CMP cases are administrative. OIG pursues them before an HHS administrative law judge, whereas DOJ pursues False Claims Act cases in Federal court on behalf of HHS. Option b is incorrect because OCR administers and enforces the HIPAA Privacy, Security, and Breach Notification Rules, and has no role in OIG's CMP cases. Option c is incorrect because a grand jury relates to criminal prosecution, such as under the criminal health care fraud statute, and not to administrative CMP proceedings. Option d is incorrect because federal court is where DOJ pursues False Claims Act cases on behalf of HHS, while CMP cases are handled administratively.

Correct Answer: Risk assessment

OIG guidance under Element 6 defines risk assessment as a process for identifying, analyzing, and responding to risk. A compliance risk assessment narrows this to risk from violations of law, regulations, or other legal requirements. Option a is incorrect because the Compliance Committee is a body that directs policy development and examines incentives; OIG does not define it as the risk process. Option b is incorrect because these make up Element 1 and give individuals a roadmap of duties and controls, not a process of identifying and analyzing risk. Option c is incorrect because a code of conduct is a tool under Element 1 that communicates an organization's mission, goals, and ethical requirements rather than a process for analyzing risk.

Correct Answer: The requesting party only

The statute and regulations make advisory opinions binding, and legally reliable, only for the requestors of the opinion. The opinion is binding on the Secretary only with respect to the requesting party. Option a is incorrect because industry-wide trends are addressed by Special Fraud Alerts, whereas an advisory opinion is specific to the facts certified by one requestor. Option c is incorrect because OIG publishes redacted opinions for informational purposes, but third parties are not bound by them and may not legally rely on them. Option d is incorrect because participation in a Federal health care program gives no right of reliance; the opinion is binding only with respect to the requestor.

Correct Answer: Physician could not reasonably have been expected to know of denial

Under 42 CFR 411.408(d), no refund is required when the physician did not know, and could not reasonably have been expected to know, that Medicare would not pay for the service as not reasonable and necessary. Option a is incorrect because a statement that there is only a possibility Medicare may not pay is not acceptable notice, and it must also be in writing. Option b is incorrect because the waiver depends on a written notice plus a signed statement from the beneficiary agreeing to pay, which a spoken agreement does not supply. Option d is incorrect because a notice given routinely to all beneficiaries is not acceptable evidence of prior notice, so it cannot support a waiver of the refund requirement.

Correct Answer: Submit the signed ABN to Medicare for approval

The form instructions require notifiers to deliver the ABN in advance, review it and answer questions, give a copy on request, and retain a signed copy on file. Submitting the signed ABN to Medicare for approval is not among those duties. Option b is incorrect because the instructions require notifiers to keep a completed, signed copy on file, so this is part of the set. Option c is incorrect because CMS instructions list this as a notifier duty; the ABN must reach the patient or representative before the items or services are furnished. Option d is incorrect because this is a listed notifier duty; the patient or representative must have the notice reviewed and questions answered before it is signed.

Correct Answer: I, II, and III

The Medicare manual has the notifier retain the ABN in case knowledge of liability is questioned, accepts electronic retention of the signed paper document, and directs a non-billing notifier to give a copy to the billing entity. Option a is incorrect because statement III is also supported by the Medicare manual, so a combination leaving it out is incomplete. Option c is incorrect because statement IV is contradicted by the manual, which has the notifier keep the ABN on file, and scanning allows the paper copy to go to the beneficiary only as an option. Option d is incorrect because it relies on statement IV, which is false, and it drops statement II, which the Medicare manual endorses as acceptable electronic retention.

Correct Answer: A QIO review

Under the hospital requested expedited review provision, a hospital that finds inpatient care is no longer needed, but cannot obtain the physician's agreement, may request a QIO review and must notify the beneficiary of the request. Option b is incorrect because a HINN is a notice the hospital issues to inform a beneficiary of potential liability, not a review that the hospital requests. Option c is incorrect because the general claims appeal process applies when a beneficiary is no longer an inpatient and disagrees with a determination, not to this hospital request. Option d is incorrect because this is a step the beneficiary may pursue after being dissatisfied with an expedited determination, so the hospital does not request it.

Correct Answer: No later than 36 hours after observation begins

The Medicare manual requires the MOON to be delivered to a beneficiary receiving outpatient observation services for more than 24 hours, and not later than 36 hours after observation services begin. Option a is incorrect because the notice must be delivered before 36 hours pass and also before a transfer, discharge or admission, so waiting until discharge can be too late. Option b is incorrect because the guidance sets no 12-hour deadline; delivery may occur early, but the required outer limit is longer than that. Option d is incorrect because this exceeds the limit set by the Medicare manual, which requires delivery no later than 36 hours after observation services begin.