AAPC-CPMA Certified Professional Medical Auditor - Set 2 - Part 1

Correct Answer: Serving as a legal document

The guidelines state that an appropriately documented medical record may serve as a legal document to verify the care provided, if necessary. That is the function the scenario describes. Option a is incorrect because data collection for research and education is a separate benefit the guidelines list, and it does not address verifying care in a dispute. Option c is incorrect because treatment planning and monitoring over time is a clinical purpose for healthcare professionals, not a way to verify care already provided. Option d is incorrect because utilization review and quality of care evaluation is an administrative function listed separately from the record's role as evidence of care.

Correct Answer: Services that are not reasonable and necessary

OIG guidance lists claims for equipment, supplies and services that are not reasonable and necessary as a billing risk area. It involves seeking reimbursement for a service not warranted by the patient's documented medical condition. Option a is incorrect because this risk area covers billing for care that was never delivered, such as surgery the physician did not perform, rather than care unsupported by the condition. Option b is incorrect because double billing means billing for the same item or service more than once, or another party billing for an item also billed by the physician. Option c is incorrect because this area concerns improper billing that results from misusing provider identification numbers, which has no link to whether the documented condition warrants the service.

Correct Answer: Rubber stamp signature

Stamped signatures are not typically acceptable, but CMS permits a rubber stamp for an author with a physical disability who can prove to the contractor that he or she cannot sign. Affixing the stamp certifies review of the document. Option a is incorrect because CMS does not require a scribe to sign or date entries, and the scribe's signature does not replace the treating practitioner's affirmation of the note. Option b is incorrect because an attestation statement is submitted later, signed and dated by the author, to support an entry; it does not stand in for a signature. Option d is incorrect because a signature log only lists the printed name of an author linked to initials or an illegible signature; it is not a signature method.

Correct Answer: I, II, and III

Under the Form and retention of record standard, the hospital maintains a record for each inpatient and outpatient, keeps records in original or legally reproduced form, and uses a coding and indexing system allowing timely retrieval. Option a is incorrect because leaves out statement III, which also reflects a stated requirement: the hospital must have a coding and indexing system supporting timely retrieval by diagnosis and procedure. Option c is incorrect because omits statement I and wrongly includes IV; the hospital must use a system of author identification, which is not a departmental choice. Option d is incorrect because includes IV, which contradicts the standard requiring a system of author identification, and also drops II, a true retention-form requirement.

Correct Answer: Surgical technologists may serve as scrub nurses without registered nurse supervision

The condition of participation allows LPNs and surgical technologists to serve as scrub nurses only under the supervision of a registered nurse. Serving as scrub nurses without that supervision is therefore not a feature of the standard. Option a is incorrect because the standard allows qualified registered nurses to perform circulating duties, so this statement matches the regulation and cannot be the exception. Option b is incorrect because the regulation states exactly this supervision requirement for operating rooms, so it is a genuine feature of the standard rather than the odd one out. Option c is incorrect because a roster of practitioners listing their surgical privileges is expressly required, alongside the delineation of privileges by competency, so this belongs to the standard.

Correct Answer: Extent and complexity of the service when fully furnished by the teaching physician

The payment level rule in the teaching physician regulation states that, for services such as evaluation and management with several levels available, the level must reflect the extent and complexity of the service when fully furnished by the teaching physician. Option b is incorrect because resident time is not the measure given; the level depends on the extent and complexity of the whole service, not on one participant's minutes. Option c is incorrect because the regulation ties the payment level to the service as fully furnished by the teaching physician, and says nothing about counting participating residents. Option d is incorrect because location of the training site affects when presence must be documented, but it does not determine the level of service reported for payment.

Correct Answer: Long term treatment goals

The plan of care must contain, at minimum, diagnoses, long term treatment goals, and the type, amount, duration and frequency of therapy services. With the other two present, long term treatment goals are the missing element. Option a is incorrect because standardized instruments are recommended to support justification for treatment, yet the guidance states such tools are not required in the plan. Option c is incorrect because therapists typically establish short term goals to track progress, but the regulation does not list them among the minimum plan contents. Option d is incorrect because certifying the plan is a separate process from establishing it and is not one of the three minimum contents of the plan.

Correct Answer: Appropriate sanctions

The Privacy Rule's administrative requirements state that a covered entity must have and apply appropriate sanctions against workforce members who violate its privacy policies and procedures or the Privacy Rule itself. Option b is incorrect because mitigation addresses any harmful effect the covered entity learns was caused by a use or disclosure in violation of its policies, not discipline of the workforce member. Option c is incorrect because training is required so workforce members can carry out their functions under the privacy policies; the guidance does not make it the response to violations. Option d is incorrect because this is a written designation by legally separate, commonly owned or controlled covered entities to act as a single covered entity, unrelated to workforce discipline.

Correct Answer: Workforce members

HHS guidance states that workforce members include employees, volunteers and trainees, and may include other persons whose conduct is under the entity's direct control, whether or not the entity pays them. Option a is incorrect because the guidance names business associates separately from the workforce, for example when it requires mitigation of harm caused by either the workforce or its business associates. Option b is incorrect because covered entities are the organizations, from the smallest provider to the largest multi-state health plan, that must train and sanction their workforce rather than the people being trained. Option d is incorrect because this label covers the designated privacy official and the contact person or office for complaints, which are specific roles rather than the whole group of employees, volunteers and trainees.

Correct Answer: Potential for redisclosure by the recipient

Under the HIPAA required statements, an authorization must also place the individual on notice that disclosed information may be redisclosed by the recipient and no longer protected. With revocation and conditioning complete, this is the remaining statement. Option b is incorrect because the conditioning statement is already complete in the form, and this consequence wording is one of two alternative ways of meeting that element. Option c is incorrect because this is only an alternative to listing exceptions and revocation steps, and the revocation element is stated to be fully met, so nothing is lacking here. Option d is incorrect because the scenario says the revocation statement is fully satisfied, and the right to revoke in writing is part of that statement, so it is present.

Correct Answer: A licensed health care professional who did not participate in the original decision

When access is denied on a permitted ground, the individual may have the denial reviewed by a licensed health care professional designated by the covered entity as reviewing official, who did not participate in the original decision. Option a is incorrect because the covered entity designates the reviewing official; the standard gives the individual the right to the review, not the power to choose who performs it. Option b is incorrect because the reviewing official must be a licensed health care professional, so a designee without that licensure does not meet the requirement. Option d is incorrect because the standard requires a reviewing official who did not participate in the original decision to deny, so the person who made it is disqualified.

Correct Answer: Reasonable belief the person may be abusing or neglecting the individual

The Privacy Rule permits an exception when a covered entity reasonably believes the personal representative may be abusing or neglecting the individual, or that treating the person as the personal representative could otherwise endanger the individual. Option a is incorrect because parents are in most cases the personal representatives of their minor children, so parental status alone does not support an exception. Option b is incorrect because access is one of the individual's rights that a personal representative may exercise, so the request itself gives no basis for refusal. Option c is incorrect because health oversight disclosures to an agency are a separate permitted disclosure and say nothing about refusing to recognize a personal representative.

Correct Answer: Equipment lease negotiation correspondence

OIG guidance identifies documents relating to educational activities, internal investigations and internal audit results as the primary compliance documents to retain. Equipment lease negotiation correspondence is not one of those three categories. Option a is incorrect because the guidance specifically stresses documenting investigations of potential violations and the resulting remedial action, which makes it a core retained compliance document. Option b is incorrect because the guidance names internal audit results as one of the three primary categories of compliance documents, so this belongs in the retained set. Option d is incorrect because OIG guidance lists documents relating to educational activities, such as training, among the primary compliance documents a practice would want to retain.

Correct Answer: Courtesy notice forewarning of financial obligation

Routine foot care is statutorily excluded, so an ABN is not required. When issued anyway, it is a courtesy that forewarns the beneficiary of impending financial obligation, with no option box or signature and no duty to follow issuance guidelines. Option b is incorrect because for care that is never covered, the beneficiary should not be asked to choose an option box or sign, so this reverses the guidance. Option c is incorrect because that use rests on a separate provision for DMEPOS Competitive Bidding Program items, and routine foot care falls outside that program. Option d is incorrect because experimental items are denied as not reasonable and necessary, which makes the ABN mandatory; routine foot care is a statutory exclusion, a different category.

Correct Answer: Up to three times the program's loss plus a per-claim penalty

Liability under the civil False Claims Act is up to three times the program's loss plus an additional penalty per claim filed. Each item or service billed counts as a claim, so liability adds up quickly. Option a is incorrect because these belong to the separate criminal False Claims Act, which requires criminal intent proved beyond a reasonable doubt, not the civil remedy. Option b is incorrect because a share of recoveries goes to a whistleblower who files suit on behalf of the United States, not to the liable party. Option d is incorrect because this is the outcome for innocent errors or negligence, where no law is violated; knowingly false claims fall outside that treatment.

Correct Answer: False, because the claims were submitted in violation of the PSL

A claim submitted in violation of the PSL is false or fraudulent, creating civil False Claims Act liability. Because the PSL is a strict-liability statute and the False Claims Act needs no proof of specific intent, staff unawareness does not protect the claims. Option b is incorrect because the guidance says such claims create liability under the civil False Claims Act; a separate criminal False Claims Act also exists, so civil liability is not excluded. Option c is incorrect because the False Claims Act requires no proof of specific intent to defraud, and a claim submitted in violation of the PSL is itself false or fraudulent. Option d is incorrect because the PSL is a strict-liability statute, so proof of intent to violate it is not required and staff ignorance does not cure the claims.

Correct Answer: Reckless disregard

The False Claims Act defines "knowing" to include actual knowledge, deliberate ignorance and reckless disregard of the truth or falsity of information. No proof of specific intent to defraud is required. Option a is incorrect because is not one of the three mental states in the statutory definition, which lists only actual knowledge, deliberate ignorance and reckless disregard. Option b is incorrect because is expressly not required, since the statute says no proof of specific intent to defraud is needed for a claim to be knowing. Option d is incorrect because describes an error that carries a duty to repay the money, but it is not a mental state within the knowing definition.

Correct Answer: Health Care Fraud Self-Disclosure Protocol

OIG makes the Health Care Fraud Self-Disclosure Protocol available to providers, suppliers, and other entities that find potential fraud through self-discovered evidence and want to resolve potential CMP liability with OIG. Option a is incorrect because Congress created statutory exceptions to define protected arrangements; they are not a channel for disclosing past conduct to OIG to resolve penalty liability. Option c is incorrect because it is the CMS mechanism for self-disclosing actual or potential violations of the Physician Self-Referral Law, not anti-kickback conduct and CMP liability with OIG. Option d is incorrect because OIG safe harbors specify practices not treated as an offense, so they help in structuring arrangements but do not resolve liability for conduct already identified.

Correct Answer: It is a strict liability statute

The Stark law (PSL) is a strict liability statute, so OIG guidance says it is usually best to begin there. An arrangement permissible under Stark must still be analyzed separately under the anti-kickback statute. Option a is incorrect because intent of the parties is weighed under the anti-kickback statute's totality-of-circumstances review, not as a feature of the strict liability Stark analysis. Option b is incorrect because safe harbors belong to the anti-kickback statute, where compliance is voluntary; Stark relies on exceptions whose requirements must be satisfied. Option c is incorrect because the guidance recommends starting with the Stark assessment, and an arrangement permissible under Stark still needs separate anti-kickback analysis afterward.

Correct Answer: DOJ, OIG, CMS and the HHS Office for Civil Rights

OIG guidance states that the Department of Justice, OIG, CMS and the HHS Office for Civil Rights are charged with interpreting and enforcing these Federal laws and regulations, and violations can bring repayment obligations, penalties and exclusion. Option b is incorrect because these contractors are not named in the guidance; it lists DOJ, OIG, CMS and OCR as the agencies charged with enforcement. Option c is incorrect because the guidance expressly states that it does not address State fraud and abuse laws, so State bodies are not named as the enforcers. Option d is incorrect because these groups are not government agencies, and the guidance assigns interpretation and enforcement to Federal government agencies instead.