AAPC-CPMA Certified Professional Medical Auditor - Set 3 - Part 2

Correct Answer: Recognition in the individual's performance review

OIG guidance says an entity may be unable to publicly recognize an individual who raises a substantiated concern, so it should find a way to recognize this in the individual's performance review. Option a is incorrect because the guidance recognizes that public recognition may not be possible for this individual, so it points to another channel instead of an announcement. Option b is incorrect because the guidance does not offer committee placement as recognition; the Compliance Committee helps decide which behaviors to incentivize rather than serving as a reward. Option c is incorrect because additional compensation is listed as one possible basis for rewarding excellent performance or significant contributions, not as the way to recognize a substantiated concern when publicity is not possible.

Correct Answer: consistency

OIG guidance on Element 5 says the compliance officer monitors investigations and resulting discipline to ensure consistency. Consequences should be applied consistently, so all levels of employees face the same consequences for similar offenses. Option a is incorrect because the guidance links significant sanctions to intentional or reckless noncompliance and says consequences depend on the facts, so harshness is not the purpose of this monitoring. Option b is incorrect because recognition is described as an incentive for compliance performance or substantiated concerns, which belongs to incentives rather than to oversight of discipline. Option d is incorrect because anonymity concerns individuals who raise concerns and wish to remain unnamed, a communication matter, not the aim of monitoring investigations and discipline.

Correct Answer: A no-retribution provision in the standards and procedures

OIG guidance says a communication system can include provisions in the standards and procedures that there will be no retribution for reporting conduct a reasonable person acting in good faith would believe to be erroneous or fraudulent. Option b is incorrect because annual training is a recommendation for individuals involved in coding and billing; it builds knowledge but gives no protection to someone who reports in good faith. Option c is incorrect because OIG recognizes that protecting anonymity may not be feasible for small practices, so a guarantee cannot be the dependable measure here. Option d is incorrect because a bulletin board is an informal way to share up-to-date compliance information; it does not shield reporting employees from consequences.

Correct Answer: Routine monitoring of known risks

OIG guidance says the compliance work plan should contain routine monitoring of ongoing risks. Monthly screening of the LEIE and State Medicaid exclusion lists is given as an example of routine monitoring of known risks. Option a is incorrect because a damages estimation is a review of affected claims, either all of them or a statistically valid random sample, done under the Self-Disclosure Protocol. Option b is incorrect because medical necessity review belongs in claims audits and is performed by an appropriately credentialed clinician, whereas exclusion list screening checks individuals against lists. Option d is incorrect because IRO reviews are required by a Corporate Integrity Agreement after a settlement, and they are not a routine screening step set by the entity's own work plan.

Correct Answer: Remediating the violation, including reporting where appropriate

OIG guidance says an investigation may reveal an overpayment that is owed. Compliance programs should therefore include processes to remediate violations found, including reporting to Government program agencies or law enforcement where appropriate, and to analyze root causes. Option b is incorrect because OIG guidance states that the existence or amount of a monetary loss to a Federal health care program is not solely determinative of whether a violation occurred. Option c is incorrect because annual training is a recommendation for staff involved in coding and billing, not a response step for a detected overpayment, and nothing calls for replacing other training. Option d is incorrect because the guidance says an investigation can reveal an overpayment that is owed, which is a separate outcome from no impropriety and still calls for remediation.

Correct Answer: Whether the program is more form than substance

OIG guidance states that how an entity responds to a violation causing a substantial overpayment or serious misconduct sets apart a strong compliance program from one that is more form than substance. Option a is incorrect because a disclosure program is a channel that generates reports; having one does not show how the entity handles a substantial overpayment or serious misconduct. Option b is incorrect because monitoring intervals are reassessed periodically or during the annual risk assessment, which is a separate review from the response to a detected violation. Option c is incorrect because retaining an outside expert is a board consideration tied to resources and compliance history, not what the response to a serious violation distinguishes.

Correct Answer: Not more than 60 days after the determination

OIG guidance says that once a reasonable inquiry gives reason to believe misconduct may violate criminal, civil, or administrative law, the entity should promptly notify the appropriate Government authority, not more than 60 days after determining credible evidence exists. Option a is incorrect because the existence or amount of monetary loss is not solely determinative of whether a violation occurred, so it does not control reporting timing. Option c is incorrect because that timing applies to the most serious conduct, such as a clear violation of criminal law, which the scenario does not describe. Option d is incorrect because the effectiveness review is a periodic assessment reported to the board; it does not set the timing for notifying Government authorities.

Correct Answer: A notation supplementing or confirming the recorded information

When ancillary staff or a patient-completed form records the ROS, the guidelines require a notation by the physician that supplements or confirms the recorded information. This notation is what documents that the physician reviewed it. Option b is incorrect because re-recording is not demanded; the guidelines accept a supplementing or confirming notation, so a complete second inventory of systems would add nothing required. Option c is incorrect because that notation belongs to reviewing and updating a ROS obtained at an earlier encounter, which is a different situation from information recorded by ancillary staff. Option d is incorrect because the guidelines place the review requirement on the physician's own notation, and say nothing about a manager's countersignature establishing that the physician reviewed the information.

Correct Answer: Comparing claim denial rates with other practices

Comparing claim denial rates with other practices is a method OIG guidance suggests for improving documentation quality. It is not one of the billing risk areas frequently investigated and audited by the OIG. Option a is incorrect because OIG guidance lists it among the frequent billing risk areas because it results in improper billing. Option b is incorrect because OIG guidance names it directly as a frequent subject of investigations and audits, describing billing for the same item or service more than once. Option c is incorrect because this appears first in the OIG list of frequently investigated billing risk areas, covering services not provided as claimed.

Correct Answer: No, only the requestor may legally rely on it

Advisory opinions come from a statutory process and are binding, and may legally be relied upon, only by the requestors. Published versions inform stakeholders about OIG's views, but no third party may rely on them. Option a is incorrect because the opinion rests on the detailed facts certified by the requestor, so similarity does not extend protection to a different party. Option c is incorrect because Special Fraud Alerts address industry-wide fraud trends and do not extend an advisory opinion's binding effect or reliance to non-requesting parties. Option d is incorrect because publication on the OIG website is for informational purposes only, and no third parties are bound by or may legally rely upon the published opinions.

Correct Answer: RAT-STATS

RAT-STATS is the statistical software OIG makes available for download to assist in claims review. It is the primary statistical tool of the Office of Audit Services and helps select random samples and estimate improper payments. Option a is incorrect because it consists of educational materials and case examples that teach physicians about the Federal laws protecting programs from fraud, waste, and abuse. Option b is incorrect because they address specific trends of health care fraud of an industry-wide character and do not provide software for sampling or estimating payments. Option d is incorrect because it is a web-based publication describing OIG reviews that are planned or underway, updated monthly and searchable by topic, not a sampling tool.

Correct Answer: A regularly audited arrangements tracking system

OIG guidance on financial arrangements tracking describes an effective and robust arrangements tracking system, audited regularly, as a compliance measure that prevents violations and mitigates potential liability under the Federal fraud and abuse laws. Option a is incorrect because OIG issues Special Fraud Alerts to address industry-wide fraud trends; they inform the public but do not monitor an entity's own agreements. Option b is incorrect because preamble text accompanying safe harbor regulations gives insight into OIG's views on risks and safeguards, yet it does not track the entity's contracts. Option c is incorrect because Special Advisory Bulletins cover topics such as gifts to beneficiaries and contractual joint ventures, not ongoing monitoring of an entity's own arrangements.

Correct Answer: To the CMS or other responsible contractor

A matter exclusively involving overpayments or errors is ineligible for the Self-Disclosure Protocol. It is disclosed directly to the appropriate CMS or other responsible contractor under the payor's voluntary refund process. Option a is incorrect because the hotline is meant for reporting potential misconduct of other parties, whereas this practice is returning its own payment error. Option b is incorrect because the protocol is reserved for potential violations of laws with CMP authority, and a matter exclusively involving overpayments or errors falls outside that conduct. Option d is incorrect because that process is the vehicle for obtaining an OIG opinion on an arrangement, not a route for returning overpayments to a payer.

Correct Answer: I and III

OIG treats conduct continuing until or after the person learned of the investigation, and steps to conceal the conduct from the Government, as indicators of higher risk. A lack of patient harm and the absence of criminal sanctions do not affect the assessment. Option b is incorrect because a lack of patient harm is stated not to affect the risk assessment, so statement II adds no higher risk to the analysis. Option c is incorrect because both statements describe facts that OIG treats as neutral, so neither one pushes a person toward the higher end of the risk spectrum. Option d is incorrect because statement III does indicate higher risk, but statement IV fails, since missing criminal sanctions leave the assessment unchanged and count for nothing.

Correct Answer: They may be reported for a very diverse group of services

Unlisted procedure codes may be reported for a very diverse group of services, so the NCCI program generally does not include edits with these codes. No consistent pairing of services can be built around them. Option a is incorrect because integral services are included in the primary procedure under standards of medical/surgical practice, whereas unlisted codes identify services that no other HCPCS/CPT code accurately describes. Option b is incorrect because laboratory panels are defined organ and disease specific groups of tests, while unlisted codes sit at the end of each section or subsection of the codebook. Option d is incorrect because modifier 91 applies to a repeated component test of a laboratory panel on the same date of service, which has no link to unlisted codes.

Correct Answer: Sequential procedure

Under the sequential procedure policy, when an initial surgical approach fails and a second approach is used at the same encounter, only the code for the second approach is reported. The failed laparoscopic code is not separately reportable. Option b is incorrect because concerns organ and disease specific groups of laboratory tests reported with one panel code when all tests are performed, which has no bearing on surgical approaches. Option c is incorrect because applies to a code whose descriptor says "separate procedure" and bars reporting it with a related procedure in the same region; it does not address failed approaches. Option d is incorrect because covers groups of codes describing related procedures in various combinations, directing use of the most comprehensive code, rather than a failed first approach followed by a second.

Correct Answer: Postoperative visit unrelated to the surgical diagnosis

A postoperative visit unrelated to the diagnosis for which the surgery was performed, and not a complication of surgery, may be reported separately with modifier 24. Recovery visits, complication visits and the minor-procedure decision are included. Option a is incorrect because the decision to perform a minor procedure is included in the payment for that procedure and is not reported as a separate E&M service. Option b is incorrect because the manual places E&M services related to complications of the surgery inside the global surgical package, so this service is included. Option c is incorrect because the global surgical package covers postoperative E&M services related to recovery from the surgical procedure during the postoperative period, so it is included.

Correct Answer: Problem Focused

The chart of the four types of history lists a brief HPI with N/A for both ROS and PFSH under Problem Focused. A chief complaint is indicated at every level, so it adds nothing to the distinction. Option a is incorrect because it pairs a brief HPI with a problem pertinent ROS, so the ROS column is not marked N/A for this type. Option b is incorrect because it calls for an extended HPI and an extended ROS, along with a pertinent PFSH, which goes well beyond a brief HPI. Option d is incorrect because it sits at the far end of the progression, requiring an extended HPI plus complete ROS and complete PFSH.

Correct Answer: Medical decision making

The history elements are chief complaint, history of present illness, review of systems, and past, family and/or social history. Medical decision making is a separate key component of E/M services, alongside history and examination. Option a is incorrect because the guidelines list it as one of the elements that each type of history includes in some form. Option c is incorrect because it is a listed history element, and the guidelines state it is indicated at all levels of history. Option d is incorrect because it is the fourth listed history element, grouped together as PFSH in the guidelines.

Correct Answer: time

When counseling and/or coordination of care dominates more than 50% of the encounter, time is the key or controlling factor for level selection. The total time and a description of the counseling must be documented. Option b is incorrect because the presenting problem influences how extensive an examination should be, but the guidelines do not name it as the controlling factor for counseling-dominated visits. Option c is incorrect because the examination is a documentation component judged by body areas and organ systems, and it does not control level selection in counseling-dominated encounters. Option d is incorrect because medical decision making is measured by diagnoses or options, data, and risk, with two of three elements needed, so it is not the controlling factor here.