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

Correct Answer: Underreporting of income under fixed-salary payment

OIG guidance links fee-for-service to overutilization, capitation to stinting on care, and performance-based payment to gaming of data. It does not describe underreporting of income under fixed-salary payment as a payment incentive risk. Option a is incorrect because OIG guidance names stinting on care as a heightened risk when an insurer pays on a capitated basis. Option c is incorrect because volume-sensitive or fee-for-service payment is described as raising the risk of overutilization, inappropriate patient steering and costlier items or services. Option d is incorrect because payments tied to quality of care or other performance measures are described as inviting gaming of data to qualify for payment.

Correct Answer: The Compliance Committee

OIG guidance on integrating quality and patient safety into compliance programs states that the Compliance Committee should include members responsible for quality assurance and patient safety, and should receive regular reports from senior leadership on those topics. Option a is incorrect because OIG guidance assigns the quality assurance and patient safety membership requirement to the Compliance Committee, not to a billing function, which is never named for that role. Option b is incorrect because an outside audit firm is not described in OIG guidance as a body that must include quality members; that expectation is directed at the committee. Option d is incorrect because screening for excluded individuals relates to the List of Excluded Individuals/Entities and is not the group OIG says should include quality and safety members.

Correct Answer: An obligation under the False Claims Act

The enforcement provision states that any overpayment retained after the deadline for reporting and returning it is an obligation for purposes of the False Claims Act, 31 U.S.C. 3729. Option a is incorrect because applicable reconciliation refers to the filing of a cost report and the timing of returns tied to SSI ratio or outlier updates, not to enforcement. Option b is incorrect because suspension applies to the deadline for related overpayments from the same cause while they are investigated, not to the status of an overpayment retained past its deadline. Option c is incorrect because a settlement agreement results from a disclosure under the OIG or CMS protocols, which satisfies reporting duties rather than describing a retained overpayment.

Correct Answer: exclusion from Federal health care programs

A CIA outlines the obligations an entity agrees to as part of a civil or administrative settlement. In exchange, OIG agrees it will not seek to exclude the entity from Medicare, Medicaid, or other Federal health care programs. Option b is incorrect because this is one of the listed CIA requirements, so the entity must establish it; it is part of the entity's obligations rather than OIG's promise. Option c is incorrect because OIG guidance names training among the common CIA requirements the entity carries out, which places it on the entity's side of the exchange. Option d is incorrect because OIG guidance lists retaining an independent review organization as a requirement the entity takes on under the CIA, not something OIG agrees to forgo.

Correct Answer: Social history

Social history is the PFSH area defined as an age appropriate review of past and current activities. The other two PFSH areas are past history and family history, each defined differently. Option a is incorrect because covers the patient's past experiences with illnesses, operations, injuries and treatments, not an age appropriate review of activities. Option b is incorrect because belongs to a separate history element that addresses the problem identified, not one of the three areas making up the PFSH. Option d is incorrect because is a review of medical events in the patient's family, including hereditary diseases or conditions that place the patient at risk.

Correct Answer: Omit separate reporting of the integral service

Under the NCCI standards of medical/surgical practice, services integral to a code defined procedure are included in that procedure. Reporting them separately with that procedure is inappropriate, so the integral service is not billed on its own. Option a is incorrect because choosing among groups of similar codes by complexity concerns a different rule; it does not authorize billing a service that is integral to another procedure. Option c is incorrect because modifier 59 is described for a separate procedure designation that qualifies as separately reportable, not for services that are already included in the primary procedure. Option d is incorrect because that step applies when no code correctly describes the procedure performed, which is a different problem from an integral service already included in a procedure.

Correct Answer: Appropriate variation for a special patient group

The guidelines state that records of infants, children, adolescents and pregnant women may have additional or modified information in each history area. Newborn HPI details of the mother's pregnancy and birth status are appropriate even though not specifically defined. Option a is incorrect because the guidelines expressly place mother's pregnancy details and infant status at birth under HPI for newborn records, so the entry sits within a recognized history element. Option b is incorrect because the chief complaint is a separate concise statement of the reason for the encounter, and the guidelines do not let newborn HPI details replace it. Option c is incorrect because time controls only visits consisting predominantly of counseling or coordination of care, which has no bearing on how newborn history content is recorded.

Correct Answer: Extended HPI

An extended HPI consists of four or more HPI elements. Location, quality, severity and duration are four of the listed elements, so the HPI meets the extended level rather than the brief level. Option a is incorrect because pertinent describes a PFSH, a review of history areas related to the HPI problem, not a level of HPI. Option b is incorrect because a brief HPI consists of only one to three elements, and this note documents four. Option d is incorrect because complete is used for the ROS and PFSH levels; the HPI is distinguished only as brief or extended.

Correct Answer: Two of the three elements

The E/M guidelines state that to qualify for a given type of decision making, two of the three elements in the chart must be either met or exceeded. This is the two-of-three rule. Option a is incorrect because the E/M guidelines do not let a single element set the type of decision making; qualification depends on a combination of elements in the chart. Option b is incorrect because the chart does not demand every element at the same level, since meeting or exceeding two of the three is enough to qualify. Option c is incorrect because the guidelines name no required element; any two of the three, whether diagnoses and options, data, or risk, can qualify the encounter.

Correct Answer: CMP authority for HHS grants, contracts, and agreements

OIG may impose CMPs, assessments, and exclusion for improper conduct tied to HHS grants, contracts, and other agreements. Knowingly using award funds for prohibited expenses, instead of the funded treatment services, is an example of grant fraud CMP liability. Option b is incorrect because the anti-kickback framework addresses practices such as offering or receiving gifts to reward past or future referrals, and the scenario describes no referral or remuneration exchange. Option c is incorrect because OIG guidance presents it as a separate authority aimed at one specific type of conduct unique to HHS and the Federal health care programs, not misuse of award funds. Option d is incorrect because it reaches health IT developers of certified health IT, health information exchanges, and networks whose practices interfere with access, exchange, or use of electronic health information, which is not alleged here.