Fraud And Compliance Rules - Certified Professional Coder CPC

1. What does HIPAA stand for in healthcare compliance?

   Health Insurance Portability and Accountability Act. Enacted in 1996, this federal law establishes standards for privacy, security, and electronic transactions in healthcare.

2. Which HIPAA rule requires safeguards to protect ePHI?

   HIPAA Security Rule. This rule mandates administrative, physical, and technical safeguards to ensure the confidentiality of electronic PHI.

3. What agreement is required when a vendor creates, receives, maintains, or transmits PHI?

   Business Associate Agreement (BAA). HIPAA requires this contract to ensure business associates safeguard PHI and comply with privacy and security rules.

4. What does NCCI stand for in CPT coding edits?

   National Correct Coding Initiative. Developed by CMS, this program promotes accurate coding methodologies for Medicare and Medicaid claims.

5. What is the CPT definition of fraud in healthcare billing?

   Intentional deception or misrepresentation to obtain payment. This aligns with CPT guidelines defining fraud as deliberate actions to secure unauthorized benefits in medical billing.

6. Which disclosure category allows PHI use without patient authorization for billing?

   Treatment, payment, and healthcare operations (TPO). HIPAA permits PHI sharing for these core functions without consent to facilitate care coordination and reimbursement.

7. Which term means billing for services not provided to the patient?

   Phantom billing. This practice violates billing integrity by claiming reimbursement for nonexistent patient encounters or procedures.

8. Which HIPAA rule requires patient notification after certain PHI breaches?

   HIPAA Breach Notification Rule. It obligates covered entities to notify affected individuals, HHS, and sometimes media following unsecured PHI breaches.

9. What is the primary purpose of a Medicare ABN?

   To shift financial liability to the beneficiary if Medicare denies. It protects providers by obtaining beneficiary consent to pay out-of-pocket when Medicare is likely to deny coverage.

10. Which HIPAA rule governs permissible uses and disclosures of PHI?

    HIPAA Privacy Rule. It sets national standards for protecting individuals' medical records and other personal health information.

11. What does ABN stand for in Medicare billing?

    Advance Beneficiary Notice of Noncoverage. This Medicare form informs beneficiaries of potential non-coverage and their financial responsibility for services.

12. What is a Business Associate under HIPAA?

    A vendor handling PHI for a covered entity under a contract. HIPAA defines this as an external entity performing functions involving PHI on behalf of a covered healthcare provider.

13. Which term means billing a higher-level service than documented or performed?

    Upcoding. It involves selecting a code with higher reimbursement than justified by the documentation or service level provided.

14. What is the CPT definition of abuse in healthcare billing?

    Improper billing practices causing unnecessary costs, not intentional. CPT distinguishes abuse from fraud by the absence of intent, focusing on practices that lead to unwarranted expenses.

15. Which modifier indicates an item or service is not reasonable and necessary and no ABN was obtained?

    Modifier $GZ$. This modifier alerts payers that coverage denial is expected due to lack of medical necessity without an ABN on file.

16. What is the term for misrepresenting who performed a service to obtain payment?

    Misrepresentation of provider (provider fraud). Fraudulent billing practices include falsely attributing services to a qualified provider to ensure payment approval.

17. What is the HIPAA standard for limiting use and disclosure of PHI?

    Minimum necessary standard. HIPAA requires limiting PHI access to only what is essential for the task, promoting privacy and reducing breach risks.

18. What is the term for billing the same service more than once for the same date?

    Duplicate billing. This occurs when claims are submitted multiple times for identical services on the same date, against compliance rules.

19. Which term means unbundling services that should be billed as a single code?

    Unbundling. This violates coding rules by separating procedures that CPT bundles into one comprehensive code for billing.

20. What is the term for billing separately for components included in a comprehensive code?

    Fragmentation (unbundling). Coding guidelines prohibit billing individual elements of a procedure when a single code encompasses them all.

21. Which modifier indicates a valid ABN is on file for an expected Medicare denial?

    Modifier $GA$. This CPT modifier signals that an ABN was provided and signed, allowing billing the patient upon Medicare denial.

22. What is the purpose of NCCI edits in claims processing?

    To prevent improper coding and unbundling of services. CMS implements these edits to detect and deny inappropriate code combinations, ensuring proper reimbursement.

23. What is PHI under HIPAA?

    Individually identifiable health information in any form. HIPAA protects health data that can be linked to an individual, regardless of whether it is electronic, paper, or oral.

24. Which modifier indicates an item or service is statutorily excluded or never covered?

    Modifier $GY$. Used in CPT coding to denote services excluded by Medicare statute, enabling patient billing without an ABN.

25. Identify when an ABN should be issued for a Medicare beneficiary.

    Before providing a service expected to be denied as not reasonable/necessary. Medicare requires issuing this notice prior to services anticipated to be deemed non-medically necessary or unreasonable.

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