Federal Sentencing Guidelines - Culpability Score Aggravating Factors - ANSWER 1. upper-
level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sentencing Guidelines - Culpability Score Mitigating Factors - ANSWER 1. effective
compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program - AN-
SWER 1. written standards of conduct
2. Chief Compliance Officer
3. effective education and training
4. audits and evaluations to monitor compliance
5. reporting processes and procedures for complaints
6. appropriate disciplinary mechanisms
7. investigation and remediation of systematic problems
The only thing worse than not having a policy is... - ANSWER ...having a policy and not
following it.
1
,Medicare reimbursement - hospital inpatient codes - ANSWER International Classification
of Diseases (ICD)
Medicare reimbursement - physician codes - ANSWER Current Procedural Technology
(CPT)
Questions to guide the scope of an internal investigation. - ANSWER 1. What is the origin
of the issue?
2. When did the issue originate?
3. How far back should the investigation go?
4. Can extrapolation of a statistical sample be used?
It is in the best interest of the organization to have the board _______. - ANSWER ...take
an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance. - ANSWER 1. embed quality into existing
processes
2. centralize common processes and controls
3. improve human resources infrastructures
4. improve information systems processes
5. emphasize training
6. monitor marketing and compensation
Baseline Audit Process - ANSWER 1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness - ANSWER 1. staff knowledge
2. all 7 elements included
2
,3. comparing issues year to year
4. tracking and trending complaints
5. tracking corrective actions
6. reviewing current audits
7. educational session pre and post tests
8. tracking bill denials
9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
Modifier - ANSWER a two digit alpha/numeric code used in conjunction with CPT or
HCPCS codes that may increase or decrease reimbursement
gives new meaning to the code
International Classification of Diseases (ICD) - ANSWER a statistical classification system
that arranges diseases and injuries into groups according to established criteria (signs and
symptoms)
Current Procedural Terminology (CPT) - ANSWER American Medical Association publishes
and maintains this coding system
Organized Health Care Arrangements (OHCA) - ANSWER HIPAA arrangement between
clinically integrated setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) - ANSWER an inpatient classification system based on:
principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status
3
, Healthcare Common Procedure Coding System (HCPCS) - ANSWER for medication, main-
tained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare pro-
gram using this expanded version
Upcoding - ANSWER providers use a billing code that reflects a higher payment rate for a
device or service provided than the actual device or service furnished to the patient
Unbundling - ANSWER submitting bills by piecemeal or in fragmented fashion to maxim-
ize reimbursement
Outlier - ANSWER additional payment for patients with long hospital length of stay
Billing and Coding Concerns (*) - ANSWER 1. coding advice (if not in book - get in writing)
2. significant increases in volume (*) (find out why increase)
3. hiring external consultants (need BAA, if provide patient care - check OIG sanction list)
4. number of auditors for Part B audits
5. teaching physicians (*) (physician must be physically present and involved in managing
care)
6. co-pay waivers (cannot routinely waive)
7. record does not support code
8. research payments (cannot bill Medicare for costs covered by sponsor)
9. disagreements (get 3rd party opinion)
10. DOCUMENTATION
"Incident To" services - ANSWER services commonly furnished in a physician's office by a
nurse practitioner in which there is direct physician personal supervision and are billed un-
der the physician's provider number (does not apply in hospital setting)
4
level employee participates, condones, or ignores offense
2. repeat offense
3. hinder investigation
4. awareness and tolerance of violation is pervasive
Federal Sentencing Guidelines - Culpability Score Mitigating Factors - ANSWER 1. effective
compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program - AN-
SWER 1. written standards of conduct
2. Chief Compliance Officer
3. effective education and training
4. audits and evaluations to monitor compliance
5. reporting processes and procedures for complaints
6. appropriate disciplinary mechanisms
7. investigation and remediation of systematic problems
The only thing worse than not having a policy is... - ANSWER ...having a policy and not
following it.
1
,Medicare reimbursement - hospital inpatient codes - ANSWER International Classification
of Diseases (ICD)
Medicare reimbursement - physician codes - ANSWER Current Procedural Technology
(CPT)
Questions to guide the scope of an internal investigation. - ANSWER 1. What is the origin
of the issue?
2. When did the issue originate?
3. How far back should the investigation go?
4. Can extrapolation of a statistical sample be used?
It is in the best interest of the organization to have the board _______. - ANSWER ...take
an active rather than a passive role in compliance.
Six tips for saving on future costs of compliance. - ANSWER 1. embed quality into existing
processes
2. centralize common processes and controls
3. improve human resources infrastructures
4. improve information systems processes
5. emphasize training
6. monitor marketing and compensation
Baseline Audit Process - ANSWER 1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness - ANSWER 1. staff knowledge
2. all 7 elements included
2
,3. comparing issues year to year
4. tracking and trending complaints
5. tracking corrective actions
6. reviewing current audits
7. educational session pre and post tests
8. tracking bill denials
9. organizational survey results
10. audit results
11. compliance topics on department/organization agendas
Modifier - ANSWER a two digit alpha/numeric code used in conjunction with CPT or
HCPCS codes that may increase or decrease reimbursement
gives new meaning to the code
International Classification of Diseases (ICD) - ANSWER a statistical classification system
that arranges diseases and injuries into groups according to established criteria (signs and
symptoms)
Current Procedural Terminology (CPT) - ANSWER American Medical Association publishes
and maintains this coding system
Organized Health Care Arrangements (OHCA) - ANSWER HIPAA arrangement between
clinically integrated setting (ex: hospitals and medical staff)
Diagnosis Related Group (DRG) - ANSWER an inpatient classification system based on:
principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status
3
, Healthcare Common Procedure Coding System (HCPCS) - ANSWER for medication, main-
tained by CMS
CMS contracts with American Medical Association to use CPT coding for the Medicare pro-
gram using this expanded version
Upcoding - ANSWER providers use a billing code that reflects a higher payment rate for a
device or service provided than the actual device or service furnished to the patient
Unbundling - ANSWER submitting bills by piecemeal or in fragmented fashion to maxim-
ize reimbursement
Outlier - ANSWER additional payment for patients with long hospital length of stay
Billing and Coding Concerns (*) - ANSWER 1. coding advice (if not in book - get in writing)
2. significant increases in volume (*) (find out why increase)
3. hiring external consultants (need BAA, if provide patient care - check OIG sanction list)
4. number of auditors for Part B audits
5. teaching physicians (*) (physician must be physically present and involved in managing
care)
6. co-pay waivers (cannot routinely waive)
7. record does not support code
8. research payments (cannot bill Medicare for costs covered by sponsor)
9. disagreements (get 3rd party opinion)
10. DOCUMENTATION
"Incident To" services - ANSWER services commonly furnished in a physician's office by a
nurse practitioner in which there is direct physician personal supervision and are billed un-
der the physician's provider number (does not apply in hospital setting)
4
