CHC Study Guide (2022/2023) Rated A+
Federal Sentencing Guidelines - Culpability Score Aggravating Factors ✔✔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 ✔✔1. effective
compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program ✔✔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... ✔✔...having a policy and not following it.
Medicare reimbursement - hospital inpatient codes ✔✔International Classification of Diseases
(ICD)
Medicare reimbursement - physician codes ✔✔Current Procedural Technology (CPT)
Questions to guide the scope of an internal investigation. ✔✔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 _______. ✔✔...take an active rather
than a passive role in compliance.
,Six tips for saving on future costs of compliance. ✔✔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 ✔✔1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness ✔✔1. staff knowledge
2. all 7 elements included
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 ✔✔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) ✔✔a statistical classification system that arranges
diseases and injuries into groups according to established criteria (signs and symptoms)
Current Procedural Terminology (CPT) ✔✔American Medical Association publishes and
maintains this coding system
Organized Health Care Arrangements (OHCA) ✔✔HIPAA arrangement between clinically
integrated setting (ex: hospitals and medical staff)
Federal Sentencing Guidelines - Culpability Score Aggravating Factors ✔✔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 ✔✔1. effective
compliance program
2. reported promptly
3. cooperation with investigation
4. accept responsibility
Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program ✔✔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... ✔✔...having a policy and not following it.
Medicare reimbursement - hospital inpatient codes ✔✔International Classification of Diseases
(ICD)
Medicare reimbursement - physician codes ✔✔Current Procedural Technology (CPT)
Questions to guide the scope of an internal investigation. ✔✔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 _______. ✔✔...take an active rather
than a passive role in compliance.
,Six tips for saving on future costs of compliance. ✔✔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 ✔✔1. outline the current operational standards
2. identify real and potential weaknesses
3. offer recommendations
Compliance Program - Measures of Effectiveness ✔✔1. staff knowledge
2. all 7 elements included
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 ✔✔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) ✔✔a statistical classification system that arranges
diseases and injuries into groups according to established criteria (signs and symptoms)
Current Procedural Terminology (CPT) ✔✔American Medical Association publishes and
maintains this coding system
Organized Health Care Arrangements (OHCA) ✔✔HIPAA arrangement between clinically
integrated setting (ex: hospitals and medical staff)
