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Exam 5: Legal and Regulatory Issues

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Question 21

Multiple Choice

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Which flat file is used to bill physician and noninstitutional services, such as services reported by a general practitioner, on the CMS-1500?

A) CDT
B) EDI
C) NSF
D) UB-04

E) C) and D)
F) B) and D)

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Question 22

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Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider's failure to disclose that the injury was work-related.

A) adjudication
B) mediation
C) overpayment
D) unbundling

E) All of the above
F) B) and C)

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Question 23

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Which documents patient information sent to authorized requestors and can be kept in manual or software formats?

Any information communicated by the __________ is considered privileged communication, and HIPAA provisions address the privacy and security of protected health information.

Which program was implemented to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare?

The Medicare Integrity Program includes medical review, which is defined by CMS as a review of claims to determine whether services provided are __________, as well as to followup on the effectiveness of previous corrective actions.

Which is a legal document containing a list of questions that must be answered in writing?

Criminal law is __________ law (statute or ordinance) that defines crimes and their prosecution.

Court decisions that establish a standard create __________ law.

Which consists of audits implemented by DHHS that examines the billing practices of physicians at teaching hospitals with the focus on compliance with the Medicare rule affecting payment for physician services provided by residents and whether the level of the physician service was coded and billed properly?

Which was created by the Centers for Medicare and Medicaid Services for the purpose of assigning unique identifiers to health care providers and health plans?

Which is testimony under oath taken outside of court, such as at the physician's office?

Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment) , some hospitals engage in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.

Civil law deals with all areas of the law that are not classified as __________ law.

Which authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program?

Which is a variable-length file format used to bill institutional, professional, dental, and drug claims?

Laws that are implemented as guidelines written by administrative agencies, such as CMS, are called __________.

Which was implemented to assist with CMS audit, oversight, anti-fraud, and anti-abuse efforts related to the Medicare Part D benefit?

Which established the Hospital IQR, RAC, and ZPIC programs?

Which specifically requires an individual's authorization prior to disclosure and for which HIPAA has established specific requirements for an authorization form?