Compliance

CCS-P · 61 questions

• An outpatient clinic note lists “possible cellulitis” without a confirmed diagnosis. The coder wants a clearer diagnosis for coding. Which approach is compliant?
• A wrist fracture is documented in a physician office note without laterality. Which query approach is appropriate?
• Wanting a higher office E/M level, a coder asks the provider, “Can we say high complexity MDM?” What is the compliance assessment of that query?
• A clinic note documents tachycardia, poor skin turgor, and elevated BUN, but the assessment does not state dehydration. What is an appropriate next step?
• A coder obtains only a verbal clarification from a physician about a missing clinic diagnosis detail and keeps no written query record. Why is this a compliance concern?
• Multiple clinically reasonable explanations exist for an abnormal clinic finding, but the coder sends a yes/no query naming only one diagnosis. What is the better practice?
• A coder drafts a query introducing a diagnosis that has no clinical indicators anywhere in the physician office chart. How should that query be classified?
• Nursing triage lists “MI,” but the physician’s assessment for the same clinic visit documents GERD as the diagnosis after evaluation. Which documentation governs diagnosis coding?
• A scribe documents a complete physician office visit note that has not been authenticated by the physician. Can the coder rely on that note for code assignment yet?
• In a multi-specialty clinic, today's note shows a copy-forwarded HPI describing severe dyspnea, but the physician's exam today documents clear lungs, normal vitals, and a resolved cough with no dyspnea. Which coding judgment is correct?
• A dermatology clinic physician documents skin lesion excision and notes that the outside pathology report confirming basal cell carcinoma is in the chart and was reviewed. What is the correct approach to diagnosis support?
• An EHR problem list auto-populates several ICD-10-CM codes onto a primary-care claim, but today's assessment addresses only hypertension refill with no mention of the other listed conditions. How should the coder proceed?
• A rheumatology physician documents review and summary of outside rheumatology records and labs, then incorporates findings into today's assessment. Which statement about documentation support is correct?
• During an office visit the patient states, 'I have rheumatoid arthritis,' but the clinician documents joint pain for evaluation and does not confirm or assess RA. What is the correct coding approach?
• A billing manager asks the coder to append modifier 59 to a procedure pair solely to bypass an NCCI PTP edit, with no documentation that the services were distinct. What is the ethical response?
• A clinic physician asks the coder to select a higher-level office E/M 'because the payer pays better,' even though MDM and time support only a lower level. What should the coder do?
• A provider asks the coder to omit a documented, treated chronic condition that maps to an HCC because 'we don't want to label the patient,' even though the assessment and plan address it today. What is the ethical coding action?
• Billing staff urge the coder to finalize CPT and ICD-10-CM codes from a half-finished office note so the claim can drop before month-end, with the physician still adding assessment and plan later. What is the correct ethical timing?
• For a Medicare patient receiving a knee joint injection in clinic, the LCD lists specific covered indications. The note documents osteoarthritis of the knee meeting those indications. How should diagnosis pointers be handled ethically?
• A physician-practice compliance lead uses the OIG Work Plan to prioritize internal audits of E/M leveling and incident-to billing. Which use of that focus is appropriate?
• Documentation supports a simple repair, but a higher-paying intermediate repair CPT is financially attractive. What ethical CPT selection rule applies?
• A Medicare office claim is ready, but the supporting encounter note lacks an authenticated provider signature. What is the correct compliance action?
• A paper clinic note ends with an illegible handwritten scribble and no printed name, credential, or other authentication method identifying the author. How should this signature issue be viewed?
• A Medicare auditor flags a clinic note missing a signature. The practice prepares a signature attestation statement when payer rules allow remediation. Which concept is correct?
• A physician-office lab draw and outside imaging referral are ordered for a Medicare patient. What signature-related requirement should the coding/compliance team confirm?
• An electronic signature timestamp on a clinic note shows authentication several days after the claim was already submitted. What compliance concern does this raise?
• A multi-specialty group reviews E/M levels on selected charts before claims are released to the payer. Which audit-timing concept does this describe?
• Compliance selects a random sample of 25 physician-office charts that used modifier 25 for focused review. What audit-methodology idea does this illustrate?
• An internal audit finds identical MDM paragraphs across many different patients' office notes with conflicting exam findings. What is the most accurate compliance interpretation?
• A clinic compares each coder's final codes on a sample set against an external auditor's baseline review of the same charts. What quality concept is being applied?
• An audit finds repeated incident-to billing failures in a primary-care clinic. Beyond recording an error rate, what follow-through is required?
• A RAC or commercial payer requests records for selected physician-office claims under audit. What is the appropriate response approach?
• In an elevator, a coder tells a coworker details about a celebrity patient's diagnosis and upcoming procedure. What HIPAA judgment applies?
• A billing analyst emails an unencrypted spreadsheet of claim denials that includes patient names and account numbers to a personal Gmail account to finish work at home. What is the correct HIPAA security assessment?
• A multi-specialty clinic billing clerk asks a coder for the full psychotherapy note so the claim form looks complete. Under HIPAA minimum necessary, what should the coder provide for routine professional-fee billing?
• A patient at a physician office pays the full allowed amount out of pocket for today’s visit and asks the practice not to tell the health plan about that encounter. What HIPAA right should the front-desk and coding staff recognize?
• A coding specialist in a group practice opens a neighbor’s electronic health record out of curiosity, with no assigned coding or billing duty for that patient. How should this access be classified?
• Ransomware encrypts the clinic EHR and may have exposed electronic protected health information. At the HIM/coder awareness level, what is the most appropriate immediate organizational expectation?
• Audit trends show several orthopedic physicians repeatedly omit laterality for joint and fracture diagnoses, forcing unspecified ICD-10-CM codes. What education approach best supports compliant physician-office coding?
• Clinic nursing staff frequently take verbal orders that remain unsigned for days, delaying procedure coding. What should coding education emphasize to ancillary staff?
• Office/outpatient E/M guidelines have changed how medical decision making (MDM) is scored. What is an appropriate coding-compliance education response for the physician group?
• Advanced practice providers and supervising physicians in a primary-care clinic are unclear when Medicare incident-to billing is allowed. What should compliance education prioritize?
• Internal coding audits reveal recurring documentation weaknesses in one specialty section. How should findings be shared to educate providers effectively and ethically?
• A physician evaluates and treats a patient in the group’s freestanding office suite that the practice owns and operates. Which place-of-service concept should appear on the professional claim?
• The same physician sees an established patient in a hospital outpatient clinic rather than in the freestanding group office. Why does place-of-service selection matter for the professional claim?
• A physician in the office suite provides a real-time audiovisual telehealth visit to a Medicare patient at home. What is the coder’s best approach to place of service and telehealth reporting?
• A physician performs an evaluation and management service for a patient residing in a nursing facility, with the encounter occurring at the nursing facility. Which POS concept is appropriate on the professional claim?
• A surgeon from a multi-specialty group performs a procedure in an ambulatory surgical center and bills the professional fee. Which place-of-service selection is appropriate?
• A professional claim contains accurate CPT and ICD-10-CM codes but the wrong place of service. What compliance lesson should coding staff reinforce?
• An APP in a physician office evaluates a Medicare patient for a brand-new problem. The physician has not personally performed the initial service or established a plan of care for that problem. How should incident-to billing be handled?
• For Medicare incident-to billing of an APP office visit that otherwise meets plan-of-care and employment requirements, what supervision concept is required?
• A physician group wants to bill Medicare incident-to for services furnished by an APP who works purely as an independent contractor with no W-2 or leased-employee arrangement. What is the compliance concern?
• When all Medicare incident-to requirements are met for an APP office service, how does billing under the physician typically compare with billing under the APP?
• An APP furnishes a service in a hospital outpatient department. The group asks whether Medicare incident-to can be used the same way as in the freestanding physician office. What is the correct compliance understanding?
• A clinic plans to bill an APP follow-up under Medicare incident-to. Beyond clinical content, what documentation linkage should coding staff look for to support the claim?
• Medicare is expected to deny a physician-office service as not medically necessary. When is an Advance Beneficiary Notice of Noncoverage (ABN) appropriate?
• Staff want to issue a Medicare ABN solely because a commercial secondary insurer might deny a service. What is the correct scope understanding?
• A front-desk workflow uses a mostly blank ABN that does not name the specific service or the reason Medicare may deny. How should coding/compliance evaluate that form?
• A Medicare patient refuses to sign an ABN that was properly presented before a service the practice believes Medicare will deny. What should staff do?
• A multi-specialty clinic plans a cosmetic skin treatment that Medicare never covers as a statutory exclusion. Front desk staff want to use a Medicare ABN so the patient can be billed if Medicare denies. What is the correct notice approach?
• A Medicare patient at a primary-care office requests another covered preventive service that already exceeds Medicare’s allowed frequency for the period. Denial for frequency is expected. When should the practice consider an ABN?