Unit 1: Healthcare System and Settings

• Topic 01

  Healthcare Delivery Models — Inpatient, Outpatient, and Ambulatory Care

  57 questions
• Topic 02

  Healthcare Professionals and Their Roles

  48 questions
• Topic 03

  Types of Healthcare Facilities — Hospital, Clinic, SNF, ASC

  21 questions
• Topic 04

  The Revenue Cycle — Patient Access through Payment

  33 questions
• Topic 05

  Compliance and the False Claims Act

  45 questions
• Topic 06

  OIG Compliance Programmes and Fraud/Abuse Definitions

  42 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. An emergency department patient presents with shortness of breath. The physician documents 'rule out pulmonary embolism' and orders a CT pulmonary angiogram. The CT results return negative; the discharge diagnosis is 'shortness of breath, cause undetermined.' What is the correct first-listed diagnosis for this outpatient encounter?

   • A
     Pulmonary embolism with a 'ruled out' modifier — ICD-10-CM provides specific codes for conditions that are ruled out during a diagnostic workup
   • B
     Code the CT pulmonary angiogram procedure as the primary service with no diagnosis code, because no confirmed diagnosis was established
   • C
     Code both shortness of breath and pulmonary embolism, with shortness of breath first, because the physician documented both in the encounter note
   • D
     Shortness of breath (dyspnea) — code the confirmed symptom that drove the encounter, not the ruled-out condition; the negative CT result confirms pulmonary embolism was not present
     Correct answer
   Explanation

   In outpatient settings, 'rule out' conditions are not coded. The coding principle is: code what is confirmed. At discharge, the confirmed condition is shortness of breath (dyspnea) — the pulmonary embolism was specifically ruled out by the negative CT. The sign/symptom (shortness of breath) is the appropriate first-listed diagnosis. If a definitive cause had been identified, it would replace the symptom code. ICD-10-CM does not have 'ruled out' modifier codes for this purpose. Key takeaway: 'rule out' diagnoses are never coded in outpatient settings; code the confirmed sign/symptom instead.

2. What is the '60-day rule' as it relates to overpayments under the Affordable Care Act?

   • A
     Providers must report and return identified Medicare or Medicaid overpayments within 60 days of identifying them; failure to do so creates a False Claims Act obligation
     Correct answer
   • B
     Providers must complete an internal audit within 60 days of receiving an OIG audit notice
   • C
     Providers have 60 days from the date of service to submit a corrected claim if a billing error is identified
   • D
     Providers have 60 days to appeal a Medicare overpayment demand before it becomes final and subject to interest charges
   Explanation

   The 60-day rule is codified at 42 U.S.C. § 1320a-7k(d) (ACA Section 6402). Once a provider has identified — or should have identified through reasonable diligence — a Medicare or Medicaid overpayment, it has 60 days to report and return the funds. Failure to return a known overpayment within 60 days converts the retention into a 'reverse false claim' under the FCA, with full treble damages and per-claim penalty exposure. Key takeaway: identified overpayments must be reported and returned within 60 days, or the provider faces reverse false claim liability under the FCA.

3. What is a Corporate Integrity Agreement (CIA), and when does the OIG typically impose one?

   • A
     A CIA is a court-ordered consent decree issued by a federal judge requiring criminal compliance monitoring after a guilty plea
   • B
     A CIA is a joint agreement between a provider and its payers that establishes claims adjudication standards
   • C
     A CIA is a contract between CMS and a provider that sets billing limits and prior authorization requirements for the next year
   • D
     A CIA is a settlement agreement between OIG and a provider that resolves compliance concerns short of exclusion; OIG typically imposes one when settling FCA or OIG enforcement matters to allow the provider to remain in federal programs under heightened oversight
     Correct answer
   Explanation

   A Corporate Integrity Agreement is a voluntary settlement instrument negotiated between OIG and a provider to resolve compliance issues without imposing exclusion. CIAs typically last five years and require the provider to implement specific compliance measures, including hiring an Independent Review Organization (IRO) to audit claims, submitting annual reports to OIG, and certifying board compliance. They are not criminal convictions or court orders, and entering a CIA does not constitute an admission of wrongdoing. Key takeaway: CIA = OIG settlement allowing continued program participation under five-year heightened oversight; not a criminal conviction.