Reimbursement and Compliance
What the candidate must know
Understand how coded data drives payment. In inpatient settings, MS-DRGs group stays by principal diagnosis, procedures, complications, and severity; in outpatient and physician settings, APCs and the MPFS/RVUs apply. Know the components of the physician fee schedule (work, practice expense, malpractice), the role of NCCI edits and modifiers in preventing improper unbundling, and the concept of medical necessity. Recognize the elements of a compliance program (policies, training, auditing, monitoring, reporting) and the purpose of RAC/MAC audits.
Traps in questions
- Assuming a higher-paying code is acceptable if "close" - upcoding is fraud.
- Forgetting that modifiers must be supported by documentation, not added to bypass edits.
- Confusing bundling (correctly reporting one comprehensive code) with unbundling (improper separate reporting).
- Overlooking that medical necessity must be documented, not inferred.
Rule of thumb
Code what the documentation supports - never what pays best. If the record does not justify it, the code does not belong.
Worked example: A claim pairs a comprehensive procedure with a component procedure from the same family. An NCCI edit flags the pair. Unless a documented, appropriate modifier (e.g., distinct service) is justified, report only the comprehensive code; adding the component without support is unbundling.