Compliance and Regulatory
This domain tests the federal and state rules that govern coding, billing, documentation, and privacy, plus the structure of an effective compliance program. Items frequently place you in an audit finding and ask what the rule requires next.
Fraud and abuse laws
- False Claims Act: liability for knowingly presenting or causing a false claim; treble damages plus per-claim penalties, with qui tam relators receiving a share. "Knowingly" includes deliberate ignorance and reckless disregard, so no specific intent is required.
- Anti-Kickback Statute: prohibits remuneration intended to induce referrals for federally payable business; intent-based, with safe harbors.
- Stark Law: strict liability prohibiting physician self-referral of designated health services when a financial relationship exists, absent an exception.
- Civil Monetary Penalties Law and OIG exclusion (check the LEIE).
- 60-day overpayment rule: identified overpayments must be quantified, reported, and returned within 60 days of identification; retained overpayments create FCA exposure.
Compliance program and audits
The seven elements of an effective compliance program: written policies, procedures, and standards of conduct; a compliance officer and committee; training and education; effective lines of communication; internal monitoring and auditing; well-publicized disciplinary standards; and prompt response with corrective action. Audit sources include internal coding audits, MAC medical necessity review (NCD/LCD), RAC post-payment review, UPIC, and CERT. NCCI procedure-to-procedure edits and medically unlikely edits cannot be overridden by modifiers unless documentation supports it.
Documentation integrity
Code only what is documented and supported. Query when the record is ambiguous, inconsistent, or unspecified; leading queries are prohibited. Inpatient records may code "probable" or "suspected" conditions as if established, but outpatient records may not.
Worked example
An auditor finds outpatient claims coded J18.9 where the physician documented "possible pneumonia." Outpatient guidelines bar coding uncertain diagnoses, so the claim should carry only supported signs or symptoms. The finding is an overpayment: quantify it, correct the claims, refund within 60 days, and address the root cause through provider education and a query practice rather than by editing future records after the fact.
Traps that cost marks
Applying an intent standard to Stark or assuming the False Claims Act requires proof of intent; relying on a query answer not documented in the record; missing the 60-day clock; overriding NCCI edits with modifier 25 without documented significant, separately identifiable service; and confusing abuse (inconsistent with accepted practice) with fraud (intentional deception).