CPCO Compliance Officer cheat sheet

The seven elements of an effective compliance program: written policies, compliance officer and committee, training and education, communication lines, internal monitoring and auditing, enforcement and discipline, and response and prevention.

The False Claims Act imposes liability for knowingly presenting false claims; penalties per claim are adjusted annually for inflation and can include treble damages.

The Anti-Kickback Statute prohibits remuneration to induce referrals for items or services reimbursed by federal healthcare programs; safe harbors provide protection for specific arrangements.

The Stark Law (Physician Self-Referral Law) prohibits physician referrals for designated health services to entities with which the physician has a financial relationship, unless an exception applies.

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects individually identifiable health information; the Security Rule sets standards for electronic protected health information.

The Office of Inspector General (OIG) publishes a Compliance Program Guidance for individual and small group physician practices; following it is voluntary but can mitigate penalties.

A compliance program should include a designated compliance officer, a compliance committee, and a code of conduct that is reviewed and updated periodically.

The Civil Monetary Penalties Law authorizes penalties for various violations, including false claims and kickbacks; amounts are published in the Federal Register.

The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to provide a medical screening examination and stabilizing treatment for emergency conditions regardless of ability to pay.

The audit process includes planning, sampling, data collection, analysis, reporting, and follow-up; each step should be documented.

Statistical sampling allows extrapolation of error rates; the sample size and confidence level must be defined before the audit.

The OIG Work Plan lists current audit and enforcement priorities; it is updated annually and guides compliance auditing.

The audit scope should define the time period, provider types, and claim types; a baseline audit establishes the current error rate.

The error rate is calculated as the number of claims with errors divided by the total number of claims audited, expressed as a percentage.

Root cause analysis identifies underlying causes of coding or billing errors; corrective action plans should address each cause.

The Compliance Program Effectiveness audit evaluates whether the seven elements are functioning; it is separate from claims audits.

Audit findings should be reported to the compliance committee and governing body; documentation of corrective actions is essential.

The RAT-STATS statistical software, developed by the OIG, is used for random sampling and extrapolation in audits.

ICD-10-CM codes are used for diagnoses; ICD-10-PCS codes are used for inpatient procedures; CPT codes are used for outpatient procedures and services.

The ICD-10-CM Official Guidelines for Coding and Reporting must be followed; they are updated annually and include conventions such as 'code first' and 'excludes1'.

CPT codes are maintained by the American Medical Association; Category I codes have five digits, Category II codes are for performance measurement, and Category III codes are for emerging technology.

Evaluation and Management (E/M) coding requires selection of the appropriate level based on medical decision making or time, per current CPT guidelines.

HCPCS Level II codes are used for supplies, drugs, and services not represented in CPT; they are maintained by CMS.

Modifiers indicate that a service or procedure has been altered; common modifiers include -25 (significant, separately identifiable E/M service) and -59 (distinct procedural service).

The coding process includes reviewing the medical record, assigning codes, and verifying code accuracy; coding must be supported by documentation.

The Medicare National Correct Coding Initiative (NCCI) edits prevent improper payment when services are billed together; they include column one/column two edits and medically unlikely edits.

Coding audits should be performed regularly to ensure compliance with coding guidelines and to identify educational needs.

The CMS-1500 claim form is used for billing outpatient services; the UB-04 claim form is used for institutional services.

The revenue cycle includes patient registration, charge capture, coding, claim submission, payment posting, and denial management.

Clean claim rate is the percentage of claims accepted on first submission without errors; it is a key performance indicator.

The Accounts Receivable (A/R) days metric measures the average number of days to collect payment; it is calculated as (total A/R / total charges) x days in period.

The Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) explains payments, adjustments, and denials; it should be reconciled with the claim.

The Medicare Physician Fee Schedule (MPFS) determines payment for physician services; it includes relative value units (RVUs) and a conversion factor.

The Outpatient Prospective Payment System (OPPS) uses Ambulatory Payment Classifications (APCs) to pay for hospital outpatient services.

Denial management includes identifying denial reasons, appealing when appropriate, and implementing preventive measures.

The coordination of benefits (COB) determines the primary and secondary payer when a patient has multiple insurance coverage.