CPMA Medical Auditor flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Seven compliance program elements

Written policies, a compliance officer and committee, training, communication lines, internal monitoring and auditing, enforcement and discipline, and prompt corrective action form the OIG's seven elements.

Anti-Kickback Statute

Prohibits knowingly offering or paying remuneration to induce referrals of federally reimbursable items or services; violations are criminal and require intent.

Stark Law

Civil strict-liability statute barring physician self-referral of designated health services to Medicare patients unless a regulatory exception applies to the financial relationship.

False Claims Act liability

Imposes treble damages plus per-claim civil penalties on entities that knowingly submit or cause false claims; qui tam relators may receive 15 to 30 percent of the recovery.

Compliance risk assessment

Process that identifies, ranks, and prioritizes compliance risks by likelihood and impact so auditing, training, and monitoring resources target the highest exposures.

Deficit Reduction Act education

Requires entities receiving at least $5 million in annual Medicaid payments to educate employees, contractors, and agents about false claims laws.

Mandatory versus permissive exclusion

OIG must exclude providers convicted of certain offenses, while permissive exclusion is discretionary for other conduct; both remove Medicare and Medicaid billing eligibility.

Statistical sampling

Random selection in which every unit has a known chance of selection, allowing sample results to be projected to the population with stated confidence and precision.

Error rate calculation

Divide the number of sampled units containing errors by the total units reviewed, then multiply by 100 to express the result as a percentage.

Extrapolated overpayment

Estimated recovery calculated by applying the sample error rate to the total dollar value of the sampling universe, reported with a confidence interval.

RAT-STATS software

Free statistical software published by the OIG that draws random samples and calculates confidence intervals and projected overpayments for audit findings.

Probe sample

Small preliminary review, often 20 to 50 units, used to estimate an error rate and decide whether a full statistical sample is warranted.

Monitoring versus auditing

Monitoring is ongoing, real-time oversight performed by operations; auditing is periodic, independent, documented review of records against defined requirements.

2021 E/M level selection

Office and outpatient levels are set by medical decision making or total time spent on the encounter date; history and examination no longer determine the level.

Medical decision making components

The level requires two of three: number and complexity of problems, amount and complexity of data reviewed, and risk of complications or morbidity.

Modifier 25

Appended to a significant, separately identifiable evaluation and management service performed on the same day as a procedure by the same physician.

Modifier 59

Indicates a procedure was distinct and independent from other services on the same date; use only when no more specific X{EPSU} modifier applies.

Global surgical package

Bundles preoperative, intraoperative, and postoperative services into one payment for a defined period of 0, 10, or 90 days.

Incident-to billing requirements

Service furnished under the physician's plan of care to an established patient while the physician provides direct supervision in the office suite.

Documentation authentication

Every entry must be signed and dated by its author; missing, illegible, or unauthorized signatures are deficiencies requiring a query or attestation.

Medicare fee schedule formula

Payment equals the sum of work, practice expense, and malpractice RVUs, each adjusted by its geographic practice cost index, multiplied by the conversion factor.

NCCI modifier indicator 0

The code pair is not payable together and no modifier may override the edit; both services cannot be billed separately.

Advance Beneficiary Notice

CMS-R-131 form given before a service when Medicare coverage is expected to be denied; a valid signed notice shifts financial liability to the patient.

Clean claim rate

Number of claims accepted on first submission without edits or rejections divided by total claims submitted, expressed as a percentage.

Days in accounts receivable

Total accounts receivable divided by average daily gross charges; measures how many days of revenue remain outstanding.

Contractual adjustment

Difference between billed charges and the payer's allowed amount written off per contract; it is not billed to or owed by the patient.

Executive summary

Concise opening section covering objective, scope, methodology, key findings, error rate, and recommendations for leaders who may not read the full report.

Corrective action plan elements

For each finding, states the root cause, specific action, responsible owner, target completion date, and method for validating that the fix worked.

Exit conference

Meeting with auditee management before the final report to confirm facts, clarify findings, and obtain management responses and corrective commitments.

Root cause analysis

Analysis identifying underlying process failures such as missing education, edit failures, or template problems rather than blaming individual coders.

Work paper documentation

Retain purpose, scope, sources, sample selection method, findings, and reviewer sign-off so another auditor could reproduce the results.

Report distribution controls

Limit reports to staff with a need to know, mark them confidential, and route legally sensitive findings through compliance counsel.