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CPMA Medical Auditor practice questions

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Question 1Compliance and Ethics

Which federal statute creates civil liability for knowingly presenting a false or fraudulent claim to a federal health care program?

  1. The False Claims Act Correct answer.
  2. The physician self-referral law
  3. The Health Insurance Portability and Accountability Act
  4. The Anti-Kickback Statute

Explanation

The False Claims Act imposes treble damages plus per-claim civil penalties on persons who knowingly present, or cause to be presented, false or fraudulent claims to the federal government. The Anti-Kickback Statute and Stark Law address remuneration and referral arrangements rather than the claim itself, and HIPAA governs privacy and security of health information.

Question 2Compliance and Ethics

The federal Anti-Kickback Statute prohibits knowingly and willfully offering or paying remuneration to induce which of the following?

  1. Referrals for services that federal programs never cover
  2. Referrals for items or services paid only by commercial insurers
  3. Referrals for items or services payable by a federal health care program Correct answer.
  4. Referrals to providers that are not enrolled in Medicare

Explanation

The statute reaches any item or service for which payment may be made in whole or in part under a federal health care program, and it requires knowing and willful conduct. Arrangements involving only commercial payers or non-covered services fall outside its reach, although state law may still apply.

Question 3Compliance and Ethics

The physician self-referral law (Stark) restricts physician referrals of Medicare patients for which category of services?

  1. All services regardless of payer
  2. Designated health services, unless an exception applies Correct answer.
  3. Only inpatient hospital procedures
  4. Only outpatient prescription drugs

Explanation

Stark prohibits a physician from referring patients for designated health services, such as clinical laboratory, imaging, and physical therapy, to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies. The prohibition is limited to the statutory list of designated health services and does not extend to every service a physician might order.

Question 4Compliance and Ethics

Which requirement appears among the OIG's seven elements of an effective compliance program at the leadership level?

  1. Designation of a compliance officer and compliance committee Correct answer.
  2. A licensed physician serving as the compliance officer
  3. An annual external audit of every claim submitted
  4. A published list of excluded providers

Explanation

The seven elements include written standards, designated leadership, effective training and education, open lines of communication, internal monitoring and auditing, consistent enforcement, and prompt corrective action. The OIG expects a designated compliance officer and committee with defined authority and reporting to the governing body.

Question 5Compliance and Ethics

The HIPAA minimum necessary standard requires covered entities to do which of the following?

  1. Obtain patient authorization before any internal use of PHI
  2. Retain all PHI for a minimum of ten years after discharge
  3. Limit PHI used or disclosed to the minimum needed for the purpose Correct answer.
  4. Disclose only the patient's name and date of birth to any requester

Explanation

The minimum necessary standard requires reasonable efforts to limit protected health information to the least amount needed to accomplish the intended purpose. It applies to uses, disclosures, and requests, with exceptions such as treatment, disclosures to the individual, and disclosures required by law.

Question 6Compliance and Ethics

Which database should a provider check to confirm that an employee or contractor is not excluded from federal health care programs by the OIG?

  1. The Healthcare Common Procedure Coding System file
  2. The OIG List of Excluded Individuals/Entities (LEIE) Correct answer.
  3. The Medicare Physician Fee Schedule
  4. The National Provider Identifier registry

Explanation

The LEIE is the OIG's database of individuals and entities excluded from participation in federal health care programs. Providers should screen employees, contractors, and vendors at hire and periodically thereafter, and should also check the System for Award Management for debarments.

Question 7Compliance and Ethics

What is the primary purpose of an organization's written code of conduct?

  1. To list the disciplinary actions available to human resources
  2. To describe CPT coding rules for each specialty
  3. To satisfy HIPAA's notice of privacy practices requirement
  4. To state the organization's ethical standards and compliance expectations for all workforce members Correct answer.

Explanation

A code of conduct is the foundational written standard that communicates the organization's commitment to ethical and lawful behavior and the expectations placed on every workforce member. It is broad in scope, while policies and procedures provide the detailed operational rules that support it.

Question 8Compliance and Ethics

A private individual who files a False Claims Act lawsuit on behalf of the government is known as a:

  1. Relator Correct answer.
  2. Whistleblower ombudsman
  3. Corporate integrity officer
  4. Compliance monitor

Explanation

A qui tam action is brought by a relator, who files under seal on behalf of the government. If the government intervenes and recovers funds, the relator may receive a statutory share of the recovery.

Question 9Compliance and Ethics

Which condition is required by the Anti-Kickback Statute safe harbor for personal services and management contracts?

  1. The agreement must be approved by the OIG before it takes effect
  2. The parties must be unrelated by blood or marriage
  3. Compensation must be renegotiated annually based on referral volume
  4. A signed written agreement of at least one year at fair market value set in advance Correct answer.

Explanation

The safe harbor requires a written, signed agreement covering at least a one-year term that specifies the services and sets aggregate compensation in advance at fair market value, with compensation not determined by the volume or value of referrals. The arrangement must also be commercially reasonable and the services must actually be provided.

Question 10Compliance and Ethics

A group practice physician orders a lab test that is performed in the practice's own laboratory in the same building, with the practice billing the technical component. Which Stark exception is designed to permit this arrangement?

  1. The isolated transactions exception
  2. The in-office ancillary services exception Correct answer.
  3. The rental of office space exception
  4. The bona fide employment exception

Explanation

The in-office ancillary services exception permits a group practice to furnish certain designated health services, including clinical laboratory services, in the same building where the referring physician's practice operates, provided supervision and billing requirements are met. The other exceptions address different financial relationships, such as leases or employment, and do not fit an internally furnished ancillary service.

Question 11Compliance and Ethics

EMTALA requires a Medicare-participating hospital with an emergency department to provide which of the following?

  1. Transfer of all uninsured patients to the nearest public hospital before treatment
  2. A medical screening examination regardless of the patient's ability to pay Correct answer.
  3. Free follow-up care to uninsured patients
  4. Payment plans for emergency services

Explanation

EMTALA requires an appropriate medical screening examination for anyone who comes to the emergency department requesting examination or treatment, without regard to insurance status or ability to pay. If an emergency medical condition exists, the hospital must stabilize the patient or arrange an appropriate transfer.

Question 12Compliance and Ethics

A corporate integrity agreement between a provider and the OIG typically requires the provider to:

  1. Obtain prior authorization for every Medicare claim
  2. Maintain a compliance program and submit to independent review organization audits Correct answer.
  3. Close its compliance department during the term
  4. Pay all claims at the Medicaid rate

Explanation

A corporate integrity agreement imposes ongoing compliance obligations, such as maintaining an effective compliance program, training, exclusion screening, reporting of overpayments, and periodic reviews by an independent review organization. Breach can lead to monetary penalties or exclusion.

Question 13Compliance and Ethics

Which OIG process allows a provider to self-report conduct that may violate federal law, with the possibility of a release from permissive exclusion?

  1. The OIG Self-Disclosure Protocol Correct answer.
  2. The provider enrollment revalidation process
  3. The Recovery Audit Contractor program
  4. The Medicare administrative appeals process

Explanation

The OIG Self-Disclosure Protocol is a formal channel for disclosing potential fraud or other misconduct; disclosures are resolved through a negotiated settlement that can include a release from permissive exclusion. Providers generally must make the disclosure before the government discovers the conduct.

Question 14Compliance and Ethics

A practice routinely waives Medicare coinsurance for all patients who pay cash on the day of service, with no assessment of financial hardship. This practice is best characterized as:

  1. An EMTALA violation
  2. Remuneration to beneficiaries that may violate the civil monetary penalties law Correct answer.
  3. A Stark exception for fair market value
  4. A permitted courtesy discount

Explanation

Routine waiver of Medicare cost-sharing is treated as remuneration offered to induce beneficiaries to use the provider's services, which can create civil monetary penalty exposure unless an exception such as documented financial hardship applies. Waivers should be based on individualized, uniformly applied criteria.

Question 15Compliance and Ethics

What is the primary purpose of an internal billing audit within a compliance program?

  1. To increase revenue by reclassifying claims
  2. To eliminate the need for staff training
  3. To identify and correct coding and documentation errors before payers discover them Correct answer.
  4. To replace external payer audits

Explanation

Internal auditing and monitoring are required elements that let an organization detect problems proactively, quantify error rates, correct identified overpayments, and target education. Audits do not eliminate the possibility of external review, but they reduce risk and demonstrate good-faith compliance efforts.

Question 16Compliance and Ethics

Which approach best meets the OIG's expectations for compliance training and education?

  1. A generic video shown once to all staff
  2. A one-time session delivered only at hire
  3. Documented, role-specific training at onboarding and periodically thereafter Correct answer.
  4. Training limited to the billing department

Explanation

Training and education is one of the seven elements and should be tailored to the risks of each role or department, delivered at hire and updated periodically, and documented to show attendance and comprehension. Effective training also addresses how to raise concerns through the organization's communication channels.

Question 17Compliance and Ethics

The False Claims Act's anti-retaliation provision protects an employee who:

  1. Files a complaint only after leaving the employer
  2. Is retaliated against for investigating or opposing conduct the employee reasonably believes violates the Act Correct answer.
  3. Refuses to do any work involving federal payers
  4. Reports only conduct already proven fraudulent by a court

Explanation

The provision protects employees who lawfully act to investigate, initiate, testify about, or assist in a False Claims Act matter, and also those who oppose conduct they reasonably believe violates the Act. Available remedies can include reinstatement, double back pay, and special damages, and no proof of a successful FCA case is required.

Question 18Compliance and Ethics

A physician bills an office visit with modifier 25 on the same day as a minor procedure. To support separate payment for the visit, documentation must show that the evaluation and management service was:

  1. Performed by a different provider in a separate specialty
  2. Billed with a different diagnosis code only
  3. Ordered at least one day before the procedure was performed
  4. Separately identifiable and above the usual work of the procedure Correct answer.

Explanation

Modifier 25 indicates that a significant, separately identifiable evaluation and management service was provided on the same day as another service and went beyond the usual preoperative and postoperative work of that service. The medical record must support the distinct nature of the visit through history, examination, and medical decision making.

Question 19Compliance and Ethics

Which set of conditions must be met to bill a service incident to a physician's professional service?

  1. The patient is new to the practice and the physician is unavailable for the visit
  2. The physician documents the plan only after the claim is submitted
  3. The service is provided in a hospital outpatient department
  4. It follows the physician's plan of care and is furnished under direct supervision Correct answer.

Explanation

Incident-to billing requires that the service be an integral part of the physician's course of treatment, furnished under the physician's direct supervision, and commonly performed in the office setting, with the physician's active participation in the plan of care. Incident-to rules generally do not apply to new patients or to services that establish a new plan of care.

Question 20Compliance and Ethics

A hospital proposes paying a physician group for medical director services. Which element is most important to support compliance of the arrangement?

  1. Payment made only when the hospital's referrals increase
  2. A verbal agreement later confirmed by email
  3. A written agreement with fair market value compensation that takes no account of referrals Correct answer.
  4. Compensation set as a percentage of hospital admissions

Explanation

Medical director arrangements should be documented in a signed written agreement, reflect fair market value for identifiable and actually performed administrative services, be commercially reasonable, and not consider the volume or value of referrals. Both the Anti-Kickback Statute and Stark require these features for the arrangement to be defensible.

Question 21Compliance and Ethics

Which statement correctly distinguishes the Anti-Kickback Statute from the Stark Law?

  1. Both apply only to physician referrals of designated health services to financially related entities
  2. Both require proof of specific intent and are enforced exclusively by the OIG
  3. Stark is criminal and intent-based, while the Anti-Kickback Statute is civil and imposes strict liability
  4. The Anti-Kickback Statute is criminal and intent-based, while Stark is civil, strict liability, and limited to designated health services Correct answer.

Explanation

The Anti-Kickback Statute is a criminal prohibition that requires knowing and willful conduct and reaches remuneration for any item or service payable by a federal program. Stark is a civil statute that imposes strict liability on physician referrals of designated health services when a financial relationship exists and no exception applies, and it is administered largely through CMS with OIG enforcement of some provisions.

Question 22Compliance and Ethics

Under the 60-day overpayment rule, a provider that identifies a Medicare overpayment must:

  1. Wait for the Medicare administrative contractor to issue a demand letter
  2. Report and return the overpayment within 60 days of identification Correct answer.
  3. Return the funds at the end of the calendar year in which they were identified
  4. Report the overpayment only if it exceeds $10,000

Explanation

A provider that receives an overpayment must report and return it within 60 days of identification, and the overpayment is identified when the provider has or should have had knowledge of it through reasonable diligence. A retained overpayment after the deadline can create False Claims Act exposure.

Question 23Compliance and Ethics

A hospital submits claims to Medicare for services furnished by a physician who has been excluded from federal health care programs. What is the usual consequence?

  1. Payment is allowed if the services were medically necessary
  2. Payment is allowed if the hospital was unaware of the exclusion
  3. No payment is allowed, and the hospital may face civil monetary penalties and repayment Correct answer.
  4. Payment is allowed at 50 percent of the fee schedule

Explanation

The exclusion statute bars payment for items and services furnished by an excluded individual or entity, regardless of medical necessity, and the provider must return amounts received. Civil monetary penalties may also apply unless the provider qualifies for the limited statutory exception for certain unknowing employments.

Question 24Compliance and Ethics

Under the Stark Law, what must the government prove about a physician's intent to establish a violation?

  1. That the physician intended to increase referrals
  2. Nothing regarding intent, because the statute imposes strict liability Correct answer.
  3. That the physician received compensation above fair market value
  4. That the physician knew the referral was prohibited

Explanation

Stark is a strict liability civil statute, so a violation can be established by the financial relationship, the referral of a designated health service, and the absence of an applicable exception, without proof of wrongful intent. Good faith does not cure a prohibited arrangement, which is why exception documentation matters so much.

Question 25Compliance and Ethics

The single-purpose test applied in Anti-Kickback Statute enforcement means that:

  1. One purpose of inducing referrals is enough to make the arrangement unlawful, even if other legitimate purposes exist Correct answer.
  2. Only one payment per year may qualify for a safe harbor
  3. The government must prove referrals were the sole purpose of the payment
  4. Only arrangements with one written purpose fall within the statute

Explanation

Under the single-purpose test, if any one purpose of the remuneration is to induce referrals of federally payable business, the arrangement violates the statute even when legitimate business reasons also exist. This makes documenting legitimate, non-referral purposes helpful but not automatically protective.

Question 26Compliance and Ethics

A billing clerk in a hospital's patient financial services department needs to review a patient's medical record to resolve a denial. Under the HIPAA Privacy Rule, which principle governs how much protected health information the clerk may access?

  1. A need-to-know rule that applies only after patient authorization
  2. A requirement to review the entire record for context
  3. The minimum necessary standard Correct answer.
  4. A requirement to use only de-identified data

Explanation

The HIPAA Privacy Rule's minimum necessary standard requires covered entities to limit access to and use or disclosure of PHI to the least amount reasonably needed for the purpose. A billing clerk resolving a denial may access only the information necessary to complete that task.

Question 27Compliance and Ethics

According to the OIG's seven elements of an effective compliance program, which element requires the organization to designate a compliance officer and compliance committee with defined authority?

  1. Written policies and procedures
  2. Designation of a compliance officer and compliance committee Correct answer.
  3. Training and education
  4. Auditing and monitoring

Explanation

The OIG's seven elements include designation of a compliance officer and compliance committee with defined authority and responsibility. This element establishes accountability for the compliance program.

Question 28Compliance and Ethics

During a medical record audit, an auditor finds that a billed service has no supporting entry in the medical record. Which principle applies?

  1. The service is treated as not having been furnished Correct answer.
  2. The service may be billed after a verbal order is obtained
  3. The service may be billed at a reduced level
  4. The service may be billed if the physician recalls performing it

Explanation

A service that is not documented in the medical record is generally treated as not furnished for billing and audit purposes. Payers require documentation to support the service and its medical necessity.

Question 29Compliance and Ethics

What is the primary purpose of the HHS OIG Work Plan?

  1. To set the Medicare conversion factor each year
  2. To license healthcare providers and suppliers
  3. To list OIG audit and enforcement priorities Correct answer.
  4. To publish annual Medicare payment rates

Explanation

The OIG Work Plan describes the audit, evaluation, and enforcement priorities the OIG intends to pursue. Providers use it to help target their compliance efforts.

Question 30Compliance and Ethics

The HIPAA Security Rule requires covered entities to conduct which activity to identify risks to electronic protected health information?

  1. A vendor background check
  2. An annual financial statement audit
  3. An accurate and thorough risk analysis Correct answer.
  4. A patient satisfaction survey

Explanation

The HIPAA Security Rule requires covered entities and business associates to conduct an accurate and thorough assessment of risks and vulnerabilities to electronic PHI. This risk analysis is the foundation for selecting appropriate safeguards.

Question 31Compliance and Ethics

A covered entity discovers a breach of unsecured protected health information. Under the HIPAA Breach Notification Rule, when must affected individuals be notified?

  1. Without unreasonable delay and no later than 60 days after discovery Correct answer.
  2. Only after the HHS Secretary approves the notification
  3. Within 30 days after the end of the calendar year
  4. Within 24 hours of discovery

Explanation

Individuals must be notified without unreasonable delay and no later than 60 calendar days after discovery of a breach of unsecured PHI. The notice must include specified content about the breach.

Question 32Compliance and Ethics

Under the False Claims Act, which state of mind satisfies the 'knowingly' standard?

  1. Only acting with specific intent to defraud
  2. Only acting after receiving written legal advice
  3. Acting with ordinary negligence in billing
  4. Acting with deliberate ignorance or reckless disregard of the truth Correct answer.

Explanation

The False Claims Act defines 'knowingly' to include actual knowledge, deliberate ignorance, or reckless disregard of the truth or falsity of information. Specific intent to defraud is not required.

Question 33Compliance and Ethics

A provider expects that a service may be denied by Medicare as not medically necessary. What document should the provider ask the beneficiary to sign before furnishing the service?

  1. A Medicare Summary Notice
  2. A Conditions of Admission form
  3. A Notice of Privacy Practices
  4. An Advance Beneficiary Notice of Noncoverage Correct answer.

Explanation

An Advance Beneficiary Notice of Noncoverage is a written notice a Medicare beneficiary may sign before receiving an item or service that the provider expects Medicare may deny as not medically necessary. It can shift potential financial liability to the beneficiary if the claim is denied.

Question 34Compliance and Ethics

What is the primary purpose of a compliance risk assessment?

  1. To determine patient satisfaction scores
  2. To calculate the organization's tax liability
  3. To identify and prioritize compliance risks for resource allocation Correct answer.
  4. To evaluate individual employee job performance

Explanation

A compliance risk assessment identifies, evaluates, and prioritizes risks so the organization can direct monitoring, training, and other resources where exposure is greatest. It is a foundational step in an effective compliance program.

Question 35Compliance and Ethics

An auditor finds identical review-of-systems text in multiple encounters that does not match each patient's history. This is best described as which documentation integrity concern?

  1. Cloned documentation Correct answer.
  2. A late entry
  3. Underdocumentation
  4. An illegible signature

Explanation

Cloned documentation occurs when text from one encounter is copied into another and does not accurately reflect that patient's encounter. It undermines documentation integrity and support for medical necessity.

Question 36Compliance and Ethics

Which OIG compliance program element addresses consistent enforcement of standards through disciplinary measures?

  1. Enforcement and discipline Correct answer.
  2. Monitoring and auditing
  3. Communication and education
  4. Written policies and procedures

Explanation

The enforcement and discipline element requires consistent, documented disciplinary action for violations of compliance standards, including for managers who fail to act. It reinforces that compliance expectations apply to everyone.

Question 37Compliance and Ethics

Under the Civil Monetary Penalties Law beneficiary inducement prohibition, which exception permits a provider to give a beneficiary an item or service of nominal value?

  1. The general de minimis exception
  2. The $10 per item and $50 per year nominal value exception Correct answer.
  3. The patient convenience exception
  4. The fair market value exception

Explanation

The CMP beneficiary inducement rules permit items or services of nominal value, generally less than $10 per item or service and less than $50 in the aggregate per year per beneficiary, provided they are not cash or cash equivalents.

Question 38Compliance and Ethics

Under the Stark Law 'stand in the shoes' provision, a physician who has an ownership or investment interest in a physician organization is treated as having which relationship with the entity?

  1. A financial relationship only for designated health services billed to commercial payers
  2. No financial relationship unless the physician personally signs each contract
  3. A financial relationship only if the physician is a general partner
  4. The same financial relationship as the physician organization Correct answer.

Explanation

Under the Stark Law, a physician who has an ownership or investment interest in a physician organization stands in the shoes of that organization. The physician is treated as having the same financial relationship with the entity furnishing designated health services as the organization has.

Question 39Compliance and Ethics

Which federal law requires certain entities that receive at least $5 million in annual Medicaid payments to provide written information about the False Claims Act to employees and contractors?

  1. The Deficit Reduction Act of 2005 Correct answer.
  2. The Affordable Care Act
  3. The Medicare Prescription Drug, Improvement, and Modernization Act
  4. The Health Insurance Portability and Accountability Act

Explanation

Section 6032 of the Deficit Reduction Act of 2005 requires entities with at least $5 million in annual Medicaid payments to establish written policies informing employees and contractors about the False Claims Act and whistleblower protections.

Question 40Compliance and Ethics

Which of the following is a designated health service under the Stark Law?

  1. Physician office visits
  2. Over-the-counter medications
  3. Routine chiropractic adjustments
  4. Clinical laboratory services Correct answer.

Explanation

Clinical laboratory services are included in the Stark Law's list of designated health services. Physician office visits, over-the-counter medications, and routine chiropractic adjustments are not designated health services.

Question 41Auditing and Monitoring

Which of the following is one of the seven elements of an effective compliance program as described by the OIG?

  1. Mandatory certification of every coder through a national credentialing body
  2. Annual publication of the organization's audited financial statements
  3. Internal monitoring and auditing Correct answer.
  4. Purchase of professional liability coverage for all billing staff

Explanation

OIG compliance program guidance identifies monitoring and auditing as one of the seven elements, along with written policies and procedures, a compliance officer and committee, training and education, lines of communication, enforcement and discipline, and response and prevention.

Question 42Auditing and Monitoring

Which activity is an example of monitoring rather than auditing?

  1. A supervisor's monthly checklist review of each coder's work Correct answer.
  2. A statistically valid sample of outpatient claims drawn for a compliance audit
  3. An annual review of 40 randomly selected inpatient claims by an outside consultant
  4. A retrospective chart review requested by a payer after a probe sample

Explanation

Monitoring is ongoing, routine surveillance built into daily operations, such as a supervisor reviewing coder output with a checklist each month. Auditing is a periodic, formal, independent review that typically uses sampling and defined criteria.

Question 43Auditing and Monitoring

What is the first step in planning an internal coding audit?

  1. Define the audit objective and scope Correct answer.
  2. Select the random sample of records to be reviewed
  3. Write the final audit report
  4. Notify the providers of the audit findings

Explanation

Planning begins with a clearly stated objective and scope, which determine the population, criteria, sample design, and resources. Sampling, fieldwork, and reporting all follow from the objective.

Question 44Auditing and Monitoring

A statistically valid sample is one in which:

  1. Records are chosen by the auditor based on perceived risk of error
  2. The sample size is fixed at 100 records regardless of population
  3. Every record in the population is reviewed at least once
  4. Every item in the population has a known chance of being selected Correct answer.

Explanation

Statistical validity requires random selection so that each item has a known, nonzero probability of being chosen. That property is what allows results to be projected to the population with a measurable level of confidence.

Question 45Auditing and Monitoring

The primary purpose of audit working papers is to:

  1. Document the work performed and support the conclusions reached Correct answer.
  2. Satisfy the payer's request for clinical records during a postpayment review
  3. Provide the basis for billing the audit hours to the department under review
  4. Serve as a substitute for the medical record when documentation is missing

Explanation

Working papers record the procedures performed, the evidence examined, and the conclusions drawn so that an independent reviewer can retrace the audit. They support findings but never replace source documents.

Question 46Auditing and Monitoring

A baseline audit is performed primarily to:

  1. Estimate the amount of money recoverable from an overpayment
  2. Determine whether a payer's claims were correctly adjudicated
  3. Confirm that corrective actions from a prior audit have been sustained
  4. Establish the current error rate before changes are implemented Correct answer.

Explanation

A baseline audit measures the organization's current level of compliance so that later audits can demonstrate the effect of training, education, or process changes. It is a starting point, not a test of prior remediation.

Question 47Auditing and Monitoring

Which three components should every audit finding include?

  1. Sample size, confidence level, and margin of error
  2. Criteria, condition, and cause Correct answer.
  3. Provider name, date of service, and payer
  4. Root cause, remediation cost, and target completion date

Explanation

An audit finding states the criteria (the requirement), the condition (what the auditor actually found), and the cause (why the deficiency occurred), usually with the effect of the deficiency. This structure makes findings verifiable and actionable.

Question 48Auditing and Monitoring

A corrective action plan should include which of the following elements?

  1. Action steps, a responsible person, and a completion date Correct answer.
  2. The names of employees who will be disciplined
  3. A projection of future revenue losses from the audit findings
  4. A copy of the payer contract that covers the audited services

Explanation

An effective corrective action plan identifies the root cause, the specific steps to fix it, the individual accountable for each step, the target date, and the method for verifying the fix. Discipline is a separate human-resources decision.

Question 49Auditing and Monitoring

When developing an annual audit work plan, an auditor should prioritize areas based on:

  1. The recommendations of the most recently hired coding supervisor
  2. The personal preferences of the highest-volume billing employees
  3. Risk factors including volume, prior error rates, and revenue Correct answer.
  4. The alphabetical order of the organization's clinical departments

Explanation

Audit resources are finite, so the work plan should target areas with the greatest combination of service volume, prior error history, and financial or regulatory exposure. This risk-based approach maximizes the value of each audit hour.

Question 50Auditing and Monitoring

An auditor pulls 25 records to see whether a suspected coding problem is widespread before committing to a full review. This is called a:

  1. Statistically valid random sample
  2. Retrospective claims review
  3. Baseline audit
  4. Probe audit Correct answer.

Explanation

A probe audit uses a small sample to test whether a suspected issue is isolated or systemic before the organization invests in a full audit. If the probe reveals problems, the scope is typically expanded using a statistically valid sample.