IAMI CPMA flashcards

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

Medical decision making elements

Three elements: number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications or morbidity. The E/M level is set by the highest two of three met.

Total time for E/M

Time spent on the date of the encounter on face-to-face and non-face-to-face work for that patient, including record review, ordering tests, and documentation. Staff time and separately reported services are excluded.

Modifier 25 purpose

Indicates a significant, separately identifiable E/M service by the same provider on the same day as a procedure. The E/M must exceed the usual pre-, intra-, and postoperative work of the procedure.

Principal diagnosis definition

Inpatient: the condition established after study to be chiefly responsible for occasioning the admission. Outpatient: the first-listed diagnosis, which is the reason for the encounter.

Provider query compliance

A query must present the clinical facts and ask for clarification without introducing a diagnosis or code the provider has not documented. Leading queries are noncompliant.

Audit finding components

A finding states the criterion (the rule), the condition (what was found), the cause, and the effect or risk. All four support a defensible conclusion.

Sampling unit definition

The unit selected for review: claim, encounter, line item, provider, or beneficiary. It must be defined before selection, because mixing units invalidates statistical projection.

Projectable versus descriptive

Probability sampling supports statistical projection to the population. Judgmental or targeted sampling supports only descriptive statements about the records reviewed.

Inter-rater reliability testing

Two reviewers independently apply the same criteria version to the same records; disagreements are adjudicated by a second-level reviewer. Results indicate consistency of the audit process.

Claim error rate formula

Number of records with at least one error divided by the number of records reviewed. Line-item error rate counts each erroneous line separately and yields a different figure.

Anti-Kickback Statute scope

Prohibits knowingly offering, paying, soliciting, or receiving remuneration to induce referrals for items or services payable by federal health care programs. Intent-based and criminal.

Stark Law character

A strict-liability civil statute restricting physician self-referral for designated health services. Compliance depends on fitting a regulatory exception, not on proving good intent.

False Claims Act liability

Imposes liability for knowingly presenting a false or fraudulent claim to the government. The qui tam provision lets private relators sue and share in the recovery.

60-day overpayment rule

A Medicare overpayment must be reported and returned within 60 days of identification. Retaining a known overpayment can create False Claims Act exposure.

Compliance program seven elements

Written policies, compliance officer and committee, training and education, communication lines, internal monitoring and auditing, enforcement and discipline, and response and prevention.

HIPAA breach notification timing

Notification without unreasonable delay and no later than 60 days from discovery. Breaches affecting 500 or more individuals also require HHS and media notice.

Source document primacy

Progress notes, operative reports, and discharge summaries are primary evidence. Coded data and claim data are secondary and must be traced back to source documents.

Cloned documentation indicator

Identical text across encounters, internal contradictions, or documentation inconsistent with the clinical picture suggest copy-paste. Such records require closer review before coding is accepted.

Diagnosis-to-treatment linkage

A reported diagnosis should be supported by monitoring, evaluation, or treatment in the record. A problem list entry alone is weak support for the code.

Data validation accuracy rate

Correct data elements divided by data elements reviewed. Each element is compared against the source document, and discrepancies are logged with a reason.

Audit report required elements

Objectives, scope, period, population, sample size and method, criteria, findings with cause and effect, risk rating, recommendations, and the audited entity's response.

Overpayment calculation method

For each record, compare the allowed amount for the supported code against the amount paid. Show the corrected code and difference, and exclude records where the original code was supported.

Draft findings response period

Draft findings are shared with the audited entity for written response before finalization. Rebuttals are evaluated against the same criteria and the disposition is documented.

Risk rating definition

Ratings such as high, medium, and low are defined in advance by likelihood and impact. Predefined scales keep ratings consistent across auditors and reports.

Fraud waste abuse distinction

Fraud is intentional deception for gain. Waste is misuse of resources without intent. Abuse is conduct inconsistent with accepted practice that may cause unnecessary cost.

Unbundling defined

Billing components of a procedure separately when a single comprehensive code exists. It increases payment and is a common audit and enforcement target.

Fraud red flag examples

Services billed on the date of death, impossible daily volumes per provider, services outside the provider's specialty or licensure, and beneficiaries with no relationship to the provider.

OIG exclusion screening

Providers should screen employees and vendors against the OIG List of Excluded Individuals/Entities and the SAM exclusion list, and document the screening.

Auditor independence meaning

The reviewer has no operational responsibility for the process being audited and no incentive tied to the audit outcome. Independence protects objectivity of findings.

Conflict of interest disclosure

Any relationship or interest that could influence judgment is disclosed and mitigated, such as by reassigning the review, before the audit begins rather than after findings are known.

Attribute versus variable sampling

Attribute sampling estimates an error rate, such as the percentage of claims with an error. Variable sampling estimates a dollar amount, such as total overpayment.

Statistical projection formula

Estimated total error equals the sample error rate multiplied by the population size or dollars. A confidence interval around the estimate is required for a valid conclusion.