Chapter 5 — Exercises

Items marked † have worked solutions in Answers to Selected Exercises, along with every odd-numbered item. All scenarios are constructed. Nothing here is legal advice.

A. Recall and vocabulary

5.1 State the four things a claim to a federal health program certifies.

5.2 Distinguish fraud from abuse on four dimensions, and name the two things that move conduct from one to the other.

5.3 † State the three prongs of "knowingly" under the False Claims Act. For each, give a coding or billing example.

5.4 What is a qui tam action? Who may bring one, what happens while it is under seal, and what protection does the relator have?

5.5 † Distinguish the Anti-Kickback Statute from the physician self-referral law on: nature, intent, scope of persons covered, scope of services covered, and form of protection.

5.6 Define "remuneration" under the Anti-Kickback Statute and give four examples that are not cash.

5.7 What does exclusion prohibit, and why does it end employability rather than merely billing?

5.8 † List the seven elements of an effective compliance program and state what each is for.

5.9 Distinguish HIPAA's three rules. Which one is the reason ICD-10-CM and CPT are national standards?

5.10 State the minimum necessary standard and name the one purpose it does not apply to.

5.11 † Give the four-part argument that downcoding is not the safe choice.

5.12 State the six-step sequence for responding to an instruction to code something the documentation does not support.

B. Apply the statute

5.13 † For each fact pattern, name the statute or statutes most directly implicated and say whether intent must be proven.

(a) A practice bills 340 visits at level 4 over a year; an internal audit eleven months ago found the documentation supported level 3 in most cases; nothing changed. (b) An imaging center provides a physician group with free after-hours use of a conference room, and the group's referrals to the center triple. (c) A physician owns a share of a laboratory and refers Medicare patients there for tests; the arrangement satisfies no exception. (d) A biller discovers a \$14,000 overpayment from Medicare, reports it internally, and is told to "leave it in the account for now." Eight months pass. (e) A coder appends a distinct-procedural-service modifier by macro to every claim carrying two specific codes, without reading any note.

5.14 For fact pattern (b) above, describe what would have to be true for the arrangement to be lawful, and explain why "we didn't intend it as a kickback" may not resolve it.

5.15 † A practice's compliance officer is the office manager, who reports to the physician-owner whose coding is the subject of a staff complaint. Identify which compliance program elements are compromised and describe the minimum viable fix for a six-person practice.

5.16 A hospital discovers that a contracted transcription vendor has no business associate agreement in place. State the exposure, the immediate action, and whether any breach has necessarily occurred.

C. Read the document

5.17 † Using Figure 5.1 (Account 31-2245): (a) identify the specific defect in line 3; (b) explain why line 2 is not a defect despite also being an additional procedure; (c) state why 11 of 42 claims that may have been legitimate could not be defended; (d) compute the demand and say what would change if the payer extrapolated across 18 months of similar claims at the same rate.

5.18 A remittance advice, a note, and an internal audit report all exist for the same encounter, and they disagree. Rank them by evidentiary weight in a dispute with a payer, and defend the ranking.

5.19 † An internal audit report reads: "Sample of 25 level 4 established visits. 9 supported at the level billed. 14 supported at level 3. 2 supported at level 2. Recommend provider education." Write the three questions you would ask before this report is filed, and state what happens legally if it is filed and nothing else occurs.

D. Judgment and process

5.20 You are asked to "use the diagnosis that gets it covered." Give the response, then explain what a legitimate version of this request would look like and why it is different.

5.21 † A physician tells you they spent 45 minutes with a patient and want a level 5, but the note documents no time and the decision making supports a level 3. Walk through §5.9's six steps for this specific case, and say what the legitimate path to a level 5 would have been.

5.22 Your practice has no compliance program. Write the one-page proposal to the owners, covering the seven elements at a scale appropriate to a five-physician practice, and anticipating the objection that this is bureaucracy they cannot afford.

5.23 † You notice that essentially all of your practice's imaging referrals go to a facility that opened six months ago and that a physician-owner mentioned "having a piece of." State what you know, what you do not know, what you should do, and — precisely — what you should not do.

5.24 Design the exclusion screening process for a 40-employee practice: who is screened, against what, how often, by whom, and what happens on a hit.

5.25 † A coworker regularly looks up records of people they know socially. They have never disclosed anything. Explain the exposure, and describe your obligation.

E. Certification-style questions

5.26 † Under the False Claims Act, "knowingly" includes:

  • A. actual knowledge only
  • B. actual knowledge, deliberate ignorance, or reckless disregard
  • C. only conduct with specific intent to defraud
  • D. negligence

5.27 Which statute imposes strict liability, requiring no proof of intent?

  • A. Anti-Kickback Statute
  • B. False Claims Act
  • C. Physician self-referral law (Stark)
  • D. Civil Monetary Penalties Law

5.28 † An identified overpayment from a federal health care program must be reported and returned within:

  • A. 30 days
  • B. 60 days
  • C. 180 days
  • D. one year

5.29 Which is not one of the seven elements of an effective compliance program?

  • A. Designating a compliance officer
  • B. Conducting internal monitoring and auditing
  • C. Obtaining professional liability insurance
  • D. Responding promptly to detected offenses

5.30 † The minimum necessary standard applies to disclosures for:

  • A. treatment
  • B. payment and health care operations
  • C. all disclosures without exception
  • D. research only

5.31 Reporting component parts of a service separately when a comprehensive code describes it is:

  • A. upcoding
  • B. downcoding
  • C. unbundling
  • D. cloning

5.32 † Exclusion from federal health care programs means that no federal program may pay for items or services:

  • A. billed by the excluded individual
  • B. furnished, ordered, or prescribed by the excluded individual, including where the individual is employed in any capacity by a billing provider
  • C. furnished in the state where the exclusion was imposed
  • D. furnished during the first year of the exclusion

F. Write it

5.33 † Write the email described in §5.9 step 3, documenting your reading of a disputed coding question. Maximum 150 words. It must be a record without reading as a threat.

5.34 Draft the anonymous-reporting section of a small practice's compliance policy: how a report is made, who receives it, what happens next, and the non-retaliation commitment.

5.35 Write the 100-word explanation you would give a new coder about why downcoding is not the safe choice.

G. The Encounter

5.36 † Using Figure 4.2 and §5.10's counterfactual: list, sentence by sentence, exactly what the real note contains that the two-line counterfactual does not, and state which of those sentences is doing the most work for modifier 25.

5.37 Construct the six-step False Claims Act theory from the chapter's counterfactual, and then identify which step is the weakest for the government and why.

5.38 † Account 10-4471's claim is defensible. Suppose the practice appended modifier 25 by macro to every claim containing an E/M and a minor procedure, and this particular note happened to support it. Has the practice done anything wrong? Answer carefully, using §5.3.

5.39 The chapter says the claim's defensibility "rests entirely on four sentences a physician chose to write, none of which were required by any template." Design the template change that would make those sentences routine, and identify the risk your design introduces. (Chapter 4 §4.6 is relevant.)

5.40 Update your Encounter Workbook (Appendix C) with the compliance reading. Note Q1 as newly visible and record where it will be raised and resolved.