Chapter 14. Compensation and Disability Assessment Flashcards
1
Q
- A concert pianist and a vice president of a
major corporation have both suffered the loss
of the second finger of the dominant hand.
Which of the following statements is true
regarding the condition of impairment or disability
caused by the injury?
(A) The concert pianist is more impaired
than the vice president
(B) The concert pianist and vice president
are equally disabled
(C) The concert pianist and vice president
are both handicapped
(D) The concert pianist is more disabled
than the vice president
(E) The concert pianist is more handicapped
than the vice president
A
- (D) Both the concert pianist and the company
vice president have impairment because of the
loss of their digit. However, the concert pianist
is significantly more disabled because the
pianist will not be able to perform but the vice
president will still be able to do the job. They
are not significantly handicapped because they
can still perform life’s activities without the
use of assistive devices or modification of the
environment.
2
Q
- Identify the true statement with regards to a
physician’s role in impairment and disability
evaluation:
(A) Determine impairment; provide medical
information to assist in disability determination
(B) Provide a disability rating which is
binding on the administrative law judge
for social security and disability
(C) In State Worker’s Compensation Law, a
physician’s role is limited to determining
only disability, not impairment
(D) The World Health Organization (WHO)
has specifically defined the role of the
physician in impairment and disability
(E) Physician’s role in impairment and disability
determination is independent,
without input from employer and without
consideration to job duties
A
- (A) Physicians’ role
A. As per the Guides to the Evaluation of
Permanent Impairment—Determine impairment;
provide medical information to assist
in disability determination.
B. As per Social Security Administration
(SSA)—Determine impairment; may assist
with the disability determination as a consultative
examiner.
C. As per State Workers’ Compensation Law—
Evaluation (rating) of permanent impairment
is a medical appraisal of the nature
and extent of the injury or disease as it
affects an injured employee’s personal efficiency
in the activities of daily living, such
as self-care, communication, normal living
postures, ambulation, elevation, traveling,
and nonspecialized activities of bodily
members.
D. As per WHO—Not specifically defined;
assumed to be one of the decision makers
in determining disability through impairment
assessment.
E. Disability is determined based on job
requirements and needs.
3
Q
- Which of the following is true statement with
reference to the Americans with Disability Act
(ADA)?
(A) The physician’s input is not essential for
determining any of the criteria under
ADA
(B) Conditions that are temporary and are
not considered to be impairment under
the ADA include pregnancy, old age,
sexual orientation, sexual addiction,
smoking, or current illegal drug use
(C) To be deemed disabled for purposes of
ADA protection, an individual needs to
have only mild physical or mental
impairment that does not limit major
life activities
(D) The person may be hypothetically or
perceived to be disabled to be qualified
under ADA
(E) It is the physician’s responsibility to
identify and determine if reasonable
accommodations are possible to enable
the individual’s performance of essential
job activities in his or her employment
A
- (B) The ADAdefines disability as a physical or
mental impairment that substantially limits one
or more of the major life activities of an individual;
a record of impairment, or being
regarded as having an impairment.
A. The physician’s input often is essential for
determining the first two criteria and valuable
for determining the third.
B. Conditions that are temporary are not considered
to be severe, such as normal pregnancy,
are not considered impairments
under the ADA. Other nonimpairments
include features and conditions such as
hair or eye color, left-handedness, old age,
sexual orientation, exhibitionism, pedophilia,
voyeurism, sexual addiction, kleptomania,
pyromania, compulsive gambling, gender
identity disorders not resulting from physical
impairment, smoking, and current
illegal drug use or resulting psychoactive
disorders.
C. A person needs to meet only one of the
three criteria in the definition to gain the
ADA’s protection against discrimination.
To be deemed disabled for purposes of
ADA protection, an individual generally
must have a physical or mental impairment
that substantially limits one or more
major life activities. A physical or mental
impairment could be any mental, psychologic,
or physiological disorder or condition,
cosmetic disfigurement, or anatomical laws
that affect one or more of the following body
systems: neurologic, special sense organs,
musculoskeletal, respiratory, speech organs,
reproductive, cardiovascular, hematologic, lymphatic, digestive, genitourinary, skin,
and endocrine.
D. It is not necessary for a person to qualify
under ADA to be disabled hypothetically
or perceptionally.
E. It is the physician’s responsibility to determine
if the impairment results in functional
limitations.
The physician is responsible for informing
the employer about an individual’s abilities
and limitations. It is the employer’s responsibility
to identify and determine if reasonable
accommodations are possible to enable
the individual’s abilities and limitations.
4
Q
- Which of the following is true regarding causation,
apportionment, and worker’s compensation?
(A) Determining medical causation requires
detective work and witness of the
accident
(B) For purposes of the Guides to the
Evaluation of Permanent Impairment, causation
means an identifiable factor, such
as an accident that results in a medically
identifiable condition
(C) The legal standard for causation in civil
litigation and in worker’s compensation
is uniform across the United States
(D) Apportionment analysis in worker’s
compensation represents assignment of
all factors
(E) The role of a physician in worker’s compensation
system is only to provide
effective medical care but not be
involved in other aspects of the care
A
- (B)
5
Q
- Which of the following is true with regards to
disability?
(A) It is a term that can be used interchangeably
with the term “handicap”
(B) It is a condition that relates to the effects
of a disease process or injury
(C) It is a condition that requires the use of
an assistive device to perform activities
of daily living
(D) It is expressed as a percentage of the
body as a whole
(E) It is a condition that relates to function
relative to work or other obligations
A
- (E) Disability is the limiting, loss, or absence of
the capacity of a person to meet personal,
social, or occupational demands, or to meet
statutory or regulatory requirements. Disability
relates to function relative to work or other
obligations and activities of daily living. It may
be characterized as temporary, permanent, partial,
or total. Methods of assessing functional
performance include measurement of range of
motion, strength, endurance, and work simulation.
Disability is not synonymous with handicap.
When an impairment is associated with
an obstacle to useful activity, a handicap may
exist; assistive devices or modifications of the
environment are often required to accomplish
life’s basic activities.
6
Q
917. The CAGE questionnaire is used in case of (A) mental retardation (B) bipolar disorder (C) major depression (D) opioid abuse (E) alcohol abuse
A
- (E) Four clinical interview questions, the CAGE
questions, have proved useful in helping to make
a diagnosis of alcoholism. The questions focus on
cutting down, annoyance by criticism, guilty
feeling, and eye-openers. The acronym “CAGE”
helps the physician recall the questions:
“C”—Have you ever felt you should cut
down on your drinking?
“A”—Have people annoyed you by criticizing
your drinking?
“G”—Have you ever felt bad or guilty about
your drinking?
“E”—Have you ever had a drink first thing in
the morning to steady your nerves or to get
rid of a hangover?
7
Q
918. The “rules” that, in many cases, define which physician referrals are legal and which are not, are found in the following regulations: (A) Stark regulations (B) Antikickback statute (C) Stark regulations and antikickback statute (D) Stark regulations, antikickback statute, and Omnibus Budget Reconciliation Act (OBRA) of 1993 (E) Stark regulations, Health Insurance Portability and Accountability Act (HIPAA), and Balanced Budget Act (BBA)
A
- (C)
A. The “Stark I” regulations were published
in the Federal Register on August 15, 1995.
The “Stark II” law that was part of the
Omnibus Budget Reconciliation Act of
1993, which expanded that application of
Stark I rules to additional types of health
care providers and to Medicaid. Note that
regulations for this law were issued in two
phases: phase I, released on Jan. 4, 2001, is
final. Phase II, released on March 26, 2004,
is effective from July 26, 2004.
B. The antikickback statute also addresses
physician referrals.
C. Physician self-referrals are governed by
Stark regulations and antikickback statute.
D. OBRA of 1993 includes Stark regulations.
E. HIPAA and BBA do not govern physician
self-referrals.
8
Q
919. Which of the following statements is correct? (A) Patient may request that a provider amend a diagnosis that was submitted on a billing claim form (B) A provider must act on a patient’s request for amendment within 30 days, either deny or amend (C) A provider does not agree with a patient’s request for an amendment. The provider must make the amendment but can note disagreement in the amendment and inform the insurer (D) Provider has to amend diagnosis in 30 days as provider may not deny the patient’s requests (E) Provider has no obligation even if the information on the claim was inaccurate
A
- (A) The privacy rule allows patients to request
amendments of their records including amendments
to billing records.
The provider is not obligated to make the
amendment if the provider believes that the
original information (the diagnosis in this scenario)
was accurate as submitted. In fact, from
a billing compliance standpoint the provider
should not make the amendment if the original
information was accurate and complete.
A provider is given 60 days to act on
amendment requests and providers are always
permitted to deny amendment requests when
the information is accurate and complete when
originally recorded.
9
Q
- What are the consequences of downcoding?
(A) Compliance with guidelines may not be
the most important aspect
(B) It is not necessary to assure proper coding
of the level of service during
downcoding
(C) Medicare will eventually reimburse all
your downcoding after 5 years
(D) Downcoding is the largest area of loss of
revenue for the practice
(E) Medicare may not investigate
downcoding
A
- (D) Downcoding
• Largest area of loss of revenue outside disbundling.
• Compliance with guidelines is important.
• Must assure proper coding of the level of
service.
10
Q
- Which is the accurate statement about billing
and compliance?
(A) A physician may mark up durable medical
equipment (DME) items under the physician self-referral Stark regulation
in-office ancillary services exception
(B) If a practice which does not have a compliance
plan discovers a billing error, it
is not necessary for this practice to make
a voluntary disclosure and a refund of
the overpayment
(C) When a provider receives a payment
from Medicare that should have gone to
the patient, the provider should keep
the payment
(D) Direct supervision is defined as “The
physician is responsible overall, but is
not necessarily present at the time of
procedure”
(E) If an employee files a qui tam (whistleblower)
suit against his or her employer,
the employer may ask the employee to
stay out of the work place and refrain
from speaking to his or her co-workers
until a full investigation has taken plan
A
- (A)
A. The DME must meet six requirements
in order to be billed as in-office ancillary
services:
• It is needed by the patient to move or
leave the doctor’s office, or is a blood
glucose monitor.
• It is provided to treat the condition that
brought the patient to the physician and
in the “same building.”
• It is given by the physician or another
physician or employee in a group practice.
• The physician or group practice meets
all DME supplier standards.
• The arrangement doesn’t violate any
billing laws or the antikickback statute.
• All other in-office ancillary requirements
are met.
B. Providers only need to self-disclose to OIG
in certain situations. They do not need to
self-disclose every time they receive an
overpayment from Medicare. However,
every provider must learn when OIG views
an overpayment as a deliberate attempt to
defraud Medicare instead of the result of a
harmless error.
If the circumstances surrounding the billing
error resemble any of the situations described
below, consider voluntary disclosure and
return of the overpayment. Otherwise, a
refund may be sufficient:
• The situation is the result of a willful disregard
for fraud and abuse laws.
• The situation is a systematic problem
that occurred over a long period of time.
• The provider has no such mechanisms
as a compliance plan in place.
• The provider took no action once the
problem was discovered.
C. Once a provider realized that he or she has
received an overpayment, the provider is
statutorily obligated to return it to Medicare.
This includes instances where the provider
receives an overpayment resulting from an
unintended mistake on their part.
D. According to the CMS, there are three levels
of supervision. General supervision means
the procedure is furnished under the physician’s
overall direction and control, but the
doctor’s presence is not required during
the procedure. (The physician remains
responsible for training nonphysician personnel
and for maintaining all necessary
equipment and supplies.) Direct supervision
means the physician must be present in
the office suite and immediately available to
furnish assistance and direction throughout
the performance of a procedure. It does not
mean that the physician must be present in
the room when the procedure is performed.
Finally personal supervision means a physician
must be in attendance in the room during
the performance of the procedure.
E. Whistleblowers who are discharged, demoted,
suspended with or without pay, threatened,
harassed or in any other manner discriminated
against by their employers in the terms
and conditions of employment are entitled to
relief. That includes reinstatement with the
same seniority, two times the amount of back
pay, interest on the back pay and compensation
for any damages, including attorney’s
fees.
11
Q
- A local clinical laboratory provides a phlebotomist
free of charge to a doctor’s office. The
phlebotomist takes specimens from the physician’s
office to the laboratory. When the phlebotomist
is not busy drawing blood, the
phlebotomist assists the doctor’s office personnel
with filing of records and other clerical
duties. What aspects of this scenario, if any,
implicate the antikickback laws?
(A) Provision by the clinical laboratory of a
phlebotomist free of charge to the
physician
(B) Performance by the phlebotomist of
clerical duties in the physician’s office
(C) Phlebotomist taking specimens from
physician’s office to the laboratory
(D) All of the above
(E) None of the above
A
- (B) Don’t accept anything from a clinical laboratory
that you didn’t pay fair market value
for. OIG indicated it was aware of a number of
deals between clinical laboratories and
providers that could implicate the antikickback
statute. When a laboratory offers or gives a
referral source anything of value without receiving
fair market value it can be viewed as an
inducement to refer. It’s also true when a potential
referral source receives anything of value
from the laboratory.
When permitted by state law, a laboratory
can make available to a physician’s office a
phlebotomist who collects specimens from
patients for testing by the outside laboratory.
Although the simple placement of a laboratory
employee in the physician’s office isn’t by itself
necessarily an inducement forbidden by the
antikickback statute, the statute does come into
play when the phlebotomist performs additional
tasks that are normally the responsibility
of the physician’s office staff. These tasks can
include taking vital signs or other nursing
functions, testing for the physician’s office laboratory,
or performing clerical services.
When the phlebotomist performs clerical
or medical functions that aren’t directly related to the collection or processing of laboratory
specimens, OIG makes the deduction
that the phlebotomist is providing a benefit in
return for the physician’s referrals to the laboratory.
In this case, the physician, the phlebotomist
and the laboratory may have exposure
under the antikickback statute. This analysis
also applies to the placement of phlebotomists
in other health care settings, including nursing
homes, clinics, and hospitals.
OIG also points out that the mere existence
of a contract between a laboratory and a
health care provider that prohibits the phlebotomist
from performing services unrelated
to specimen collection does not eliminate the
concern over possible abuse, particularly if it’s
a situation where the phlebotomist is not
closely monitored by his or her employer or
where the contractual prohibition is not rigorously
enforced.
12
Q
- What do the physician self-referral Stark rules
prohibit?
(A) They prohibit physicians from referring
patients to hospitals where the physicians
work
(B) They prohibit physicians from referring
patients for designated health services to entities in which the physicians have
financial relationships, unless an exception
applies
(C) They prohibit health care providers
from billing for services of patients they
refer to other providers
(D) They prohibit health care providers
from receiving money from their services
for any referrals to physical therapy
(E) The prohibit physicians performing
cases in ambulatory surgery centers with
physician ownership of 50% or more
A
- (B) Stark regulations prohibit physicians from
referring to an entity with which they or their
immediate family members have a financial
relationship for the furnishing of any of 11 designated
Medicare-reimbursable health services
if claims for those services are submitted to
Medicare or Medicaid. Also, physicians may
not bill Medicare or Medicare for such referred
services. The 11 designated health services are
as follows: - Clinical laboratory services.
- Physical therapy services (including speechlanguage
pathology services). - Occupational therapy.
- Radiology and certain other imaging
services. - Radiation therapy services and supplies.
- Durable medical equipment and supplies.
- Parenteral and enteral nutrients, equipment,
and supplies. - Prosthetics, orthotics, prosthetic devices
and supplies. - Home health services.
- Outpatient prescription drugs.
- Inpatient and outpatient hospital services
(with exceptions).
Adesignated health service remains a designated
service under Stark regulations even
when it’s billed as something else or bundled
with other services. CMS has released an
appendix to the Stark regulations detailing,
by CPT and HCPCS (Healthcare Common
Procedure Coding System) code, those services
that are subject to the prohibition.
13
Q
- Centers for Medicare and Medicaid Services
(CMS) guidelines in a documentation of evaluation
and management services recommend
the use of the following:
(A) SOAP—subjective, objective, assessment,
and plan
(B) SOAPER—subjective, objective, assessment,
plan, education and return
instructions
(C) SOAPIE—subjective, objective, assessment,
plan, implementation, and evaluation
(D) SNOCAMP—subjective, nature of presenting
problem, counseling, assessment,
medical decision making, and plan
(E) Documentation involving elements, bullets,
and level of care
A
- (E)
14
Q
- Identify true statements about current procedural
technology (CPT) and International Classification
of Diseases (ICD-9) codes?
(A) ICD-9 is a systematic listing of procedure
or service accurately defining and
assisting with simplified reporting
(B) CPT is a systematic listing and coding of
procedures and services performed by
physicians
(C) ICD-9 identifies each procedure or service
with a five-digit code
(D) CPT provides systematic listing of disease
classification and provides alphabetic
index to diseases
(E) CPT and ICD-9 both provide a tabular
list of diseases
A
- (B) CPT
- Systematic listing and coding of procedures
and services performed by physicians. - Procedure or service is accurately defined
with simplified reporting. - Each procedure or service is identified with
a five-digit code.
ICD codes classify diseases and a wide variety
of signs, symptoms, abnormal findings,
complaints, social circumstances, and external
causes of injury or disease. Every health condition
can be assigned to a unique category
and given a code, up to six characters long. Such
categories can include a set of similar diseases.
15
Q
- Which of the following factors will determine
the number of drug-receptor complexes formed?
(A) Efficacy of the drug
(B) Receptor affinity for the drug
(C) Therapeutic index of the drug
(D) Half-life of the drug
(E) Rate of renal secretion
A
- (B) Receptor affinity for the drug will determine
the number of drug-receptor complexes
formed. Efficacy is the ability of the drug to
activate the receptor after binding has occurred.
Therapeutic index (TI) is related to safety
of the drug. Half-life and secretion are properties
of elimination and do not influence formation
of drug-receptor complexes.
16
Q
- In response to a call from the patient’s spouse
informing the physician that the patient is
abusing narcotics prescribed by the physician,
the physician notes in the patient’s medical
record that the spouse called to report such
information. The spouse is concerned that her
husband would be extremely upset if he knew
she called with the information. In an event
that the husband requests a complete copy of
his records, which of the following is correct
statement?
(A) The physician is permitted to withhold
the information
(B) The physician must provide entire chart
immediately
(C) The physician must determine with
100% certainty that, wife will be
harmed, to withhold the information
(D) The physician is required to provide
oral information, but withhold written
information
(E) The physician may provide this information
only after spouse’s death
A
- (A) The physician is permitted to withhold certain
portions of a patient’s record under limited
circumstances including when the protected
health information requested includes reference
to another person and the physician has
determined that access to the information is
reasonably likely to cause substantial harm to
the person who has provided the information.
Although the general rule is that a patient
must be provided full access to his or her information.
Certain exceptions to this rule apply in
this scenario.
17
Q
- Which of the following is a true statement
applicable to a patient’s request for a copy of
his or her record?
(A) The physician is not required to give the
patient any records that were not created
or generated by the practice
(B) The provider is required to give a copy
of all the records
(C) Designated record sets include only the
medical records generated by the
provider
(D) Medical records may be released only
after patient has paid his bill in full
(E) Patient’s access is limited to only certain
areas of medical record
A
- (B) Unless a limited exception applies, a health
care provider must give a patient access to his
or her records that are maintained in a designated
record set. Apatient is entitled to inspect
and copy records that are maintained in a designated
record set. A designated record set
includes medical records maintained by or for
the health care provider and includes any item,
collection used or disseminated by or for a covered
entity. There is no exception for records
maintained by the provider but generated by
others, and thus a provider is not permitted to
withhold records held by the provider that
have been created by another provider.
18
Q
- What are the ramifications of the antikickback
statute on your practice?
(A) It is a felony—10 years imprisonment
(B) It is a crime to offer, solicit, pay, or
receive remuneration, in cash or in kind,
directly or indirectly, for referrals under
a federally funded health care program
(C) Civil penalties—$500,000 per violation
(D) “Multipurpose” rule
(E) No safe harbors
A
- (B) It is a crime to offer, solicit, pay, or receive
remuneration, in cash or in kind, directly or
indirectly, for referrals under a federally funded
health care program. The penalties of antikickback
statute are
• Felony—Five years imprisonment.
• Civil penalties—$50,000 per violation.
• “One purpose” rule.
• Safe harbors—Safe harbors immunize certain
payment and business practices that
are implicated by the antikickback statute
from criminal and civil prosecution under
the statute. To be protected by a safe harbor,
an arrangement must fit squarely in the
safe harbor. Failure to comply with a safe
harbor provision does not mean that an
arrangement is per se illegal.
19
Q
930. The training requirements of needlestick safety include all of the following EXCEPT (A) work hours (B) ninety days after initial assignment (C) at a cost to employee (D) within 365 days after effective date of standard (E) within 10 years of previous training
A
930. (C) Training requirements of needlestick safety include • At no cost to employee • During work hours • At time of initial assignment • Within 90 days after effective date of standard • Within 1 year of previous training • Shift in occupational exposure
20
Q
- Identify accurate statement in the scenario
where a health care provider fails to honor a
patient’s written request for an itemized statement
of items or services within 30 days. What
penalties may the provider face from the HHS
(United States Department of Health and
Human Services) Office of Inspector General
(OIG)?
(A) Exclusion from Medicare program
(B) Civil monetary penalty of $5000
(C) Civil monetary penalty and exclusion
(D) Civil monetary penalty of $100 for each
unfilled request
(E) Criminal penalty with 6-month prison
time
A
- (D) Under the Social Security Act Medicare
patients have the right to submit a written
request for an itemized statement to any physician,
provider, supplier, or any other health
care provider for any item or service provided
to the patient by the provider. After receiving a request, the provider has
30 days to furnish an itemized statement describing
each item or service provided to the patient.
Providers who fail to honor a request may be
subject to a civil monetary penalty of $100
for each unfulfilled request. In addition, the
provider may not charge the beneficiary for the
itemized statements.
21
Q
- What is the true statement about global fee
policy?
(A) Global fee policy describes packaging or
inclusion of certain services in
allowance for a surgical procedure
(B) Global fee policy describes unbundling
or combining multiple services into a
single charge
(C) Global package includes preoperative
and postoperative services for 120 days
D) Global package includes initial evaluation
if performed on the same day
(E) Global package includes all diagnostic
tests
A
- (A) Global fee policy is described as packaged
or certain services are included in allowance for
a surgical procedure. Bundling is described as
combining multiple services into a single
charge. Global package includes the following:
• Preoperative
• Procedure
• Postoperative
Global package does not include the
following:
• Initial evaluation
• Unrelated visits
• Diagnostic test(s)
• Return trips to operating room
• Staged procedures
Global period is
• Major day prior, day of, and 90 days after
• Minor day of or day of and 10 days after
22
Q
- Pay for performance is being considered by
Medicare and third-party payers. Identify accurate
statements:
(A) Compensation incentives will not
induce changes in the quality of services
(B) Outcome measures are easy to develop
(C) Compensation incentives rest on the
economic field of agency theory
(method of compensation induces
conduct)
(D) Quality measures are already in place
(E) It is simple to finance incentives
A
- (C) Pay for performance
• Compensation incentives rest on the economic
field of agency theory
• Method of compensation induces conduct
• Compensation incentives will not induce
changes in the quality of services
• Issues to consider in paying for performance:
• How to measure quality
• Vehicles for encouraging quality
• What to reward
• How to finance incentives
23
Q
934. For a service to be reasonable and necessary it must be (A) safe (B) experimental (C) investigational (D) patient can afford to pay (E) furnished only in a hospital
A
- (A) For a service to be reasonable and necessary
it must be
• Safe and effective.
• Not experimental or investigational.
• Appropriate, including the duration and
frequency that is considered appropriate
for the service, in terms of whether it is
• Furnished in accordance with accepted
standards of medical practice for the diagnosis
or treatment of the patient’s condition
or to improve the function.
• Furnished in a setting appropriate to the
patient’s medical needs and condition.
• Ordered and/or furnished by qualified
personnel.
• One that meets, but does not exceed, the
patient’s medical need.
24
Q
935. Which of the following is an accurate statement about proper billing? (A) Bill for items or services not rendered or not provided as claimed (B) Submit claims for equipment, medical supplies, and services that are not reasonable and necessary (C) Double bill resulting in duplicate payment (D) Bill for noncovered services as if covered (E) Knowingly do not misuse provider identification numbers, which results in improper billing
A
- (E) Proper documentation summary says never
• Bill for items or services not rendered or not
provided as claimed.
• Submit claims for equipment, medical supplies,
and services that are not reasonable
and necessary.
• Double bill resulting in duplicate payment.
• Bill for noncovered services as if covered.
• Knowingly misuse provider identification
numbers, which results in improper billing.
• Unbundle (billing for each component of
the service instead of billing or using an allinclusive
code).
• Upcode the level of service provided.
25
Q
- What are important aspects of the Needlestick
Safety and Prevention Act of 2001?
(A) It has 24 areas of change
(B) Two terms were added to definitions
(C) It was enacted because of a total of more
than 20 million needlesticks per year
(D) Risks of contracting disease were
minimal
(E) Psychologic stress was the only issue
A
936. (B) Needlestick Safety and Prevention Act of 2001—November 6, 2000 • Four areas of change • Two terms added to definitions • Why • Total of more than 600,000 needlesticks per year • Risk of contracting disease • Adverse side effects of treatments • Psychologic stress Modification of definitions—area 1 • Relating to engineering controls • Definition: Includes all control measures that isolate or remove a hazard from the workplace. • Examples: Blunt suture needles, plastic or Mylar wrapped capillary tubes, sharps disposal containers, and biosafety cabinets. Modification of definitions—area 2 • Revision and updating of the exposure control plan • Review no less than annually • Reflect a new or modified task/procedure • Revised employee positions • Reflect changes in technology • Document consideration and/or implementation of medical devices Modification of definitions—area 3 • Solicitation of employee input • Nonmanagerial employees who are responsible for direct patient care and potentially exposed to injury • Identification, evaluation, selection of effective engineering and work practice controls • Document employee solicitation in exposure control plan Modification of definitions—area 4 • Record keeping • Sharps injury log • Type and brand of device involved • Department or work area of exposure incident • Explanation of how the incident occurred
26
Q
937. Multiple components of proper medical record documentation do not include the following: (A) The reason for the patient’s visit (B) The indication of services provided (C) The location of the services (D) Itemized billing for services (E) Plan of action including return appointment
A
- (D) Proper medical record documentation
includes the following:
• Why did the patient present for care?
• What was done?
• Where were the services rendered?
• When is the patient to return or what is the
plan of action?
• Will there be follow-up tests or procedures
ordered?
27
Q
- Which of the following is an accurate statement
describing legitimate professional
courtesy?
(A) When a physician practice waives coinsurance
obligations or other out-ofpocket
expenses for other physicians or
family members, but only based on their
referrals
(B) When a hospital or other institution
waives fees for services provided to
their medical staff, but not employees
(C) When an organization waives fees based
on proportion of referrals
(D) When a physician practice is able to collect
full fee, by increasing charges proportionately
(E) When a physician practice waives all or
part of a fee for services for office staff,
other physicians or family members
A
- (E) The following are general observations
about professional courtesy arrangements for
physicians to consider:
• Regular or/and consistent extension of professional
courtesy by waiving the entire fee
for services rendered to a group of persons
(including employees, physicians, or their
family members) may not implicate any of
OIG’s fraud and abuse authorities if membership
in the group receiving the courtesy is
determined in a way that does not take into
account directly or indirectly any group member’s
ability to refer to or otherwise generate
federal health care program business for, the
physician.
• Regular or consistent extension of professional
courtesy by waiving otherwise applicable
co-payments for services rendered to a
group of persons (including employees,
physicians, or their family members), would
not implicate the antikickback statute if
membership in the group is determined in a
way that does not take into account directly
or indirectly any group member’s ability to
refer to, or otherwise general federal health
care program business for, the physician.
28
Q
- Impairment is correctly characterized by the
following definition(s):
(1) A loss, loss of use, or derangement of any
body part, organ system, or organ function
(2) An alteration of an individual’s capacity
to meet personal, social, or occupational
demands because of impairment
(3) An anatomical, physiological, or psychologic
abnormality that can be shown by
medically acceptable clinical and laboratory
diagnostic techniques
(4) Abarrier to full functional activity that may
be overcome by compensating in some way
for the causative impairment
A
- (B) Impairment definitions
As per Guides to the Evaluation of Permanent
Impairment—A loss, loss of use, or derangement
of any body part, organ system, or organ
function.
As per WHO—Problems in body function or
structure as a significant deviation or loss.
Impairments of structure can involve an
anomaly, defect, loss, or other significant
deviation in body structures.
As per SSA—An anatomical, physiological, or
psychologic abnormality that can be shown
by medically acceptable clinical and laboratory
diagnostic techniques.
As per State Workers’ Compensation Law—
Permanent impairment is any anatomic or
functional loss after maximal medical improvement
has been achieved and which abnormality
or loss, medically, is considered stable or
nonprogressive at the time of evaluation.
Permanent impairment is a basic consideration
in the evaluation of permanent disability
and is a contributing factor to, but not necessarily
an indication of, the entire extent of permanent
disability.
29
Q
- Identify the true statement(s) describing functional
restoration:
(1) Functional restoration is a monotherapy
intended to return patients to work
(2) Functional restoration includes an interdisciplinary
approach with physical therapy,
occupational therapy, vocational rehabilitation,
psychology, nursing, and physician
(3) Indications for functional restoration
include temporary disability and ability to
return to work following exercise program
(4) Phases of rehabilitation and functional
restoration include initial reconditioning,
comprehensive phase, and follow-up phase
A
- (C) Functional restoration is a comprehensive,
multidisciplinary program intended primarily
to correct disability in the patient with chronic
low back pain who has demonstrated multiple
barriers to recovery, including deconditioning,
lack of motivation, psychologic dysfunction,
and secondary gain issues. An interdisciplinary
approach integrates physical therapy,
occupational therapy, vocational rehabilitation,
psychology, nursing, and the physician.
Indications
• Persistent disability despite completion of
proper primary and secondary work-up
and treatment
• Presence of barriers to recovery
• Deconditioning
• Lack of motivation
• Psychologic dysfunction
• Secondary gain issues
• Willingness to participate
• Willingness to comply
Elements
• Quantification of physical function
• Physical reconditioning of injured functional
unit
• Work simulation and whole body coordination
training
• Cognitive-behavioral disability management
• Fitness maintenance program with outcome
assessment using objective criteria
Program content
• Initial medical evaluation
• Quantification of physical function
• Trunk range of motion
• Trunk strength
• Whole body task performance
• Assessment of symptom self-reports—pain
and disability
• Psychologic evaluation
• Vocational assessment
Various phases of rehabilitation for functional
restoration:
Initial reconditioning phase
• Focus: improving mobility, overcoming neuromuscular
inhibition and pain sensitivity,
and measuring cardiovascular endurance—
up to 12 appointments over 4 to 6 weeks.
• Supervised stretching, aerobic, and light
work simulation exercises for 2 hours twice
per week.
Comprehensive phase
• 10 h/d, 5 d/wk, 3 weeks
• Vigorous stretching and aerobics classes
• Progressive resistive exercises twice a day
under supervision of physical therapist
• Daily work—simulation of tasks, lifting
drills, and position-tolerance training exercises
similar to work hardening
• Classes on goal setting, work issues, stress
management, and interpersonal skills development
under direction of psychologist
30
Q
- Sedentary work is characterized by which of
the following criteria?
(1) Lifting a maximum of 10 lb
(2) Carrying objects weighing up to 10 lb
(3) Requirement of occasional walking and
standing, but mostly sitting
(4) Pushing and pulling of arm or leg controls
A
- (B) Sedentary work is defined as lifting 10 lb
maximum, with occasional lifting or carrying
of small, light objects. The work involves
mostly sitting, with a small amount of walking
or standing to perform job duties.
To perform light work, the employee must
be able to lift up to 20 lb and carry up to 10 lb.
Walking or standing may be required for significant
periods of the work day. Pushing or
pulling of arm or leg controls in the sitting or
standing position are also classified as light
work. For medium work, the employee must
be able to lift 50 lb frequently and carry up to
25 lb. For heavy work, the employee must be
able to lift up to 100 lb frequently and carry up
to 50 lb. For very heavy work, objects more
than 100 lb must be lifted and objects more
than 50 lb are carried.
31
Q
- The Social Security Administration uses a
number of criteria for determination of eligibility
for disability benefits. The sequential
evaluation for determination of benefits includes
which of the following factors? (Nonexertional
factors [evaluation of the applicant’s cognitive
capabilities] are part of the evaluation of residual
functional capacity.)
(1) Age
(2) Educational background
(3) Previous work history
(4) Residual functional capacity
A
- (E) To determine eligibility for Social Security
funds, the applicant must undergo a sequential
evaluation process that considers the applicant’s
ability to perform work despite any functional
restrictions associated with physical
impairment. Medical and psychologic variables
are considered, along with the applicant’s age,
educational background, and previous work
history. The applicant must undergo a medical evaluation to determine residual functional
capacity. Both exertional factors (evaluation of
the applicant’s ability to perform work functions
in several different work environments)
and nonexertional factors (evaluation of the
applicant’s cognitive capabilities) are part of
the evaluation of residual functional capacity.
32
Q
- The following statement(s) is (are) true to
describe the purposes of rehabilitation:
(1) To resolve deconditioning syndrome that
developed from prolonged bed rest with
loss of muscle strength, decreased flexibility,
and increased stiffness
(2) To optimize outcome by restoring function
and returning to activity
(3) To minimize potential or recurrence or
reinjury
(4) Short periods of rest between activities
help to exacerbate the deleterious effects
of inactivity
A
- (A) Purposes of rehabilitation are as follows:
To resolve deconditioning syndrome:
• Prolonged bed rest
• Flexibility
• Stiffness (loss of intrinsic muscle strength
muscle strength, 10%-15% per week, 70% in
6 months)
• Cardiovascular fitness
• Disc nutrition
• Depression
• Short periods of rest between activities
help to minimize the deleterious effects of
inactivity
To optimize outcome by
• Restoring function
• Returning to activity
• Minimize potential recurrence or reinjury
• Rehabilitation continues beyond resolution
of symptoms
To minimize need for surgical intervention:
• Failure of conservative care is the most
common indication for surgery
33
Q
- Identify true statement(s) to assist in your practice
by specialty designation of interventional
pain management:
(1) Physician profiling or comparative utilization
assessment
(2) 500% increase of practice expense calculation
immediately
(3) Carrier advisory committee (CAC) membership
(4) 100% increase in physician’s reimbursement
A
944. (B) Interventional pain management-09 designation. The purpose of the designation is for • Profiling • Practice expense • CAC membership
34
Q
- Which of the following statement(s) is (are) true
with regards to the Controlled Substances Act of
the Comprehensive Drug Abuse Prevention
and Control Act of 1970?
(1) It is the legal foundation of the government’s
fight against the abuse of drugs and
other substances
(2) It is a consolidation of numerous laws regulating
the manufacture and distribution
of narcotics, stimulants, depressants, hallucinogens,
anabolic steroids, and chemicals
used in the illicit production of controlled
substances
(3) All the substances that are regulated under
existing federal law are placed into schedule
I of the five schedules
(4) Schedule I is reserved for the least dangerous
drugs that have the highest recognized
medical use
A
- (A) The Controlled Substances Act (CSA), title 2
of the Comprehensive Drug Abuse Prevention
and Control Act of 1970 is the legal foundation
of the government’s fight against the abuse of
drugs and other substances. This law is a consolidation
of numerous laws regulating the
manufacture and distribution of narcotics,
stimulants, depressants, hallucinogens, anabolic steroids, and chemicals used in the illicit production
of controlled substances.
All the substances that are regulated
under existing federal law are placed into
schedules I of the five schedules. This placement
is based upon the substances’ medicinal
value, harmfulness, and potential for abuse or
addiction.
Schedule I is reserved for the most dangerous
drugs that have no recognized medical
use. Schedule V is the classification used for
the least dangerous drugs. The Act also provides
a mechanism for substances to be controlled,
added to a schedule, decontrolled,
removed from control, rescheduled, or transferred
from one schedule to another.
35
Q
- What does the following HIPAA compliance
administrative simplification do?
(1) Increases costs associated with administrative
and claims related transactions
(2) Establishes a national uniform standards
for eight electronic transactions, and claims
attachments
(3) Eliminates unique provider identifiers
(4) Establishes protections for the privacy and
security of individual health information
A
- (C) HIPAA compliance—administrative simplification
- Reduces costs associated with administrative
and claims-related transactions
• More than $30 billion in savings for more
than 10 years. - Establishes a national uniform standards
for eight electronic transactions, and claims
attachments. - Established unique provider identifiers.
- Establishes protections for the privacy and
security of individual health information. - Implementation costs
• More than $500 billion for more than 10 years.
36
Q
- What are true statements about fraud in medicine
in the United States?
(1) Medicare fee for service error rate was 8%
in 2004
(2) A GAO (US Government Accountability
Office) audit reported that in the United
States approximately 10% of every health
care dollar is lost to fraud annually
(3) Estimated net improper payments of CMS
for 2004 exceeded $50 billion
(4) Fraud and abuse cases include 60% public
and 40% private cases
A
- (C) A GAO audit reported that in the United
States approximately 10% of every health care
dollar is lost to fraud annually:
• 10% = $100 billion of $1 trillion or $100,000
million
• In 2004—10% = $179.3 billion of $1.7934 of
trillion or $1793.4 million
• By 2010—10% = $263.74 billion of $2.6374
trillion or $263,740 million
Fraud and abuse cases include 60% public
and 40% private cases.
37
Q
- Which of the following statement(s) is (are)
accurate?
(1) Voluntary disclosure program offers immunity
to providers who come forward within
30 days of discovering an offence
(2) Providers must always repay all Medicare
overpayments within 30 days
(3) Health care providers in medically underserved
areas (MUAs) may automatically
waive coinsurance and deductible payments
(4) Before the OIG issues a demand letter in a
civil money penalty case, the government
must have legally sufficient evidence for
eight elements of civil monetary penalties
offense
A
- (D)
- The voluntary disclosure program is
designed to allow providers and others to
come forward and admit health care fraud
in exchange for the possibility of lenient
treatment from the federal government.
Providers already under investigation for
fraud can also come forward to volunteer
information. Making full disclosure to the
investigative agency at an early stage generally
benefits the individual or company,
but there is no limit as to 30 days. - Normally, Medicare expects overpayments
to be paid back in 30 days after the first
demand letter. But if a lump sum refund
would cause severe financial hardship, a
provider can apply for an extended repayment
plan (either through direct payments
or deductions from the provider’s future
payments). For part B providers, here are
the deadlines a provider may face for making
payments (MCM 7160) (MIM 2224):
• $5000 or less within 2 months
• $5001 to $25,000 within 3 months
• $25,001 to $100,000 within 4 months
• $100,001 and above within 6 months - Regardless of their location, doctors, DME
suppliers and other part B billers must make
a good faith effort to collect the deductible
and coinsurance payments owed by their
Medicare patients—or face reimbursement
cuts from CMS and possible Medicare suspension
or exclusion. OIG sent out a fraud
alert in 1990 targeting physicians and other
suppliers who inappropriately waive copayments
or deductibles.
The government also could hold a
provider liable under the antikickback statute
because routinely forgiving co-payments or
deductibles may be considered an improper
inducement for patients to buy Medicare
items or services. Government penalties for
illegal waivers can include imprisonment,
criminal fines, civil damages and forfeitures,
fines and exclusion from Medicare and
Medicaid.
Typically, if providers make a reasonable
collection effort for coinsurance or
deductibles, failure to collect payment isn’t
considered a reason for the carrier to reduce
the charge or refer the provider to OIG or the
Justice Department. A“reasonable collection
effort” is one that is consistent with the effort
a doctor’s office typically makes to collect
co-payments and deductibles. It must
involve billing the patient and may include
subsequent billings, collection letters, telephone
calls or personal contacts, depending
on the provider’s usual practice. These
efforts must be genuine, not token, collection
efforts. A provider should check to see
whether its local carrier or intermediary has
defined a fair effort to collect, for instance,
three bills in 120 days. - The OIG has identified eight elements of a
civil money penalties offense:
• Any person
• Presents or causes to be presented
• To the United States or an agent of the
United States
• A Claim
• For an item or service
• Not provided as claimed
• Which the person knows or has reason to
know was not provided as claimed
• Materiality
