Legal Flashcards
According to the documentation requirements of the Center for Medicare and Medicaid Services
(CMS), which factor is not considered part of a patient’s History?
(a) Chief complaint
(b) Allergies
(c) Review of systems
(d) Social history
(b)
Evaluation and management coding (E/M) is the process by which physician-patient encounters are translated into to numeric codes to facilitate billing. Different E/M codes exist for different types of encounters, such as inpatient or outpatient encounters and new patient or established patient encounters. Documentation for E/M services is based on 3 key components, including (1) history, (2) physical exam and (3) medical decision-making. While a patient’s
allergy history is an important part of the evaluation, E/M coding does not credit this
documentation as part of a patient’s history. The history is comprised of the patient’s chief complaint, history of present illness, review of systems, and past medical, family, and social
history.
Reference: Department of Health and Human Services, Center for Medicare and Medicaid
Services, Medicare Learning Network fact sheet: Evaluation and management (E/M) services: Complying with documentation requirements
2013
A 57-year-old man with chronic low back pain is referred to see you. He has commercial medical insurance. The patient leaves radiologic films and medical records for review and also asks you to complete disability paperwork. That evening you review the films and records, fill out the paperwork, and call the referring physician. In addition to the charges for a New Patient
Consultation, what charges may you submit to the commercial medical insurance for these services?
(a) No additional charges, since all your services are covered by the New Patient
Consultation charge
(b) No additional charges to the commercial insurance, although you may charge the
disability insurance for completing the disability paperwork
(c) One additional charge for Prolonged Services, up to 60 minutes for the time needed to
complete all the additional services Page 12 of 23
(d) Two additional charges, one for radiology review and another for Prolonged Services, up
to 60 minutes for the time needed to complete the other services
Answer: (a)
Commentary: For outpatient services, Evaluation and Management (E/M) coding allows providers to bill based on time spent, as long as that time is spent face-to-face, and at least 50% of that time is used for patient counseling and education. Provider services that occur outside of the actual face-to-face encounter are assumed as part of the work necessary to complete the evaluation and management of the patient and may not be billed separately as “Prolonged Services.” Commercial and disability insurance companies are not obligated to reimburse providers to complete paperwork, and providers may opt to charge patients directly for completion of disability paperwork. Had this patient presented through the Workers’ Compensation (WC) system, some of these additional services may have been reimbursable, depending on the specific WC laws that are stipulated by each state.
Reference: American Medical Association. Current procedural terminology (CPT) 2012
professional edition. Chicago (IL) American Medical Association; 2011. P 8.
2013
A physiatrist assesses each of the following patients during hospitalization and determines that
each one is clinically appropriate for an admission to your acute inpatient rehabilitation unit.
Which patient does NOT qualify for the Center for Medicare and Medicaid Services (CMS) 60%
Rule (formerly known as the 75% Rule)?
(a) 28-year-old woman with multiple sclerosis exacerbation, status-post intravenous
methylprednisolone (Solu-Medrol)
(b) 60-year-old woman with active polyarticular rheumatoid arthritis, status-post left total
shoulder arthroplasty
(c) 63-year-old man with end-stage kidney disease, status-post kidney transplant,
complicated by sepsis
(d) 87-year-old man with end-stage osteoarthritis, status-post elective left total knee
replacemen
Answer: (c)
Commentary: Inpatient Rehabilitation Facilities (IRFs) must follow the Center for Medicare and Medicaid Services (CMS) criterion regarding admissions in order to receive payment. Previously known as the “75% Rule,” CMS changed the percentage to 60% in 2007. Currently, 60% of all admissions to an IRF must have 1 or more of 13 selected conditions that include stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur (hip fracture), brain injury, neurological disorders (including multiple sclerosis, motor neuron disease,
polyneuropathy, muscular dystrophy, Parkinson disease), and burns. Other conditions such asrheumatologic arthritides or osteoarthritis have additional stipulations. Patients undergoing elective hip and/or knee joint replacements must also meet 1 of 3 additional criteria, including (1)
bilateral joint replacement surgeries, (2) body mass index greater than 50, or (3) age 85 or older. The CMS criterion does not prohibit admission to an IRF if a patient does not have 1 of these 13 conditions, though IRFs must continually monitor compliance to ensure reimbursement. While the patient who underwent a kidney transplant may be able to participate in and benefit from 3 hours of interdisciplinary therapy daily and requires ongoing inpatient nursing and physician management, his diagnosis is not included in the 13 medical conditions recognized by the CMS criterion
2013
A 67-year-old man who had a stroke is being discharged from the hospital. His 32-year-old
nephew plans to care for him at home, but is unfamiliar with the Family Medical Leave Act
(FMLA). How does FMLA apply to the nephew?
(a) He does not qualify since he is not the spouse or an immediate family member.
(b) FMLA only applies to the patient, not to the caregiver.
(c) He will be paid 66% of his usual salary while he is taking FMLA.
(d) If he takes FMLA, he may lose his employer-sponsored health insurance
Answer: (a)
Commentary: The Family Medical Leave Act (FMLA) entitles eligible employees of covered
employers to take unpaid, job-protected leave for specified family and medical reasons with
continuation of group health insurance coverage. Eligible employees are entitled to 12 work
weeks of leave in a 12-month period for any of the following reasons:
1. the birth and care of the newborn child of an employee
2. the placement with the employee of a child for adoption or foster care
3. to care for an immediate family member (spouse, child, or parent) with a serious health
condition
4. to take medical leave when the employee is unable to work because of a serious health
condition Employees are eligible for leave if they have worked for their employer at least 12 months, have
worked at least 1250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles
2012
Injured workers with acute low back pain treated with high-dosage opioids compared to low-dose
or nonopioid medications demonstrated which outcome?
(a) Lower overall medical costs
(b) Same duration of disability
(c) Higher risk for surgery
(d) Shorter duration of opioid use
Answer: (c)
Commentary: Injured workers with acute low back pain who received higher dosages of opioids in early treatment had adverse outcomes compared to patients given no or low-dose opioids. In the high-dose opioid group, adverse outcomes included higher medical costs, prolonged disability, higher risk for surgery, and continued use of opioids. The high-dose opioid group was disabled 69 days longer than the non-opioid group, had a 3 times greater risk for surgery, and a 6-times-greater risk of receiving long-term opioids. The severity of the low back injury was a strong predictor of all outcomes
2011
For injured workers with chronic low back pain, which outcome is associated with better
performance during a functional capacity evaluation (FCE)?
(a) Shorter usage of temporary disability benefits
(b) Lower subjective reports of perceived disability
(c) Higher likelihood of sustainable work tolerance
(d) Fewer recurrences of low back pain over the next 12 months
Answer: (a)
Commentary: Functional capacity evaluations (FCEs) are commonly used to determine readiness
for return to work. These evaluations measure the injured worker’s functional abilities relative to
the physical demands required by the job. The clinical assumption is that workers who perform
better during FCEs will have a lower risk of reinjures and less pain exacerbation upon return to
work. One-year follow-up of patients with chronic low back pain whose FCE demonstrated
performance that met or exceeded physical job requirements did not demonstrate a reduction of
recurrent low back pain, improved occupational sustainability, or improved perception of
disability. Better FCE performance was mildly associated with faster return to work and shorter
duration of temporary disability benefits.
2011
A physiatrist assesses each of the following patients during hospitalization and determines that each one is clinically appropriate for an admission to your acute inpatient rehabilitation unit. Which patient does NOT qualify for the Center for Medicare and Medicaid Services (CMS) 60% Rule (formerly known as the 75% Rule)?
(a) 28-year-old woman with multiple sclerosis exacerbation, status-post intravenous methylprednisolone (Solu-Medrol)
(b) 60-year-old woman with active polyarticular rheumatoid arthritis, status-post left total shoulder arthroplasty
(c) 63-year-old man with end-stage kidney disease, status-post kidney transplant, complicated by sepsis
(d) 87-year-old man with end-stage osteoarthritis, status-post elective left total knee replacement
Answer: (c)
Commentary: Inpatient Rehabilitation Facilities (IRFs) must follow the Center for Medicare and Medicaid Services (CMS) criterion regarding admissions in order to receive payment. Previously known as the “75% Rule,” CMS changed the percentage to 60% in 2007. Currently, 60% of all admissions to an IRF must have 1 or more of 13 selected conditions that include stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur (hip fracture), brain injury, neurological disorders (including multiple sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy, Parkinson disease), and burns. Other conditions such as
Page 17 of 23
rheumatologic arthritides or osteoarthritis have additional stipulations. Patients undergoing elective hip and/or knee joint replacements must also meet 1 of 3 additional criteria, including (1) bilateral joint replacement surgeries, (2) body mass index greater than 50, or (3) age 85 or older. The CMS criterion does not prohibit admission to an IRF if a patient does not have 1 of these 13 conditions, though IRFs must continually monitor compliance to ensure reimbursement. While the patient who underwent a kidney transplant may be able to participate in and benefit from 3 hours of interdisciplinary therapy daily and requires ongoing inpatient nursing and physician management, his diagnosis is not included in the 13 medical conditions recognized by the CMS criterion
2013
A 57-year-old man with chronic low back pain is referred to see you. He has commercial medical insurance. The patient leaves radiologic films and medical records for review and also asks you to complete disability paperwork. That evening you review the films and records, fill out the paperwork, and call the referring physician. In addition to the charges for a New Patient Consultation, what charges may you submit to the commercial medical insurance for these services?
(a) No additional charges, since all your services are covered by the New Patient Consultation charge
(b) No additional charges to the commercial insurance, although you may charge the disability insurance for completing the disability paperwork
(c) One additional charge for Prolonged Services, up to 60 minutes for the time needed to complete all the additional services
(d) Two additional charges, one for radiology review and another for Prolonged Services, up to 60 minutes for the time needed to complete the other services
Answer: (a)
Commentary: For outpatient services, Evaluation and Management (E/M) coding allows providers to bill based on time spent, as long as that time is spent face-to-face, and at least 50% of that time is used for patient counseling and education. Provider services that occur outside of the actual face-to-face encounter are assumed as part of the work necessary to complete the evaluation and management of the patient and may not be billed separately as “Prolonged Services.” Commercial and disability insurance companies are not obligated to reimburse providers to complete paperwork, and providers may opt to charge patients directly for completion of disability paperwork. Had this patient presented through the Workers’ Compensation (WC) system, some of these additional services may have been reimbursable, depending on the specific WC laws that are stipulated by each state
2013
The current workers’ compensation system in the United States is a “no fault” system. This
means that the
(a) employee does not have to prove that the employer is at fault for the injury.
(b) employer does not have to prove they are at fault for the employee’s injury.
(c) employee and employer do not have to prove that the other is at fault for the injury.
(d) employer does not have to prove that the employee is at fault for the employee’s injury
Answer: (c)
Commentary: In the United States workers’ compensation system the injured worker does not
have to prove that the employer is at fault for the employee’s injury. Similarly, the employer
does not have to prove that the injured worker is at fault for his/her injury. If the injury occurred
at work, the medical costs and partial payment of lost income are covered.
2010
A 67-year-old man who had a stroke is being discharged from the hospital. His 32-year-old
nephew plans to care for him at home, but is unfamiliar with the Family Medical Leave Act
(FMLA). How does FMLA apply to the nephew?
(a) He does not qualify since he is not the spouse or an immediate family member.
(b) FMLA only applies to the patient, not to the caregiver.
(c) He will be paid 66% of his usual salary while he is taking FMLA.
(d) If he takes FMLA, he may lose his employer-sponsored health insurance.
Answer: (a)
Commentary: The Family Medical Leave Act (FMLA) entitles eligible employees of covered
employers to take unpaid, job-protected leave for specified family and medical reasons with
continuation of group health insurance coverage. Eligible employees are entitled to 12 work
weeks of leave in a 12-month period for any of the following reasons:
1. the birth and care of the newborn child of an employee
2. the placement with the employee of a child for adoption or foster care
3. to care for an immediate family member (spouse, child, or parent) with a serious health
condition
4. to take medical leave when the employee is unable to work because of a serious health
condition
Employees are eligible for leave if they have worked for their employer at least 12 months, have
worked at least 1250 hours over the past 12 months, and work at a location where the company
employs 50 or more employees within 75 miles.
2012
A 47-year-old woman with T8 ASIA A spinal cord injury (SCI) applied for a position as a store
clerk. She felt that she was being discriminated against because of her SCI. Under the Americans
with Disabilities Act (ADA), she may have a right to file a complaint if
(a) the employer requested a pre-employment physical to see if she qualified.
(b) the employer hired her, but then requested a pre-placement physical to determine the
most appropriate position for her.
(c) the job description required climbing ladders and working from heights.
(d) the employer did not make all accommodations to allow her to work from her wheelchair.
Answer: (a)
Commentary: The Americans with Disabilities Act (ADA) is a federal law designed to help
protect the rights of disabled citizens. Employers must not discriminate against hiring a disabled
applicant if that person is able to perform the key components of the job. Pre-employment
physicals are not allowed under the ADA, but a pre-placement physical can be used after an
individual is hired to help determine the most appropriate job for that person. An employer may
decline to hire a disabled individual if that person is unable to perform the essential functions of
the job, so long as the employer has attempted to make reasonable accommodations to allow the
disabled individual to perform these job functions. This individual would not be able to climb
ladders or work from heights because of her SCI, despite any accommodations.
2012
Two medical experts (Drs. A and B) have differing opinions in a medical-legal case. Dr. A
accuses Dr. B of citing “junk science,” and states that Dr. B’s testimony fails to meet the Daubert
standard. Which statement supports the opinion that Dr. B has not met the Daubert standard?
(a) Dr. B’s research experience and publications are less than Dr. A’s.
(b) Dr. B’s peer-reviewed references are all more than 10 years old
(c) Dr. B’s cited references did not have a known error rate.
(d) Dr. B’s opinions are not fully accepted by the medical community.
Answer: (c)
Commentary: The Daubert standard refers to a federal Supreme Court decision to prevent “junk
science” from influencing juries. Information given by expert testimony must meet certain
criteria, and if these criteria are not met the expert can be barred from testifying. The information
provided by medical experts must meet the following four criteria:
1. Generally well accepted in the medical community
2. Published in peer-reviewed literature
3. Have a scientific basis
4. Have a known error rate
In the scenario presented, Dr. B satisfied the Daubert standard except for his failure to provide a
known error rate in his research.
2012
A 47-year-old woman with secondary progressive multiple sclerosis is applying for Social
Security Disability Insurance (SSDI). She asks her primary care physician for help. His correct
response to her is that
(a) SSDI benefits and policies vary from state to state.
(b) SSDI benefits include medical insurance.
(c) he will make the final determination of disability and employability.
(d) she must satisfy non-medical criteria before medical factors are considered.
Answer: (d)
Commentary: The Social Security Administration (SSA) provides both Social Security Disability
Insurance (SSDI) and Supplemental Security Income (SSI). SSDI and SSI are federal programs
with identical benefits and policies from state to state. SSDI and SSI provide financial assistance
to disabled individuals, but do not provide medical insurance. Final determination of SSDI or SSI
is made by the SSA, not the treating provider. However, medical information is usually requested
from treating providers in order to make a determination of disability. An applicant must first
meet certain non-medical (eg, economic) criteria before medical factors are considered.
2012
Which statement about the Functional Independence Measure (FIM) is TRUE?
(a) The instrument is limited by its lack of evaluation of cognitive skills.
(b) It is used by inpatient rehabilitation programs to compare the outcomes of their patients
with regional and national outcomes.
(c) It uses a 5-point scale to rate the amount of assistance that an individual requires in
various functional areas.
(d) It is routinely applied only at discharge from an inpatient rehabilitation facility
Answer: B
Commentary:The Functional Independence Measure (FIM) is an outcomes measurement tool
used by inpatient rehabilitation facilities across the country. It enables inpatient rehabilitation
programs to compare their patients’ outcomes with regional and national outcomes. The FIM
measures an individual’s functional abilities and level of assistance required in 18 separate functional areas, including cognition and communication. The FIM instrument uses a 7-point
scale to rate the amount of assistance that an individual requires in each of these functional areas.
The FIM can be completed at any frequency, but is typically completed at least at the time of
admission and at the time of discharge from an inpatient rehabilitation facility.
2009
Continuous quality improvement (CQI) is a method of quality control widely used in the manufacturing industry to analyze and improve production processes. Applied to health care delivery, what is a general principle of CQI?
a. Systemization of care is preferred, although it may be perceived as a loss of provider autonomy.
b. Most errors are attributable to individuals, rather than to a system being suboptimal.
c. A negative medical event must occur in order to trigger the CQI process.
d. The increased cost of health care by implementing “best practices” is offset by the continued access to new technologies.
Option a is correct.
Continuous quality improvement (CQI) programs focus on both outcome and process of care. Quality improvement relies on a critical evaluation of current practice to develop process improvements, reduce practice variation, and optimize resource consumption. A work environment with needless variation increases the likelihood of medical errors by the health care personnel involved. Physicians often resist standardizing care, fearing a loss of autonomy or loss of their ability to provide individualized care. Frequently, an inherent tension exists between standardization to excellence and physician autonomy. That tension needs to be understood and confronted. CQI focuses on process or system improvement, rather than placing blame on individuals. A general principle behind CQI is that 85% of errors occur because of a suboptimal system, and only 15% of errors are attributable to individuals. Experts using CQI in health care believe it is possible to improve quality and save money at the same time. The objectives of quality improvement are to ensure access to new technology, good procedural outcomes, and patient satisfaction, while concurrently identifying opportunities that will reduce expense.
2014
Answer: D
Commentary:Nachemson measured the relative pressure changes within the third lumbar disc
with changes of position. Standing erect was the reference position and pressures decreased with
lying supine and increased in the seated position. Seated and flexed forward further increased disc
pressures. Several other positions were evaluated
Answer: B
Commentary:A benchmark is a target value or standard for comparison for a performance
indicator. Functional outcomes and efficiency of functional improvement during inpatient
rehabilitation admission are examples of performance indicators. The UDS-FIM database
provides a means by which individual rehabilitation units can compare their outcomes to other
centers across the nation. This process of comparing outcomes to a standard is referred to as
benchmarking.
2009
According to the American Medical Association Code of Ethics Opinion, which statement is
TRUE?
(a) Individual gifts of minimal value from pharmaceutical representatives to physicians are
permissible so long as the gifts are related to the physician’s work.
(b) It is acceptable for physicians to request free pharmaceuticals for personal use or use by
family members.
(c) Subsidies to underwrite the costs of continuing medical education are permissible when
provided directly from the pharmaceutical company to the physician.
(d) Faculty presenting at conferences cannot accept honoraria and reimbursement for travel,
lodging, and meal expenses.
Answer: A
Commentary:According to the AMA Code of Ethics Opinion, individual gifts of minimal value
from pharmaceutical representatives to physicians are permissible, so long as the gifts are related
to the physician’s work. It is not acceptable for physicians to request free pharmaceuticals for
personal use or use by family members. Subsidies to underwrite the costs of continuing medical
education are permissible when they are accepted by the conference’s sponsor and are not
provided directly to the physician. It is acceptable for faculty at conferences to accept reasonable
honoraria and reimbursement for travel, lodging, and meal expenses.
2009
. In terms of continuous quality improvement, a sentinel event is defined as
(a) a benchmark event that sets the standard for patient care.
(b) an occurrence that requires dismissal of personnel.
(c) a single occurrence that is highly problematic or socially unacceptable.
(d) an event that results in the opening of a new hospital program
C
Commentary:In terms of continuous quality improvement, a sentinel event is defined as a single
occurrence that is highly problematic or socially unacceptable. Sentinel events will typically
trigger an in-depth root cause analysis to determine the cause of the event as well as potential
solutions. The focus of these investigations is to evaluate the processes and systems that are in
place rather than to focus blame on individual practitioners
2009
Disability as defined by the Americans with Disabilities Act (ADA) is
(a) a physical or mental impairment that substantially limits 1 or more major life activities.
(b) abnormality of the physiologic or anatomic structure or function.
(c) the barriers society places on the individual interacting in his/her community.
(d) a rating based on an independent medical examination.
Answer: A
Commentary:The Americans with Disabilities Act defines disability as a physical or mental
impairment that substantially limits 1 or more of a person’s major life activities. The person has a
record of such impairment, or is regarded as having such impairment. Impairment is the actual
physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places
on an individual to perform function in the community. A permanent disability rating is used to
determine financial compensation for an injury.
2009
How are mobility devices paid for through Medicare?
(a) The patient must make a 50% down payment, with the rest covered by Medicare upon
delivery of the device.
(b) Medicare part A pays 80% of the allowed purchase price and Medicare part B pays the
remaining 20%.
(c) Medicare will pay for purchase but not rental of mobility devices. (d) Medicare part B pays 80% of the allowed purchase price in one lump sum
(d) Medicare part B pays 80% of the allowed purchase price in one lump sum
Answer: D
Commentary:Medicare Part B pays 80% of the allowed purchase price in one lump sum payment
if the patient chooses to purchase the device. The patient is required to pay 20% of the allowed
purchase price. If the patient chooses to rent a wheelchair, Medicare part B will pay 80% of the
allowed rental price for months 1 through 10 and the patient will pay 20% of the allowed rental
charge
2009
Which structure is required by the American with Disabilities Act (ADA) to have adequate
accessibility for individuals with disabilities, so long as the modifications to it are readily
achievable?
(a) House of worship
(b) Physician’s office within a private residence
(c) Commercial airplane
(d) Residential private apartments
Answer: B
Commentary:If a publicly accessible office is present within a single family home, it is required to be accessible under the ADA, so long as the necessary modifications are readily achievable. Accessibility of commercial airplanes is covered under the Air Carrier Access Act, not the ADA. Access to houses of worship or strictly residential private apartments is not required under the
ADA
2009
A recent study of individuals undergoing a single knee or hip replacement surgery who were
treated at an inpatient rehabilitation facility (IRF) compared to those treated at a skilled nursing
facility (SNF) found that those treated in an IRF were more likely to
(a) need the use of a walker to ambulate.
(b) require home care services.
(c) be discharged home.
(d) ambulate a shorter distance
Answer: C
Commentary: Patients undergoing single knee or hip replacement surgery who were treated at an
IRF were more likely to be discharged home, less likely to require home care services upon
discharge, and were able to ambulate farther distances compared to those treated in an SNF.
2009
Which factor is associated with increased risk for occupational injury in an older individual?
(a) White collar occupation
(b) Female gender
(c) Impaired hearing
(d) Self employment
Answer: C
Commentary:Predictors of increased injury risk in an older worker include male gender, less
education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several
specific job requirements. Service workers, mechanics, machine operators, and laborers are at
increased risk for occupational injury compared to people in white collar occupations. Individuals
who are self-employed have a lower risk of injury.
2009
Which abbreviation or symbol is acceptable to use when writing prescriptions, according to The Joint Commission (JC)?
(a) QD for once daily
(b) U for units
(c) ml for milliliters
(d) cc for milliliters
Answer: C
Commentary:Of the options given the Joint Commission has only approved the use of the
abbreviation ml for milliliters. Using the abbreviation QD can be dangerous since it may be
mistaken for QID, which stands for four times per day
2009
