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.
