Certified Revenue Cycle Representative (CRCR) Practice Exam

What is the purpose of internal controls regarding coding and reimbursement changes?

1. To guard against underpayments

2. To prevent denials

3. To avoid compliance fraud by upcoding

4. To reduce charge master error

The correct answer is: To avoid compliance fraud by upcoding

The purpose of internal controls regarding coding and reimbursement changes is fundamentally to ensure compliance with regulations and prevent fraudulent activities, such as upcoding. Upcoding involves coding a service or procedure at a higher level than what was actually performed, which can result in improper and illegal reimbursement. Implementing internal controls helps organizations maintain integrity in their coding practices by providing guidelines, oversight, and checks to identify and prevent such fraudulent behavior. While internal controls can also indirectly address issues like underpayments, denials, and charge master errors, their primary role focuses on maintaining compliance and preventing fraud specifically related to coding accuracy. This ensures that healthcare organizations adhere to billing regulations and avoid penalties that could arise from fraudulent coding practices.