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Quiz dotyczący sztucznej inteligencji w zakresie kodowania medycznego

Testuje, dlaczego flagi AI wymagają potwierdzenia audytora, dlaczego ukierunkowanych przeglądów nie można ekstrapolować i jak zasada 60-dniowej nadpłaty wpływa na audyty kodowania.

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Pytanie 1 z 8

A hospital's AI reviewed every outpatient claim and flagged 400 errors. What is the status of those flags?

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  1. A hospital's AI reviewed every outpatient claim and flagged 400 errors. What is the status of those flags?
    • They are leads until a qualified auditor confirms them
    • They are final findings that must be refunded right away
    • They can be extrapolated across all claims
    • They satisfy a RAC audit automatically
  2. Why can't a targeted review of high-risk claims be used to estimate an overpayment across all claims?
    • Targeted reviews are illegal
    • Targeted claims are chosen on purpose, not at random, so they do not represent the whole group
    • RAT-STATS does not support outpatient claims
    • Only payers may review high-risk claims
  3. What free tool does the OIG offer for statistical sampling?
    • PEPPER
    • NCCI
    • RAT-STATS
    • CERT
  4. The hospital reran Medically Unlikely Edits on paid outpatient claims. What were those checks looking for?
    • Missing patient signatures
    • Out-of-network providers
    • Invalid diagnosis codes
    • Billed units above the maximum usually reported for a service
  5. Why does the overpayment rule raise the stakes of AI auditing?
    • It bans AI in compliance programs
    • Once an overpayment is identified, it must be reported and returned within set deadlines, so surfaced problems need a resolution process
    • It requires auditing 100 percent of claims
    • It applies only to Medicare Advantage plans
  6. In the inpatient example, what triggered the AI's flag?
    • A missing admission order
    • A duplicate claim number
    • A major complication supported by one mention of acute respiratory failure with no clinical indicators
    • A patient older than 90
  7. Which document lists auditing and monitoring as a core compliance element?
    • The OIG's General Compliance Program Guidance from November 2023
    • The ICD-10-CM Tabular List
    • The X12 835 standard
    • The CPT E/M guidelines
  8. Why should coding error rates be reported by claim, by code line and by dollar?
    • CMS requires exactly three reports
    • It lets the AI run faster
    • Dollar rates are always zero
    • The three measures can tell different stories about the size and impact of errors