ExamworthyExamworthy
Open the appStart free

CPC - Compliance, Regulatory, and Practical Application - Section 6.1

Apply coding compliance and regulatory rules, including HIPAA, fraud and abuse statutes, medical necessity, and the distinction between upcoding, unbundling, and a legitimate claim.

Recognise the regulatory framework that governs coding - HIPAA privacy and transaction standards, the False Claims Act, the Anti-Kickback Statute, and the OIG compliance program guidance - and distinguish honest coding from fraud and abuse. Identify upcoding, unbundling, and billing without medical necessity as compliance failures, and recognise the role of an Advance Beneficiary Notice (ABN) when a service may not be covered.

HIPAAFraud and abuseMedical necessityUpcoding and unbundling

Practice question for this objective

Free sampleCompliance, Regulatory, and Practical Applicationmedium

Which federal statute imposes liability chiefly for knowingly presenting a false or fraudulent claim for payment to a federal healthcare programme?

  • AThe Anti-Kickback Statute, which prohibits knowingly offering or receiving remuneration to induce referrals of federally reimbursed items or services.
  • BThe Stark Law, which prohibits a physician from referring designated health services to an entity with which the physician has a financial relationship.
  • CThe False Claims Act, which imposes liability for knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval. Correct
  • DThe HIPAA Privacy Rule, which restricts how covered entities may use and disclose a patient's protected health information.
The False Claims Act is the primary federal statute for knowingly submitting false or fraudulent claims for payment. The False Claims Act attaches liability to knowingly presenting a false or fraudulent claim to the government, which is why upcoded or unbundled claims can trigger it. The Anti-Kickback Statute and Stark Law instead target remuneration and self-referral relationships.

Why A is wrong: The statute is closely tied to healthcare fraud and often overlaps with false claims, but its core prohibition targets remuneration for referrals, not the act of submitting a false claim itself.

Why B is wrong: Stark addresses physician self-referral for designated health services and is a plausible fraud-and-abuse pick, but it is a referral prohibition rather than a false-claims submission statute.

Why C is correct: The False Claims Act is the principal statute reaching knowingly submitted false claims to federal programmes, including claims inflated by upcoding or unbundling, and is the correct match.

Why D is wrong: The Privacy Rule governs information handling, so a candidate may reach for a familiar HIPAA name, but it does not create liability for submitting false payment claims.

See more CPC practice questions with worked answers.

More in this domain

Back to all Compliance, Regulatory, and Practical Application objectives, or the CPC cert hub.

Examworthy is not affiliated with or endorsed by AAPC. Original, blueprint-aligned practice material only.