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166 Cards in this Set

  • Front
  • Back

Physician works in place of another physician

Locum Tenes

Who is the main care giver in ambulatory Care?

Physician

What is given at the conclusion of the visit?

Encounter Form

Patient is told to come in at 10:00 and will be seen on a first come first serve basis

block appointment

I show up as an outpatient for a gall stone removal, what facility am I at?

Ambulatory surgery center

who monitors compliance with reimbursement law and regulations?

OIG

Doctors reporting quality measures to CMS

DQRI

Uses HCPCS codes and is divided into groups

ASCs

who is the best choice to transfer my records to a new facility?

Currier

what is a downfall for using a PDA?

security risk

they own their own facility

staff

they contract with 1 or more group

network

contracts with 1 multispeciatlity group

group

this is for solo physicians for the advantage of managed care

IPA

2 or more groups

mixed

what is another term for subscriber?

member

what is a selling point for managed care?

reduced cost

what does the financial review?

reviews percentages

who accredits MCOs?

TJC
AAAH
NCQA

where would claims management be found?

in the MCO

if i have a preplanned surgery, what must I obtain before the surgery?

preadmission certificate

If I wanted something like a botox procedure, what would I need?

preauthorization

the utilization nurse is going and reviewing the patients chart daily, what review is she performing?

concurrent review

this is used when a person takes pretaxed money and puts it in an account to be used for health care purposes.

FSA

who decides if additional care is required?

Gatekeeper

what should I associate CLIA with?

laboratory's

what covers nursing and room and board services?

per diem

what system is in managed care?

HEDIS

T/F


managed and HMO are synonymous

false

an insurance entity that provides or arranges for health services for a covered population after prepayment of a fixed premium

HMO

the insured population is allowed to use any provider but using network providers results in a lower cost to the patient

PPO

an insurance plan tat combines the health maintenance and preferred provider concepts it allows the individual to make the choice at the time of service

POS

an insurance plan that reimburses the insured for expenses incurred, but incorporates some arranged care to control cost

managed indemnity plan

te HMO is the most tightly organized facility. it owns its own facilities and arranges for healthcare through employed physicians

staff

this HMO contracts with more than one physician group or hospital to provide a comprehensive health package

network

the HMO has an exclusive contract with one multispeciality medical group that provides all services

group

this HMO was developed primarily so solo practice physicians could take advantage of managed care

IPA

this HMO operates within 2 or more different types of organized structures to provide flexibility o members

mixed

the term subscriber can be used interchangeably with

member

managed care appeals to many because

reduced costs

dr.jones is actually an employee of sunny side HMO. she is paid on a monthly basis. what concept does this represent?

salary

dr. alms is given a fixed amount for each covered person he provides certain services to in his clinic during 2014. what revenue concept does this represent?

capitation

medical managed care operations quality indication includes all the following except?

fire drill rates

michael byers, comptroller of ABC hospital is reviewing the percentage of accounts owed over 90 days. this measure is an example of the following indicators

financial

this is NOT an organization that accredits MCOs

CMS

just is a recent graduate of the HIT program she has a great interest in working in an MCO. which of the following is a possibility as a job opportunity?

claims management

liz has been referred by her PCP to a cardiologist for an evaluation of a heart murmur. what type of data will be collected when the referral is made?

referral data

john, a coder, enters his diagnosis and procedure for an inpatient visit into a program. this program will provide John with the DRG for the encounter. what is the program called?

grouper

susie has been admitted to the hospital for pneumonia. a utilization review nurse is reviewing her chart daily for medical necessity. what is this process called?

concurrent review

bob is a new employee at ABC clinic. he is interested in the different benefits offered by his new employer. one of those benefits allows him to take pre-taxed monies from his check and place it in an account for health care cost. the downside to this he will loos the money at the end of the year if he does not use it. what type of benefit is this?

FSA

the medical executive committee is reviewing the file of dr. john smith who would like to apply to offer medical services.what is this process called?

credentialing

which would be a prerequisite for a credentialing file?

felony convictions


national practitioner database information


challenged of licensure

flat-rate payment such as $10/visit made by the covered individual for a specific service at the time of service is called

copayment

amount of expenses the insured must pay each year from their own pocket before the plan will reimburse them

deductible

primary care provider who coordinates at the patients health care and decides if additional care is required

gatekeeper

ABC hospital is opening a new community hospital in a nearby town. which would be required in order for their lab to operate in there?

CLIA certificate

is NOT a managed care accreditation association

AHRQ

these are ways that MCOs determine their premium amount

community rating


experiencing rating


composite rating

when utilizing a "per drum" rate for reimbursement purposes, which is true?

per drum covers nursing plus room and board charges

which database utilizes managed care?

HEIDS

t/f


the most popular method of determining who the primary payer is the "birthday rule"

true

t/f


managed care is the provision of comprehensive healthcare coordinated through a PCP which emphasis preventive care

true

t/f


an MCO produces revenue by selling patient supplies

false

t/f


providers are recredentialed every three years

false

what is axis I?

clinical disorders

axis IV = ?

homeless

counselor = ?

group therapy

how long is the stay of a residential inpatient abuse?

28 days

who would help me find an apartment?

case manager

follow ups are NOT what?

not administrative

SNF = ?

Medicare part A

MD = ?

directs care

where would you find patients with feeding tubes?

skilled care

short term is less than ?

100 days

NA's are ?

non licensed

how many e=beds must a hospital have to require a social worker?

120 beds

how many beds must a hospital have to require a dietician?

150 beds

when do standard surveys occur?

every 15 months

who has regular scheduled visits?

outpatient mental health facility

group home = ?

24 hour care

what is an example of permanent living?

personal care homes

this is short term, and early stage

crisis center

inpatient psych. hospitals = ?

dont respond

what manual does mental facilities go by?

CAMBHC

physic. evaluation = ?

60 hours

if a child is between 9-17 years old, how long can they be placed in restraints?

2 hours

what does SMI stand for?

serious mental illness

who orders the seclusion?

psychiatrist

what is an example of temporary illness?

losing a loved one

what type of program allows you to ATTAIN SKILLS?

day program

case management= ?

medications/prescriptions filled

what type of degree do case managers have to have?

bachelors

what document justify payments?

progress notes

RN = ?

Final rule

who publishes the DSM?

APA

a facility where clients RECEIVE regularly scheduled outpatient substance abuse treatment

outpatient substance abuse facility

a setting where clients are treated for substance abuse under the direction of physician, which includes all services of an acute care hospital

inpatient detox

mandates that strict confidentiality guidelines and legal procedures be adhered to by any federally assisted substance abuse treatment program

42 C.F.R

what are some examples of ADLs?

bathing


eating


going to the bathroom


dressing

these are often found as a distinct part within a long-term care facility

special care units

some are designed of the Alzheimers residents who benefit from a physical environment that is quiet, homelike, and adapted to their needs

special care unit

what are the 3 basic components of the RAI?

CAA


RAPs


MDS

triggers of a CAA might include:

pressure ulcer


physical restraints


physchotopic drug use


cognitive loss/dementia

who pays 100 days?

Medicare

if a facility is NOT certified for medicare or medicaid, what would provide the regulatory structure for documentation standards?

state licensure requirements

what happens when a facility is certified for medicare & medicaid?

both the federal and the state requirements must be met

AOE = ?

not a body

when did CMHCs become publicly funded entities established nationally by the mental health Act?

1965

? is set by the state and varies state to state

lisencure

what type of facility usually has to meet the standards of the licensure?

birthing centers


ambulatory surgery centers

in this format, all info is entered in chronological order by visit.

integrated

this is an example of what?


the family number might be 425687, with the father being 425687-1, the mother being 425687-2, the child being 435687-3 and so on

family numbering system

the process of determining he appropriateness of services and treatment provided to the patient, based on the patients needs.

utilization management

what does utilization management focus more on in the ambulatory setting?

on the necessity of service such as referral to a specialist or the use of an expensive procedure

the service is examined before it is provided

precertification

data is collected by nurse from the patient to a physician

precertificaition

the physician sends the patient to the hospital for a radiological exam. the patient returns to the physicians office for a follow-up of test results. from the point of view of the hospital, what type of hospital patient is this?

referred outpatient

which setting allows for the performance of elective surgical procedures on patients who are classified as outpatients and typically are released from the surgery center on that day of surgery, thus avoiding an overnight in the health care facility?

ambulatory surgery

regional databases are used to validate claims and track utilization throughout the US that contains info on each Medicare beneficiary in an ? that include dat from both hospital and physicians claims

common working file

john has pneumonia and is going revive around the clock services. what type of patient would he be if this level of care is needed?

inpatient

under EMT ALLhospital that offer emgency services

must screen and stabilize if necessary any patient who arrives in the emergency dept.

lucy is a medicare patient in a long term acute hospital, what is the payment system there based on/

MS-LTC-DRGS

ABC hospital is opening in the state of kansas, what is required for the hospital to begin offering serves

license by the state of kansas

without the documentation of the diagnosis or symptoms that prompted the physician to order the test the hsopialt will lack info needed to demonstrate that the test was

medically necessary

TJC requires that a medical record contain a summary list for each patient that includes

medical diagnosis


medical procedure


allergies

CMS replaced past claims processing contractors known as fiscal intermediaries and medicare carriers with 19 new

medicare administrative contractors

the standard form for submitting info for 3rd party payers when filing claims for hospital services is ?

CMS codes

at most hospitals the patient records starts with ?

registration process

the legislative act witch provides an incentive to providers to adopt the EHR

ARRA

which is not a criteria for demonstrating meaningful use stage 1 criteria ?

electronic exchange of all physician notes

all are roles of a HIM professional in a hospital setting except ?

respiratory therapist

when a hospital provides services to a medicare patient as an outpatient with 72 hours before a related inpatient admission charges for these outpatient serves ?

must not be billed separately from the inpatient bill

amy williams, is a phyicisfn who provides comphensicve services to patient in the hospital but does not see patients outside the hospital. she is known as a ?

hospitalist

a computer file that contains a list of codes and associated charges for the services provided to hospital patients is referred to as a ?

chargemaster

dr. moore admits mary to the hospital for observation. if he feels mary meets the criteria for admission as an inpatient dr. moore must generally make that decision within ?

24 hours

what specifies definitions and rules for selecting the principal diagnose and principle procedure and several other elements related to DRG assignment and payment for the hospital case?

UACDS

which data set is relevant for dat collection in an emergency dept.?

DEEDS

in occurrence that may result in litigation against the health care provider of may require a health care provider to compensate an injured

potentially compensable event

hospitals that meet the standards of TJC or DNV are ? to meet the conditions of participation

deemed

an organized unit for the monitoring of unstable patients and assessing whether or not the patients require inpatient admissions is ?

observation unit

a teaching physician may bill medicare for his or her services if:

documentation indicates the physicians presence and participation in the care of the patient

the medicare reimbursement for hospital outpatients is termed ?

ambulatory payment classification

the coding classifications utilized in the inpatient setting include:

ICD-9-CM


HCPCS


REVENUE CODES

the average length of stay for a hospital setting is

5 days

the average length of stay for a long term care facility is

25 days or more

all of the following would be in an ambulatory surgery record EXCEPT

labor & delivery record

according to TJC standards, which documentation requirements are required for patients receiving urgent or immediate care

the time care was provided


if the patient left against medical advice


final disposition

lucy was treated at sunny side hospital in the emergency for diabetes management. what type of system will be used for reimbursement on lucy?

APCs

one major difference in APCs and DRGs are :

outpatient may be assigned more than one APC per encounter whereas an inpatient can only one DRG

medical visits in an emergency dept. are classified and paid according to the level of service based on ?

E and M codes

linda is in the hospital for 8 days for some severe respiratory issues. linda ia insured by medicare. which part of medicare takes care of the hospital bill?

medicare part A

bob was seen in dr. oz office on 1/21/2013. bob is insured by medicare. which part of medicare will take care of the office visits?

medicare part B

which of the following settings is not considered a hospital based care?

dialysis

which of the following is generally a type of caregiver NOT FOUND in a hospital setting?

dentist

what software program is used to assign patients case to a DRG?

grouper

which dept. would be responsible for focusing on the appropriateness, efficiency, and cost effectiveness of the care being provided in their facility?

utilization management

t/f


the average length of stay for a long term care hospital is 24 days.

false

t/f


the code for federal regulations contain the basic rules that regulate medicare payments to teaching physicians

true


t/f


tom presents to the ER for a severe laceration to the left temple. he was told the business office staff would have to see hi to verify insurance info before he could be stitched up

false

t/f


the process of coding is crucial to a facility so they can receive appropriate reimbursement

true

t/f


failure of a facility to comply with the 72 hour rule may result in jail time

false

t/f


it is acceptable for a teaching physician to merely or ONLY countersign a residents notes to justify payment for that service.

false

t/f


the hospitalist continues to follow a patient for primary healthcare needs after they are discharged

false

t/f


ambulatory surgery has grown tremendously due to advances in technology

true

t/f


a compliance officer might focus on auditing coding and billing issues.

true

t/f


revenue codes are used on the UB-04 to indicate the general nature of services provided

true