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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 |
|
where would claims management be found? |
in the MCO |
|
if i have a preplanned surgery, what must I obtain before the surgery? |
preadmission certificate |
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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 |
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the insured population is allowed to use any provider but using network providers results in a lower cost to the patient |
PPO |
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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 |
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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 |
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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 |
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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 |
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this is NOT an organization that accredits MCOs |
CMS |
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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 |
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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 |
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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 |
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amount of expenses the insured must pay each year from their own pocket before the plan will reimburse them |
deductible |
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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 |
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is NOT a managed care accreditation association |
AHRQ |
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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 |
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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 |
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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 |