Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
115 Cards in this Set
- Front
- Back
|
CMS assigns one _____ to each APC and each _____ code. - payment status indicator, HCPCS - MS-DRG, CPT - CPT code, HCPCS - payment status indicator, ICD-10-CM and ICD-10-PCS |
payment status indicator, HCPCS |
|
|
HIPAA administrative simplification require all of the following code sets to be used except: - CDT - ICD-10-CM - CPT |
DSM |
|
|
ICD-10-PCS procedure codes are used on which of the following forms to report services provided to a patient? - CMS-1491 - MDC 02 - CMS-1500 - UB-04 |
UB-04 |
|
|
This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of his family has a financial interest - Civil Monetary Penalties Act - Federal Antikickback Statute - False Claims Act - Stark I Law |
Stark I Law |
|
|
Under ASC PPSs, bilateral procedures are reimbursed at _____ of the payment rate for their group. - 50% - 200% - 150% - 100% |
150% |
|
|
Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, except: - the patient has a total of 60 lifetime reserve days - lifetime reserve days are paid under Medicare Part B - lifetime reserve days are not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges - lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay |
lifetime reserve days are paid under Medicare Part B (lifetime reserve days are applicable for hospital inpatient stays that are payable under Medicare Part A, not Part B) |
|
|
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value. These three components are _____ - physician work, practice expense, and malpractice insurance - fee-for-service, per diem payement, and capitation - geographic index, wage index, and cost of living index - conversion factor, CMS weight, and hospital-specific rate |
physician work, practice expense, and malpractice insurance expense |
|
|
This initiative was instituted by the government to eliminate fraud and abuse and recover overpayments, and involves the use of _____. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government. - Quality Improvement Organizations (QIO) - Recovery Audit Contractors (RAC) - Clinical Data Abstraction Centers (CDAC) - Medicare Code Editors (MCE) |
Recovery Audit Contractors (RAC) |
|
|
Under APCs, payment status indicator "V" means _____ - significant procedure, not discounted when multiple - inpatient procedure - clinic or emergency department visit (medical visits) - ancillary services |
clinic or emergency department visit (medical visits) |
|
|
Accounts Receivable (A/R) refers to _____ - claims for which money has been received - the amount the hospital was paid - denials that have been returned to the hospital - claims for which money has not yet come in |
claims for which money has not yet come in |
|
|
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called _____ - APCs - MS-DRGs - APGs - RBRVS |
APCs |
|
|
Under the APC methodology, discounted payments occur when _____ - there are two or more (multiple) procedures that are assigned to status indicator "T" - modifier -78 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started - there are two or more (multiple) procedures that are assigned to status indicator "S" - pass-through drugs are assigned to status indicator "K" |
there are two or more (multiple) procedures that are assigned to status indicator "T" |
|
|
Under APCs, payment status indicator "C" means _____ - ancillary services - inpatient procedures/services - significant procedures, not discounted when multiple - significant procedure, multiple procedure reduction applies |
inpatient procedures/services |
|
|
Under APCs, payment status indicator "S" means _____ - clinic or emergency department visits (medical visits) - significant procedure, multiple procedure reduction applies - ancillary services - significant procedure, multiple procedure reduction does not apply |
significant procedure, multiple procedure reduction does not apply |
|
|
Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, except _____ - providers must file all Medicare claims - fees are restricted to charging no more than the "limiting charge" on nonassigned claims - collections are restricted to only the deductible an coinsurance due at the time of service on an assigned claim - nonparticipating providers have a higher fee schedule than that for participating providers |
nonparticipating providers have a higher fee schedule than for participating providers |
|
|
This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service. - global payment - Medicare Severity-Diagnosis Related Groups (MS-DRGs) - capitation - Medicare Physician Fee Schedule (MPFS) |
Medicare Physician Fee Schedule (MPFS) |
|
|
The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS). - psychiatric hospital - rehabilitation hospital - cancer hospital - long-term care hospital |
cancer hospital |
|
|
When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service. - CPT code 99358 (prolonged evaluation and managemetn service) - CPT code 35001 (direct repair of aneurysm) - CPT code 99291 (critical care) - CPT code 50300 (donor nephrectomy) |
CPT code 99291 (critical care) |
|
|
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n) _____ - scrubber - encoder - case-mix analyzer - grouper |
grouper |
|
|
In calculating the fee for a physician's reimbursement, the three relative value units are each multipled by the _____ - national conversion factor - cost of living index for the particular region - geographic practice cost indices - usual and customary fees for the service |
geographic practice cost indices (the three relative value units are physician work, practice expense, and malpractice expense. These are adjusted by multiplying them by the geographical practice cost indices. Then, this total is multiplied by the national conversion factor) |
|
|
_____ is a joint federal and state program that provides health care coverage to low-income populations and certain aged and disabled individuals. - Medicare Part B - TRICARE - Medicare Part A - Medicaid |
Medicaid |
|
|
All of the following items are "packaged" under the Medicare ASC payments, except for _____ - brachytherapy - splints and casts - medical supplies - implanted prosthetic devices |
brachytherapy |
|
|
When the third-party payer refuses to grant payment to the provider, this is called a _____ - clean claim - rejected claim - unprocessed claim - denied claim |
denied claim |
|
|
Changes in case-mix index (CMI) may be attributed to all of the following factors except: - changes in coding rules - changes in services offered - changes in coding productivity - changes in medical staff composition |
changes in coding productivity |
|
|
Coinsurance payments are paid by the _____ and determined by a specified ration - physician - patient (insured) - third-party payer - facility |
patient (insured) |
|
|
Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS website or on a CD-ROM. - PEPP (Payment Error Prevention Program) - HHASS (Home Health Agency Software System) - HAVEN (Home Assessment Validation and Entry) - PACE (Patient Assessment and Comprehensive Evaluation) |
HAVEN (Home Assessment Validation and Entry) |
|
|
Health care claims transactions use one of three electronic formats, including which one of those listed below? - ANSI ASC X12N 837 format - National Claim Format - Medicare Summary Notice Format - CMS-1500 flat-file format |
ANSI ASC X12N 837 format |
|
|
A patient is admitted for a diagnostic workup for cachexia. The final diagnosis is malignant neoplasm of lung with metastasis. The present on admission (POA) indicator is _____ - W = provider is unable to clinically determine if condition was present at the time of admission - N = not present at the time of inpatient admission - Y = present at the time of inpatient admission - U = documentation is insufficient to determine if condition was present at the time of admission |
Y = present at the time of inpatient admission |
|
|
A lump-sum payment distributed among the physicians who performed the procedure or interpreted its results and the health care facility that provided equipment, supplies, and technical support is known as _____ - a global payment - a prospective payment system - capitation - fee-for-service |
a global payment |
|
|
This is the amount the facility actually bills for the services it provides: - contractual allowance - charges - costs - reimbursement |
charges |
|
|
_____ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist. - abuse - whistle-blowing - assault - fraud |
fraud |
|
|
This prospective payment system is for _____ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs) - skilled nursing facilities - home health agencies - inpatient rehabilitation facilities - long-term acute care hospitals |
inpatient rehabilitation facilites |
|
|
The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called _____ - health information exchange (HIE) - electronic data interchange (EDI) - HIPAA (Health Insurance Portability and Accountability Act) - health data exchange (HDE) |
electronic data interchange |
|
|
To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the _____ - chargemaster - remittance advice - periodic interim payments - DNFB (discharged, no final bill) |
DNFB (discharged, no final bill) |
|
|
The present on admission (POA) indicator is required to be assigned to the _____ diagnosis(es) for _____ claims on _____ admissions. - principal and secondary; all; inpatient and outpatient - principal; Medicare; inpatient and outpatient - principal and secondary; Medicare; inpatient - principal; all; inpatient |
principal and secondary; Medicare; inpatient |
|
|
Under APCs, payment status indicator "X" means ____ - significant procedure, not discounted when multiple - significant procedure, multiple procedure reduction applies - ancillary services - clinic or emergency department visits (medical visits) |
ancillary services |
|
|
The _____ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider,and what the patient must pay the provider. - remittance advice - advance beneficiary notice - Medicare summary notice - coordination of benefits |
Medicare summary notice |
|
|
These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid. - minimum data set - payment status indicator - major diagnostic categories - geographic practice cost indices |
payment status indicator |
|
|
This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes are listed in the memoranda. - OSHA (Occupational Safety and Health Administration) - SI/IS (Severity of Illness/Intensity of Service Criteria - LCD (Local Coverage Determinations) - PEPP (Payment Error Prevention Program) |
LCD (Local Coverage Determinations) |
|
|
In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation," except: - the volume of services and their expense do not affect reimbursement - capitation means paying a fixed amount per member per month - each service is paid based on the actual charges - capitation involves a group of physicians or an individual physician |
each service is paid based on the actual charges |
|
|
The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is _____ - evidence-based medicine - appropriateness - medical necessity - benchmarking |
medical necessity |
|
|
A patient is being care for in her home by a qualified agency participating in Medicare. The data-entry software used to conduct all patient assessments is known as: - HHRG - HAVEN - IRVEN - RBRVS |
HAVEN |
|
|
LCDs and NCDs are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors. LCD and NCD are acronyms that stand for: - list of covered decisions and noncovered decisions - local coverage determinations and national coverage determinations - local contractor's decisions and national contractor's decisions - local covered determinations and noncovered determinations |
local coverage determinations and national coverage determinations |
|
|
A patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively, he develops a pulmonary embolism. The present on admission (POA) indicator is: - W = provider is unable to clinically determine if condition was present at the time of admission - Y = present at the time of inpatient admission - N = not present at the time of inpatient admission - U = documentation is insufficient to determine if condition was present at the tie of admission |
N = not present at the time of inpatient admission |
|
|
CMS-identified "Hospital-Acquired Conditions" mean that when a particular diagnosis is not "present on admission," CMS determines it to be ______ - a valid comorbidity - reasonably preventable - medically necessary - the principal diagnosis |
reasonably preventable |
|
|
Under ASC PPS, when multiple procedures are performed during the same surgical session, a paymetn reduction is applied. The procedure in the highest level group is reimbursed at _____ and all remaining procedures are reimbursed at _____ - 100%; 25% - 100%; 50% - 100%; 75% - 50%; 25% |
100%, 50% |
|
|
This program, formerly called CHAMPUS (Civilian Health and Medical Program-Uniformed Services), is a health care program for active members of the military and other qualified family members. - TRICARE - workers' compensation - Indian Health Service - CHAMPVA |
TRICARE |
|
|
This accounting method attributes a dollar figure to every input required to provide a service - charge accounting - reimbursement - contractual allowance - cost accounting |
cost accounting |
|
|
There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by _____ - leaving notes in the chart - emailing physicans - using physician query forms - calling the physician's office |
using physician query forms |
|
|
When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a ______ - Corporate Integrity Agreement - Fraud Prevention Memorandum of Understanding - Noncompliance Agreement - Recovery Audit Contract |
Corporate Integrity Agreement |
|
|
The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process it not complete. DNFB is an acronym for _____ - diagnosis not finally balanced - days not fiscally balanced - dollars not fully billed - discharged no final bill |
discharged no final bill |
|
|
The Correct Coding Initiative (CCI) edits contain a list of codes under two columns titled "comprehensive codes" and "component codes." According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service, _____ - do not code either one - code only the comprehensive code - code only the component code - code both the comprehensive code and the component code |
code only the comprehensive code |
|
|
In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a(n) _____ - revenue master - superbill - chargemaster - encounter form |
chargemaster |
|
|
If the Medicare non-PAR approved payment amount is $128 for a proctoscopy, what is the total Medicare approved payment amount for a doctor who does not accept assignment, applying the limiting charge for this procedure? - $147 - $192 - $140.80 - $143 |
$147.20 The limiting charge is 15% above Medicare's approved payment amount for doctors who do not accept assignment ($128 x 1.15 = $147.20) |
|
|
The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ______ for patients with Medicare. - hospital based outpatients - freestanding ambulatory surgery centers - intermediate care facilities - skilled nursing facilites |
skilled nursing facilities |
|
|
CMS adjusts the Medicare Severity DRGs and the reimbursement rates every _____ - quarter - calendar year beginning January 1 - month - fiscal year beginning October 1 |
fiscal year beginning October 1 |
|
|
_____ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients - adverse preventable events - potential compensable events - misadventures - never events or Sentinel events |
never events or Sentinel events |
|
|
If a participating provider's usual fee for a service is $700 and Medicare's allowed amount is $450, what amount is written off by the physician? - $340 - none of it is written off - $391 - $250 |
$250 The participating physician agrees to accept Medicare's fee as payment in full; therefore, the physician would write off the difference between $700 and $450, which is $250 |
|
|
Assume the patient has already met his or her deductible and that the physician is a Medicare participating (PAR) provider. The physician's standard fee for the services is $120. Medicare's PAR fee is $60. How much reimbursement will the physician receive from Medicare? - $48 - $96 - $120 - $60 |
$48 If the physician is a participating physician (PAR) who accepts the assignment, he will receive the lesser of the "total charges" or the "PAR amount" (on the Medicare Physician Fee Schedule). Since the PAR amount is lower, the physician collects 80% of the PAR amount ($60.00) x .80 =$48.00, from Medicare. The remaining 20% ($60.00 x .20 = $12.00) of the PAR amount is paid by the patient to the physician. Therefore, the physician will receive $48.00 directly from Medicare. |
|
|
These are financial protections to ensure that certain types of facilities (e.g. children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments - indemnity insurance - limiting charge - pass through - hold harmless |
hold harmless |
|
|
Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services? - the provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus 10% - the provider cannot bill the patients for the balance between the MPFS amount and the total charges - the provider is a nonparticipating provider - the provider is reimbursed at 15% above the allowed charge |
The provider cannot bill the patients for the balance between the MPFS amount and the total charges |
|
|
For those qualified, the _____ rule states that hospitals are paid a graduated per diem rate for each day of the patient's stay, not to exceed the prospective payment DRG rate - OASIS MS-DRG - IPPS Transfer - POA indicator |
IPPS transfer |
|
|
An Advance Beneficiary Notice (ABN) is a document signed by the _____ - provider indicating that Medicare will not pay for certain services - utilization review coordinator indicating that the patient stay is not medically necessary - physician adviser indicating that the patient's stay is denied - patient indicating whether he/she wants to receive services that Medicare probably will not pay for |
patient indicating whether he/she wants to receive services that Medicare probably will not pay for |
|
|
The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator is _____ - W = provider is unable to clinically determine if condition was present at the tie of admission - U = documentation is insufficient to determine if condition was present at the time of admission - N = not present at the time of inpatient admission - Y = present at the time of inpatient admission |
U = documentation is insufficient to determine if condition was present at the time of admission. Query the physician as to whether the decubitus ulcer was present on admission or developed after admission. |
|
|
The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the non-PAR fee schedule amount. The limiting charge is: - 10% - 20% - 50% - 15% |
15% |
|
|
Some services are performed by a nonphysician practitioner (such as a Physician Assistant). These services are an integral yet incidental component of a physician's treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called _____ - "incident to" billing - "assistant" billing - "technical component" billing - "assignment" billing |
"incident to" billing |
|
|
Terminally ill patients with life expectancies of _____ may opt to receive hospice services |
6 months or less |
|
|
When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital _____ - makes a profit - can bill the patient for the difference - can bill Medicare for the difference - absorbs the loss |
absorbs the loss |
|
|
A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. The charge for the office visit was $125. The Medicare beneficiary had already met his deductible. The Medicare Fee Schedule amount is $100. Dr. Zachary does not accept assignment. The office manager will apply a practice termed as "balanced billing," which means that the patient is _____ - financially liable for charges in excess of the Medicare Fee Schedule, up to a limit - financially liable for only the deductible - not financially liable for any amount - financially liable for the Medicare Fee Schedule amount |
financially liable for charges in excess of the Medicare Fee Schedule, up to a limit |
|
|
A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by home health agencies (HHA) and _____ - skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) - physical therapy (PT) centers and inpatient rehabilitation faciliteis (IRFs) - ambulatory surgery centers (ASCs) and skilled nursing facilities (SNFs) - ambulatory surgery centers (ASCs) and physical therapy (PT) centers |
skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) |
|
|
The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the _____ - CMS-1491 - CMS-1600 - UB-04 - CMS-1500 |
UB-04 |
|
|
Of the following, which is a hospital-acquired condition (HAC)? - air embolism - breach birth - traumatic wound infection - stage I pressure ulcer |
air embolism |
|
|
The category "Commercial payers" include private health information and _____ - Medicare/Medicaid - TriCare - employer-based group health insurers - Blue Cross Blue Shield |
employer-based group health insurers |
|
|
This is the amount collected by the facility for the service it bills. - charges - costs - reimbursement - contractual allowance |
reimbursement |
|
|
When payments can be made to the provider by EFT, this means that the reimbursement is _____ - sent to the provider by check - sent to the patient, who then pays the provider - combined with all other payments from the third party payer - directly deposited into the provider's bank account |
directly deposited into the provider's bank account |
|
|
The process by which health care facilities and providers ensure their financial viability by increasing revenue, improving cash flow and enhancing the patient's experience is called _____ - revenue cycle management - patient orientation - auditing - accounts receivable |
revenue cycle management |
|
|
When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n) _____ - qualified discharge - transfer - per diem - interrupted stay |
interrupted stay |
|
|
Health plans that use _____ reimbursement methods issue lump-sum payments to providers to compensate them all for the health care services delivered to a patient over a specific period of time. - capitation - episode-of-care (EOC) - fee-for-service - bundled |
capitation |
|
|
In a global payment methodology, which is sometimes applied to radiological and similar types of procedures that involve professional and technical components, all of the following are part of the "technical" components except: - physician services - radiological supplies - radiologic technicians - radiological equipment |
physician services |
|
|
This process involves the gathering of charge documents from all departments within the facility that have provided services to patients. The purpose is to make certain that all charges are coded and entered into the billing system. - charge capturing - revenue cycle - precertification - insurance verification |
charge capturing |
|
|
The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of _____ years, unless state law specifies a longer period - six - ten - seven - five |
six |
|
|
The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement. - NPI codes - ICD-10-CM/PCS codes - HCPCS/CPT codes - NCPCS/CPT codes and ICD-10-CM/PCS codes |
NCPCS/CPT codes and ICD-10-CM/PCS codes |
|
|
_____ offers voluntary, supplemental medical insurance to help pay for physician's services, outpatient hospital services, medical services, and medical-surgical supplies not covered by the hospitalization plan - Medicare Part D - Medicare Part C - Medicare Part A - Medicare Part B |
Medicare Part B |
|
|
Currently, which prospective payment system is used to determine the payment to the "physician" for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient? - APCs - RBRVS - ASC PPS - MS-DRGs |
ASC PPS |
|
|
The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called _____ - Ambulatory Patient Classifications (APCs) - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Resource Based Relative Value System (RBRVS) - Resource Utilization Groups (RUGs) |
Resource Utilization Groups (RUGs) |
|
|
What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care? - home health resource groups - long-term care Medicare severity diagnosis-related groups - inpatient rehabilitation facility - the skilled nursing facility prospective payment system |
home health resource groups |
|
|
The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that the patietn was not admitted with, but were acquired during the hospital stay. Therefore, hosptials are required to report an indicator for each diagnosis. This indicator is referred to as _____ - a hospital acquired condition - a sentinel event - present on admission - a payment status indicator |
present on admission |
|
|
Which of the following statement is false regarding the use of modifiers with the CPT codes? - all modifiers will alter (increase or decrease) the reimbursement of the procedure - modifiers are appended to the end of the CPT code - not all procedures need a modifier - some procedures may require more than one modifier |
all modifiers will alter (increase or decrease) the reimbursement of the procedure |
|
|
Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true? - the level of service codes reported by the facility must match those reported by the physician - each facility is accountable for developing and implementing its own methodology - each facility must use acuity sheets with acuity levels and assign points for each service performed - each facility must use the same methodology used by physician coders based on the history, examination, and medial decision-making components |
each facility is accountable for developing and implementing its own methodology |
|
|
The term "hard coding" refers to _____ - HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill - HCPCS/CPT codes that are coded by the coders - ICD-10-CM/ICD-10-PCS codes that appear in the hospital's chargemaster and that are automatically included on the patient's bill - ICD-10-CM/ICD-10-PCS codes that are coded by the coders |
HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill |
|
|
The prospective payment system (PPS) requiring the use of DRGs for inpatient care was implemented in 1983. This PPS is used to manage the costs for _____ - home health care - medical homes - inpatient hospital stays - assisted living facilities |
inpatient hospital stays |
|
|
When a provider bills separately for procedures that are a part of the major procedure, this is called _____ - discounting - fraud - packaging - unbundling |
unbundling |
|
|
When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called _____ - fraud - abuse - hypercoding - unbundling |
abuse |
|
|
This is the difference between what is charged and what is paid. - costs - reimbursement - contractual allowance - customary |
contractual allowance |
|
|
Under the inpatient prospective payment system (IPPS), there is a 3-day payment window (formerly referred to as the 72-hour rule). This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for _____ - therapeutic (or nondiagnositc) services whereby the inpatient princiapl diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services - diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services - therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) does not match the code used for preadmission services - diagnostic services |
diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services |
|
|
State medicaid programs are required to offer medical assistance for ______ - patients receiving dialysis for permanent kidney failure - patients with end stage renal disease - individuals with qualified financial need - all individuals age 65 and over |
individuals with qualified financial need |
|
|
All of the following statements are true of MS-DRGs, except: - there are several types of hospitals that are excluded from the Medicare inpatient PPS - the MS-DRG payment received by the hospital may be lowe than the actual cost of providing the services - a patient claim may have multiple MS-DRGs - special circumstances can result in a cost outlier payment to the hospital |
a patient claim may have multiple MS-DRGs |
|
|
The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement. - ICD-10-CM / ICD-10-PCS codes - HCPCS/CPT codes - both HCPCS/CPT codes and ICD-10-CM / ICD-10-PCS codes - revenue codes |
ICD-10-CM / ICD-10-PCS codes |
|
|
Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's non-PAR fee is $57.00. What is the amount Medicare will pay the beneficiary on this claim? - $45.60 - $60 - $57 - $120 |
$57 Since the physician is a nonparticipating physician, he will receive the nonPAR fee.The Medicare nonPAR fee is $57.00. Medicare will pay 80% of the nonPAR fee ($57.00 x 0.80 = $45.60). The patient will pay 20% of the nonPAR fee ($57.00 x 0.20 = $11.40). Since the physician is accepting assignment on this claim, he cannot charge the patient any more than the 20% co-payment. Therefore, the physician will receive $45.60 directly from Medicare. |
|
|
APCs are groups of services that the OPPS will reimburse. Which one of the following services is not included in the APCs? - screening exams - radiation therapy - organ transplantation - preventive services |
organ transplantation |
|
|
Based on CMS's DRG system, other systems have been developed for payment purposes. The one that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients, is known as _____ - IR-DRGs - APR-DRGs - AP-DRGs - RDRGs |
APR-DRGs |
|
|
A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator is _____ - W = provider is unable to clinically determine if condition was present at the time of admission - Y = present at the time of inpatient admission - U = documentation is insufficient to determine if condition was present at the time of admission - N = not present at the time of inpatient admission |
Y = present at the time of inpatient admission |
|
|
Under APCs, the payment status indicator "N" means that the payment _____ - is packaged into the payment for other services - is for ancillary services - is discounted at 50% - is for a clinic or an emergency visit |
is packaged into the payment for other services |
|
|
There are seven criteria for high-quality clinical documentation. All of these elements are included except: - complete - precise - consistent - covered (by third-party payer) |
covered (by third-party payer) |
|
|
A Medicare Summary Notice (MSN) is sent to _____ as their EOB. - physicians - skilled nursing facilities - patients (beneficiaries) - hospitals |
patients (beneficiaries) |
|
|
This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms. - National Practitioner Databank (NPD) - National Provider Identifier (NPI) - Master Patient Index (MPI) - Universal Physician Number (UPN) |
National Provider Identifier (NPI) |
|
|
The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from the _____ - UHDDS (Uniform Hospital Discharge Data Set) - OASIS (Outcome and Assessment Information Set) - UACDS (Uniform Ambulatory Core Data Set) - MDS (Minimum Data Set) |
OASIS (Outcome and Assessment Information Set) |
|
|
Under APCs, payment status indicator "T" means _____ - clinic or emergency department visit (medical visits) - ancillary services - significant procedure, multiple procedure reduction applies - significant procedure, not discounted when multiple |
significant procedure, multiple procedure reduction applies |
|
|
CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital _____ - will receive additional payment for these conditions whether they are present on admission or not - will not receive additional payment for these conditions when they are present on admission - will receive additional payment for these conditions when they are not present on admission - will not receive additional payment for these conditions when they are not present on admission |
will not receive additional payment for these conditions when they are not present on admission |
|
|
Commercial insurance plans usually reimburse health care providers under some type of _____ payment system, whereas the federal Medicare program uses some type of _____ payment system. - retrospective, prospective - retrospective, concurrent - prospective, concurrent - prospective, retrospetive |
retrospective, prospective |
|
|
A three-digit code that describes a classification of a product or service provided to a patient is a _____ - CPT code - HCPCS Level II code - ICD-10-CM code - revenue code |
revenue code |
|
|
_____ classifies inpatient hospital cases into groups that are expected to consume similar hospital resources - IPPS - CMS - MAC - DRG |
DRG |
|
|
This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS's Web site. - the Federal Register - the OIG's Evalution and Management Documentation Guidelines - the OIG's Model Compliance Plan - the OIG's Workplan |
the OIG's Workplan |
|
|
The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology. - radiology/radiation therapy - clinic/emergency visits - surgical procedures - Durable Medical Equipment |
Durable Medical Equipment |
|
|
The _____ is a statement sent to the provider to explain payments made by third-party payers - advance beneficiary notice - remittance advice - attestation statement - acknowledgement notice |
remittance advice |
