Reimbursement final

Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?

CPT

What are the five criteria for queries?

Legibility, completeness, clarity, consistency, precision

What are the three elements of RVU?

Work, PE, MP

Case mix index X hospital rate =

Average DRG payment

What joint program between the federal and state governments to provide healthcare benefits to low-income persons and families?

Medicaid

Which of the following is not a component of the coding compliance plan?

Wage index adjustment

The coding professional shall not misrepresent the patient's clinical picture through ________ of diagnosis or procedure codes, or the _______ of diagnosis or procedure codes unsupported by health documentation to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or quality for insurance policy coverage benefits.

Intentional incorrect coding or omission; addition

The goal of a compliance program is to:

Prevent accusations of fraud and abuse, make operations run more smoothly, improve services, contain costs ALL OF THE ABOVE

A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Co where the accident occurred. Basic manufacturing carried workers' compensation insurance. The workers' compensation paid the fees of the neurosurgeon. Which entity is the "third party"?

Workers' compensation insurance

Which part of the medicare program was created under he Medicare Modernization Act of 2003?

Part D

The purpose of Recovery Audit Contractors is to identify _________ and _________ for claims filed under Medicare Part A and Part B.

Underpayments and Overpayments

The health plan reimburses Dr. T $15 per patient per month. In January, Dr. T saw 300 patients so he received $4500 from the health plan. What method is the health plan using to reimburse Dr. T?

Capitated rate

In which type of healthcare payment method does the healthcare plan recompense providers with a fixed rate for each day a covered member is hospitalized?

Per diem

The practice of undercoding can affect a hospital's MS-DRG case-mix in which of the following ways?

makes it lower than warranted by the actual service/resource intensity to the facility

Which of the following services has the highest likelihood of being a covered service?

medically necessary

Match the type of insurance with the situation:
Nursing home care
Medicare deductibles and coinsurance
Salary security for lengthy illness
Accidental amputation

-long-term (extended) care -Medigap -disability income protection -accidental death and dismemberment

All of the following are true of state Medicaid programs EXCEPT:

services offered to beneficiaries are the same in each state

If an ABN is not completed and signed by the patient before the test is performed, and the test is considered o be "noncovered" by Medicare, the facility can bill the patient for the test?

False

To determine a case mix index: divide the number of DRG cases into the total _______ of all the DRGs.

Weight

What is the general term for software that assigns inpatient diagnosis related groups?

Grouper

All of the following sets represent criteria for medical necessity and utilization review except

Federal Register Index and Ratings

Medicare defines medical necessity as a determination that a service is __________ and _________ for the diagnosis or treatment of an illness or injury.

Reasonable, necessary

If an ordered test or service is found to be medically unnecessary based on policy, the patient must be asked to sign an:

ABN

All of the following are characteristics of managed care organizations except

freedom of choice and autonomous decision making

What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?

Utilization review

What is Medicare's term for a facility with a high percentage of low income patients?

disproportionate share hospital

What is the name of the entity that pass Medicare part A claims?

Medicare Administrative Contractor

A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?

The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG.

In terms of grouping and reimbursement, hoow are the MS-LTC-DRGs and acute care MS-DRGs similar?

based on principal diagnosis

According to the CMS, what is one of the purposes of the IRF PPS?

to promote equity for beneficiaries, facilities and taxpayers

All of the following are elements of the IRF PPS except

major diagnostic category

What is the term used in a rehabilitation facility to mean " a patient's ability to perform activities of daily living"?

functional status

The UCR is

Usual, customary, and reasonable

The CPR is

customary, prevailing, and reasonable

Describe two purposes of managed care

reduce healthcare costs and ensure continuing quality of care

What is the advantage of capitated payments for providers?

Knowing the cost of the reimbursement services

How do third party payers set per-diem payment rates?

historical data

In episode-of-care reimbursement approach, providers are reimbursed a lump sum for all provided services related to a patient's condition or disease. True or false?

True

In the United States, what is healthcare insurance?

Reduction of a person's or a group exposure to risk for unknown healthcare costs by the assumption of that risk by an entity

The physician's office sent a request for payment to Able Insurance Company. The term used in the healthcare industry for this request for payment is a:

Claim

In the healthcare industry, what is another term for "charge"

Fee

In which type of healthcare payment method, does the healthcare plan oversee both the costs of healthcare and the outcomes of care?

managed care

In which type of healthcare payment method, does the healthcare plan recompense providers with a fixed rate for each day a covered member is hospitalized?

per diem

From the patient's healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient's healthcare insurance plan using?

Case based

Common forms of fraud and abuse include all of the following except:

refiling claims after denials

What is the primary use of a case mix index analysis?

To asses quality of facility's coding and billing practices

The policies and procedures section of a coding compliance plan should include:

all of the above

MS-DRG relationships comparing with CC (complications/ comorbidities) to without CC DRGs for the same clinical condition should be reviewed because

CCs can be overcoded CCs can be undercoded A and B are correct

What resource can managers use to discover current hot areas of compliance?

OIG workplan

The international classification of Diseases ICD is maintained by the American Medical Association. True or False?

False

Why is the federal government a dominant player in the healthcare sector?

The federal Medicare program is the largest single payer for health insurance

What is the health insurance plan that covers federal government employees?

Federal employment program

Voluntary health insurance plan payments account for about one-fourth of US healthcare expenditures. True or false?

False

Copayments are cost-sharing provisions of policies that require insureds to pay a flat fee to healthcare service providers and suppliers. True or false?

True

All of the following entities are voluntary healthcare insurance except

Medicare

Which of the following characteristics is representative of commercial healthcare insurances?

For-profit in the private sector

What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?

Policy

Fifteen year old female is noted to have bicornuate uterus. What is the appropriate POA indicator for this condition?

EXEMPT

Patient with a long history of asthma is admitted to the hospital for a cholecystectomy. The day after admission, the patient develops acute exacerbation of asthma. he coder assigned the asthma with exacerbation to code. What is the correct POA indicator for this code?

NO

65 year old admitted to the hospital with chest pain, shortness of breath and elevated cardiac enzymes. The patient expired before a complete workup could be completed. The final diagnosis was documented as probable myocardial infarction. What is the correct POA indicator o be assigned for the probable myocardial infarction?

YES

Which program replaced Aid to Families with Dependent Children

Temporary Assistance for Needy Families

Individuals eligible for Railroad Retirement disability or retirement benefits are ineligible for Medicare? True or false?

false

Individuals who are eligible may choose between TRICARE benefits and CHAMPVA. True or false?

False

In states having no mandated workers' compensation fund, employers must purchase insurance from private carriers or provide self-insurance coverage? true or false

True

Disease management is closely associated with coordination of care tools of MCOs because efforts of multiple providers must be synchronized in disease management. True or false?

true

Integrated delivery systems typically have horizontal rather than vertical integration of services. True or false?

False

The least binding degree of healthcare service integration is affiliation, and the highest degree of integration is the merger. True or false?

true

CMS states that the query form can/should:

All of the above

The query practice brief states that documentation is used to evaluate

the adequacy and appropriateness of quality of care, provide clinical data for research and education

When performing the payment determination for IPF PPS admissions, which step comes first; WI adjustment or application of the patient and facility level adjustments?

Wage index adjustment

Claims for RBRVS physician payments are prepared using _________ that have associated RVUs

CPT codes

When a patient is pronounced dead during ambulance transport medicare payment rules are followed as if the patient were alive. True or false?

True

CMS, not APC advisory panel or MED PAC, makes the final ruling for updates and changes to HOPPS? True or false?

True

The number of APCs per encounter for a single patient is limited to ten? True or false.

false

For CMS to define a facility as and LTCH, how many days must its medicare patients average length of stay be?

25 or more days

On the IRF PAI the patient's ability to perform acts of daily living or _______ is recorded on the _______.

Functional status; functional status assessment tool

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines. true or false?

false

Facilities my transmit IRF PAIs to the centers for medicare and medicaid services using CMS' free IRVEN software. True or false?

True

In the HHPPS, the________ software is used to collect and submit OASIS data.

HAVEN

How is durable medical equipment reimbursed in the HHPPS?

DME fee schedule

Which of the following is the definition of revenue cycle management?

Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

In healthcare settings, the record of the cash the facility will receive from the services it has provided is known as which of the following terms?

Accounts receivable

Most facilities begin counting days in accounts receivable at which of the following times?

The date the claim is submitted to third-party payer/bill drops

The dollar amount the facility actually bills for the services it provides is known as:

Charge

Which of the following is NOT a function of the revenue cycle?

Volunteer services

In a typical acute care setting, Charge Entry is located in which revenue cycle area?

Claims processing

In a typical acute care setting, Patient Education of Payment Policies is located in which revenue cycle area?

Pre-claims submission

In a typical acute care setting, Explanation of Benefits, Medicare Summary Notice and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?

Claims reconciliation/collection

In a typical acute care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error free claims (clean claims) are submitted to third party payers?

Claims processing

The very first pay-for-performance systems emerged in the early 1990's. True or false?

false

The CMS has attempted to "brake" the trend to pay-for-performance and value-based purchasing systems because it's experts believe the linkage of quality and rewards jeopardizes the care of patients. True or false?

false

List three other countries that are investigating or having implemented pay-for-performance system for their healthcare delivery systems.

Australia, Canada, Great Britain

Withholding compensation would be considered a penalty-based model of pay-for-performance. True or false?

true

What piece of legislation mandated CMS to develop a value-based purchasing program?

DRA

The same quality indicators are utilized under RHQDAPU and HOPDQRP. True or false?

false

The Hospital Acquired Conditions provision is what type of VBP program?

paying for value

How do organizations control costs indirectly?

reduce errors

Why are incremental implementations of pay-for-performance systems preferable to full-scale implementations?

sponsors can evaluate policies and procedures

The Tax Relief and Health Care Act of 2006 (MIEA-TEHCA) expanded CMS quality initiatives to which two settings?

Hospital outpatient departments and Ambulatory Surgical Centers

Which condition is NOT included in the Hospital Acquired Conditions (HAC) provision list?

Staphylococcus infection

Which of the following entities sponsor value-based purchasing or pay-for-performance systems?

Centers for Medicare and Medicaid Services Employers Health Plans All of the above

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Which of the following coding systems was created for reporting procedures and services performed by physicians in clinical practice?

CPT

What are the five criteria for queries?

Legibility, completeness, clarity, consistency, precision

What are the three elements of RVU?

Work, PE, MP

Case mix index X hospital rate =

Average DRG payment

What joint program between the federal and state governments to provide healthcare benefits to low-income persons and families?

Medicaid

Which of the following is not a component of the coding compliance plan?

Wage index adjustment

The coding professional shall not misrepresent the patient’s clinical picture through ________ of diagnosis or procedure codes, or the _______ of diagnosis or procedure codes unsupported by health documentation to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or quality for insurance policy coverage benefits.

Intentional incorrect coding or omission; addition

The goal of a compliance program is to:

Prevent accusations of fraud and abuse, make operations run more smoothly, improve services, contain costs ALL OF THE ABOVE

A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Co where the accident occurred. Basic manufacturing carried workers’ compensation insurance. The workers’ compensation paid the fees of the neurosurgeon. Which entity is the "third party"?

Workers’ compensation insurance

Which part of the medicare program was created under he Medicare Modernization Act of 2003?

Part D

The purpose of Recovery Audit Contractors is to identify _________ and _________ for claims filed under Medicare Part A and Part B.

Underpayments and Overpayments

The health plan reimburses Dr. T $15 per patient per month. In January, Dr. T saw 300 patients so he received $4500 from the health plan. What method is the health plan using to reimburse Dr. T?

Capitated rate

In which type of healthcare payment method does the healthcare plan recompense providers with a fixed rate for each day a covered member is hospitalized?

Per diem

The practice of undercoding can affect a hospital’s MS-DRG case-mix in which of the following ways?

makes it lower than warranted by the actual service/resource intensity to the facility

Which of the following services has the highest likelihood of being a covered service?

medically necessary

Match the type of insurance with the situation:
Nursing home care
Medicare deductibles and coinsurance
Salary security for lengthy illness
Accidental amputation

-long-term (extended) care -Medigap -disability income protection -accidental death and dismemberment

All of the following are true of state Medicaid programs EXCEPT:

services offered to beneficiaries are the same in each state

If an ABN is not completed and signed by the patient before the test is performed, and the test is considered o be "noncovered" by Medicare, the facility can bill the patient for the test?

False

To determine a case mix index: divide the number of DRG cases into the total _______ of all the DRGs.

Weight

What is the general term for software that assigns inpatient diagnosis related groups?

Grouper

All of the following sets represent criteria for medical necessity and utilization review except

Federal Register Index and Ratings

Medicare defines medical necessity as a determination that a service is __________ and _________ for the diagnosis or treatment of an illness or injury.

Reasonable, necessary

If an ordered test or service is found to be medically unnecessary based on policy, the patient must be asked to sign an:

ABN

All of the following are characteristics of managed care organizations except

freedom of choice and autonomous decision making

What is the term that means evaluating, for a healthcare service, the appropriateness of its setting and its level of service?

Utilization review

What is Medicare’s term for a facility with a high percentage of low income patients?

disproportionate share hospital

What is the name of the entity that pass Medicare part A claims?

Medicare Administrative Contractor

A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?

The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG.

In terms of grouping and reimbursement, hoow are the MS-LTC-DRGs and acute care MS-DRGs similar?

based on principal diagnosis

According to the CMS, what is one of the purposes of the IRF PPS?

to promote equity for beneficiaries, facilities and taxpayers

All of the following are elements of the IRF PPS except

major diagnostic category

What is the term used in a rehabilitation facility to mean " a patient’s ability to perform activities of daily living"?

functional status

The UCR is

Usual, customary, and reasonable

The CPR is

customary, prevailing, and reasonable

Describe two purposes of managed care

reduce healthcare costs and ensure continuing quality of care

What is the advantage of capitated payments for providers?

Knowing the cost of the reimbursement services

How do third party payers set per-diem payment rates?

historical data

In episode-of-care reimbursement approach, providers are reimbursed a lump sum for all provided services related to a patient’s condition or disease. True or false?

True

In the United States, what is healthcare insurance?

Reduction of a person’s or a group exposure to risk for unknown healthcare costs by the assumption of that risk by an entity

The physician’s office sent a request for payment to Able Insurance Company. The term used in the healthcare industry for this request for payment is a:

Claim

In the healthcare industry, what is another term for "charge"

Fee

In which type of healthcare payment method, does the healthcare plan oversee both the costs of healthcare and the outcomes of care?

managed care

In which type of healthcare payment method, does the healthcare plan recompense providers with a fixed rate for each day a covered member is hospitalized?

per diem

From the patient’s healthcare insurance plan, the rehabilitation facility received a fixed, pre-established payment for the patient rehabilitation after a total knee replacement. What type of healthcare payment method was the patient’s healthcare insurance plan using?

Case based

Common forms of fraud and abuse include all of the following except:

refiling claims after denials

What is the primary use of a case mix index analysis?

To asses quality of facility’s coding and billing practices

The policies and procedures section of a coding compliance plan should include:

all of the above

MS-DRG relationships comparing with CC (complications/ comorbidities) to without CC DRGs for the same clinical condition should be reviewed because

CCs can be overcoded CCs can be undercoded A and B are correct

What resource can managers use to discover current hot areas of compliance?

OIG workplan

The international classification of Diseases ICD is maintained by the American Medical Association. True or False?

False

Why is the federal government a dominant player in the healthcare sector?

The federal Medicare program is the largest single payer for health insurance

What is the health insurance plan that covers federal government employees?

Federal employment program

Voluntary health insurance plan payments account for about one-fourth of US healthcare expenditures. True or false?

False

Copayments are cost-sharing provisions of policies that require insureds to pay a flat fee to healthcare service providers and suppliers. True or false?

True

All of the following entities are voluntary healthcare insurance except

Medicare

Which of the following characteristics is representative of commercial healthcare insurances?

For-profit in the private sector

What is the term for the contract between the healthcare insurance company and the individual or group for whom the company is assuming the risk?

Policy

Fifteen year old female is noted to have bicornuate uterus. What is the appropriate POA indicator for this condition?

EXEMPT

Patient with a long history of asthma is admitted to the hospital for a cholecystectomy. The day after admission, the patient develops acute exacerbation of asthma. he coder assigned the asthma with exacerbation to code. What is the correct POA indicator for this code?

NO

65 year old admitted to the hospital with chest pain, shortness of breath and elevated cardiac enzymes. The patient expired before a complete workup could be completed. The final diagnosis was documented as probable myocardial infarction. What is the correct POA indicator o be assigned for the probable myocardial infarction?

YES

Which program replaced Aid to Families with Dependent Children

Temporary Assistance for Needy Families

Individuals eligible for Railroad Retirement disability or retirement benefits are ineligible for Medicare? True or false?

false

Individuals who are eligible may choose between TRICARE benefits and CHAMPVA. True or false?

False

In states having no mandated workers’ compensation fund, employers must purchase insurance from private carriers or provide self-insurance coverage? true or false

True

Disease management is closely associated with coordination of care tools of MCOs because efforts of multiple providers must be synchronized in disease management. True or false?

true

Integrated delivery systems typically have horizontal rather than vertical integration of services. True or false?

False

The least binding degree of healthcare service integration is affiliation, and the highest degree of integration is the merger. True or false?

true

CMS states that the query form can/should:

All of the above

The query practice brief states that documentation is used to evaluate

the adequacy and appropriateness of quality of care, provide clinical data for research and education

When performing the payment determination for IPF PPS admissions, which step comes first; WI adjustment or application of the patient and facility level adjustments?

Wage index adjustment

Claims for RBRVS physician payments are prepared using _________ that have associated RVUs

CPT codes

When a patient is pronounced dead during ambulance transport medicare payment rules are followed as if the patient were alive. True or false?

True

CMS, not APC advisory panel or MED PAC, makes the final ruling for updates and changes to HOPPS? True or false?

True

The number of APCs per encounter for a single patient is limited to ten? True or false.

false

For CMS to define a facility as and LTCH, how many days must its medicare patients average length of stay be?

25 or more days

On the IRF PAI the patient’s ability to perform acts of daily living or _______ is recorded on the _______.

Functional status; functional status assessment tool

For inpatient rehabilitation facility patients, codes on the IRF PAI should follow the UHDDS and the UB-04 guidelines. true or false?

false

Facilities my transmit IRF PAIs to the centers for medicare and medicaid services using CMS’ free IRVEN software. True or false?

True

In the HHPPS, the________ software is used to collect and submit OASIS data.

HAVEN

How is durable medical equipment reimbursed in the HHPPS?

DME fee schedule

Which of the following is the definition of revenue cycle management?

Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

In healthcare settings, the record of the cash the facility will receive from the services it has provided is known as which of the following terms?

Accounts receivable

Most facilities begin counting days in accounts receivable at which of the following times?

The date the claim is submitted to third-party payer/bill drops

The dollar amount the facility actually bills for the services it provides is known as:

Charge

Which of the following is NOT a function of the revenue cycle?

Volunteer services

In a typical acute care setting, Charge Entry is located in which revenue cycle area?

Claims processing

In a typical acute care setting, Patient Education of Payment Policies is located in which revenue cycle area?

Pre-claims submission

In a typical acute care setting, Explanation of Benefits, Medicare Summary Notice and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?

Claims reconciliation/collection

In a typical acute care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error free claims (clean claims) are submitted to third party payers?

Claims processing

The very first pay-for-performance systems emerged in the early 1990’s. True or false?

false

The CMS has attempted to "brake" the trend to pay-for-performance and value-based purchasing systems because it’s experts believe the linkage of quality and rewards jeopardizes the care of patients. True or false?

false

List three other countries that are investigating or having implemented pay-for-performance system for their healthcare delivery systems.

Australia, Canada, Great Britain

Withholding compensation would be considered a penalty-based model of pay-for-performance. True or false?

true

What piece of legislation mandated CMS to develop a value-based purchasing program?

DRA

The same quality indicators are utilized under RHQDAPU and HOPDQRP. True or false?

false

The Hospital Acquired Conditions provision is what type of VBP program?

paying for value

How do organizations control costs indirectly?

reduce errors

Why are incremental implementations of pay-for-performance systems preferable to full-scale implementations?

sponsors can evaluate policies and procedures

The Tax Relief and Health Care Act of 2006 (MIEA-TEHCA) expanded CMS quality initiatives to which two settings?

Hospital outpatient departments and Ambulatory Surgical Centers

Which condition is NOT included in the Hospital Acquired Conditions (HAC) provision list?

Staphylococcus infection

Which of the following entities sponsor value-based purchasing or pay-for-performance systems?

Centers for Medicare and Medicaid Services Employers Health Plans All of the above

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