Chapter 9 Workbook questions and Review Questions

Medicare Physician Fee Schedule
The Resource-Based Relative Value Scale (RBRVS) system is also known as
prospective cost-based
Which reimbursement system establishes rates in advance of services and is based on reported charges from which a per diem rate is determined?
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Review the following ambulance fee schedule and calculate the Medicare payment rate in year 6 (for an ambulance company reasonable charge of $600)
Review the following ambulance fee schedule and calculate the Medicare payment rate in year 5 (for an ambulance company reasonable charge of $720).
The Deficit Reduction Act of ______ established the Medicare clinical laboratory fee schedule.
assignment of multiple APCs that reflect all services provided, with discounting.
Sally Brown registered as an outpatient at the hospital for three encounters: chest x-ray, gait training physical therapy, and excision of lesion from right upper arm. Ambulatory patient classification (APC) reimbursement will be based on the?
A episode of care in the home health prospective payment system (HHPPS) is _____ days.
In which year was the inpatient prospective payment system implemented?
Which type of hospital is exclude from the inpatient prospective payment system?
72 hours
The IPPS window requires outpatient preadmission services provided by a hospital up to ____ prior to a patient’s inpatient admission to be covered by the IPPS MS-DRG payment.
practice expense
Which is a relative value unit (RVU) in the Medicare physician fee schedule payment system?
place of service
Medicare Part B radiology services payments vary according to?
The physician fee schedule for CPT code 99214 is $75. Calculate the nonPAR limiting charge for this service.
The physician fee schedule for CPT code 99214 $75. Calculate the nonPAR allowed charge?
protect Medicare enrollees financially.
The intent of establishing a limiting charge for nonPAR is to?
Jeffery BOrder received care from his participating physician, who charged $300 for her services. (Mr. Border has already at his Medicare Part B deductible.) Mr. Border has primary coverage with his employer group health plan (EGHP). The EGHP’s allowed charge for the service was $260, of which 80% was paid by the EGHP ($208). The Medicare physician fee schedule for the procedure is $240. Using the rules to determine the amount of Medicare secondary benefits, calculate the Medicare secondary payment.
physician assistant
Which is classified as a nonphysician practitioner?
program transmittal
Which publication communicates new or changed policies and procedures that are being incorporated into a specific CMS manual?
a site of service differential.
When an office-based service is performed in a health care facility, payment is affected by the use of?
Medicare Secondary Payer (MSP) refers to situations in which the Medicare program does not have primary responsibility for paying a beneficiary’s medical expenses. For which of the following payers would Medicare be considered primary?
denied and rejected claims
Diagnosis and procedure codes that are entered incorrectly during billing and claims processing result in ____ by the third-party payer.
entering late or lost charges or making corrections to previously processed CMS-1500 or UB-04 claims.
CMS-1500 or UB-04 claims that are resubmitted to third-party payers usually result in payment delays and claims denials. The resubmission of claims is a result of?
analyzing electronic reimbursement received from payers to identify variations in expected payments.
The process of posting electronic remittances based on third-party payer reimbursement involves?
appeal letters
The analysis of reimbursement received from third-party payers identifies variations in expected payments or contracted rates and may result in submission of ____ to third-party payers.
self-pay balances billed to the patient.
Deductibles, copayments, and noncovered charges are considered?
Ambulance fee schedule
Ambulatory surgical center payment rates
Inpatient prospective payment system
Inpatient psychiatric facility PPS
Skilled nursing facility PPS
Which PPS provides a predetermined payment that depends on the patient’s principal diagnosis, comorbidities, complications, and principal and secondary procedures?
Which abbreviation indicates where services were provided to beneficiaries?
computer-generated list used by facilities, which contains procedures, services, supplies, revenue codes, and charges.
The chargemaster is a(n)?
Resource utilization groups (RUGs) use a ___ reimbursement methodology used by skilled nursing facilities.
Which of the following legislated implementation of the long-term (acute) care hospital inpatient prospective payment system?
Medicare physican fee schedule
The Resource-Based Relative Value Scale (RBRVS) system is more commonly called the?
case mix
Reimbursement rates based on the anticipated care needs of patients result in reduced risks to facilities and to payers. The process by which health care facilities and payers determine anticipated care needs by reviewing types and/or categories of patients treated by a facility is called its?
major diagnostic catogries
Diagnosis-related groups are organized into mutually exclusive categories called ______, which are loosely based on body systems.
relative-value units
Physician work, practice expense, and malpractice expense are components in computing ______ for the Resource-Based Relative Value Scale system.
Four-digit ______ codes are reprinted on a facility’s chargemaster to indicate the location or type of service provided to an institutional patient.
The type of bill (TOB) is a required element that is entered in FL4 on the UB-04, and it contains ____ digits.
Which is responsible for developing data elements reported on the UB-04?
continued because an electronic version of the requisition form is avaiable from the physician office in the hospital’s EHR system
A 50-years-old female patient reports to the hospital’s registration department to begin the patient registration process. The patient tells the patient registration clerk that her physician wants her to undergo a screening mammogram. The clerk asks the patient for the requisition form (physician order for screening mammogram) and is told that the patient left it at home. he registration clerk is aware that the patient’s physician office has implemented use of the electronic health record, and so the patient registration process is?
validates the patient’s health insurance coverage
An 18-years-old male patient arrives at the hospital’s registration department to begin the patient registration process for scheduled wisdom teeth extraction under anesthesia. in addition to obtaining appropriate consents for treatment and release of information along with collecting patient demographic and insurance information, the patient registration clerk?
captures chge data by using an automated system that links to the hospital’s chargemaster
A female patient is properly registered for scheduled blood work and arrives at the hospital’s laboratory department. The laboratory technician who performs venipuncture?
health information management
Diagnosis and procedure coding required for the assignment of APCs, DRGs, and so on, is typically performed by _____ personnel.
patient information is verified, discharge instructions are provided, patient follow-up visit is scheduled, consent forms are reviewed for signatures, and patient policies are explained to the patient.
During the patient discharge processing stage of revenue cycle management?
hospital-acquired conditions
Medical conditions or complications that patients develop during inpatient hospital stays and that were not present at admission are called ______.
present on admission
A condition that exists at the time an order for inpatient admission occurs is categorized according to ______.
N (not present at the time of inpatient admission)
A patient is admitted as a hospital inpatient with a diagnosis of possible myocardial infarction. During admission the patient falls while walking and fractures his left hip. Which present on admission (POA) indicator applies to the left hip fracture diagnosis?
Y (present at the time of inpatient admission)
A patient is admitted as hospital inpatient for treatment of pneumococcal pneumonia. The patient also has chronic asthma and diabetes mellitus, both of which were medically manged during the inpatient admission. Which present on admission (POA) indicator applies to the pneumococcal pneumonia?
W (provider is unable to clinically determine whether condition was present on admission or not)
A patient is admitted as a hospital inpatient and undergoes bilateral knee replacement surgery. The responsible physician documents severe arthritis bilateral knees. Upon discharge, the patient is provided with instructions for follow-up and care postoperative as well as for hypothyroidism. Which present on admission (POA) indicator applies to the hypothyroidism?
A hospital has 290 inpatient cases that are assigned to DRG 169, which has a relative weight of 1.106. What is the total relative weight for the cases?
A nursing facility has 12 Medicare cases that are reimbursed at $9,995 per case. What is the total Medicare reimbursement for all of the cases?

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