a. Resource Utilization Groups (RUGs).
b. Ambulatory Patient Classifications (APCs).
c. Medicare Severity Diagnosis Related Groups (MS-DRGs).
d. Resource Based Relative Value System (RBRVS).
a. UHDDS (Uniform Hospital Discharge Data Set).
b. UACDS (Uniform Ambulatory Core Data Set).
c. MDS (Minimum Data Set).
d. OASIS (Outcome and Assessment Information Set).
________ indicates that the claim is suspended in the billing system awaiting late charges, diagnoses/procedure codes that are soft coded by the coders, and/or insurance verification.
a. Bill drop
b. Concurrent review
c. Bill hold
d. Accounts receivables
a. anesthesia.
b. medical visits.
c. recovery room.
d. medical supplies.
a. conversion factor, CMS weight, and hospital-specific rate.
b. physician work, practice expense, and malpractice insurance expense.
c. geographic index, wage index, and cost of living index.
d. fee-for-service, per diem payment, and capitation.
a. MS-DRGs.
b. APCs.
c. APGs.
d. RBRVS
a. financially liable for only the deductible.
b. not financially liable for any amount.
c. financially liable for the Medicare fee schedule amount.
d. financially liable for charges in excess of the Medicare fee schedule, up to a limit.
a. skilled nursing facilities
b. intermediate care facilities
c. freestanding ambulatory surgery centers
d. hospital-based outpatients
a. acknowledgment notice
b. attestation statement
c. remittance advice
d. advance beneficiary notice
a. 25
b. 80
c. 100
d. 2,000
a. health data exchange (HDE).
b. health information exchange (HIE).
c. HIPPA (Health Insurance Portability and Accountability Act).
d. electronic data interchange (EDI).
a. scrubber.
b. grouper.
c. encoder.
d. case-mix analyzer.
a. CMS-1600.
b. CMS-1491.
c. UB-04.
d. CMS-1500.
a. 100%, 75%
b. 100%, 25%
c. 50%, 25%
d. 100%, 50%
a. coordination of benefits
b. advance beneficiary notice
c. Medicare summary notice
d. remittance advice
a. ASCs
b. RBRVS
c. MS-DRGs
d. APGs
a. The provider is a nonparticipating provider.
b. The provider cannot bill the patients for the balance between the MPFS amount and the total charges.
c. The provider is reimbursed at 15% above the allowed charge.
d. The provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus 10%.
a. can bill Medicare for the difference.
b. absorbs the loss.
c. makes a profit.
d. can bill the patient for the difference.
a. 150%
b. 200%
c. 50%
d. 100%
MS-DRG Description Number of Patients CMS Relative Weight
470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871
392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121
194 Simple pneumonia & pleurisy w CC 1,150 1.0235
247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255
293 Heart failure & shock w/o CC/MCC 850 0.8765
313 Chest pain 650 0.5489
292 Heart failure & shock w CC 550 1.0134
690 Kidney & urinary tract infections w/o MCC 400 0.8000
192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145
871 Septicemia w/o MV 96+ hours w MCC 250 1.7484
The case-mix index (CMI) for the top 10 MS-DRGs above is
a. 1.097.
b. 0.782.
c. 1.164.
d. 1.278
MS-DRG Description Number of Patients CMS Relative Weight
470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871
392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121
194 Simple pneumonia & pleurisy w CC 1,150 1.0235
247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255
293 Heart failure & shock w/o CC/MCC 850 0.8765
313 Chest pain 650 0.5489
292 Heart failure & shock w CC 550 1.0134
690 Kidney & urinary tract infections w/o MCC 400 0.8000
192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145
871 Septicemia w/o MV 96+ hours w MCC 250 1.7484
Which individual MS-DRGs has the highest reimbursement?
a. 293
b. 871
c. 247
d. 470
MS-DRG Description Number of Patients CMS Relative Weight
470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871
392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121
194 Simple pneumonia & pleurisy w CC 1,150 1.0235
247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255
293 Heart failure & shock w/o CC/MCC 850 0.8765
313 Chest pain 650 0.5489
292 Heart failure & shock w CC 550 1.0134
690 Kidney & urinary tract infections w/o MCC 400 0.8000
192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145
871 Septicemia w/o MV 96+ hours w MCC 250 1.7484
Based on this patient volume, during this time period, the MS-DRG that brings in the highest “total” reimbursement to the hospital is
a. 871.
b. 392.
c. 470.
d. 247.
MS-DRG Description Number of Patients CMS Relative Weight
470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871
392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121
194 Simple pneumonia & pleurisy w CC 1,150 1.0235
247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255
293 Heart failure & shock w/o CC/MCC 850 0.8765
313 Chest pain 650 0.5489
292 Heart failure & shock w CC 550 1.0134
690 Kidney & urinary tract infections w/o MCC 400 0.8000
192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145
871 Septicemia w/o MV 96+ hours w MCC 250 1.7484
Based on this patient volume, the MS-DRG that brings in the highest total profit to the hospital is
a. It cannot be determined from this information.
b. 392.
c. 470.
d. 247
a. ten
b. seven
c. six
d. five
a. Assault
b. Abuse
c. Fraud
d. Whistle-blowing
a. payment status indicator
b. minimum data set
c. geographic practice cost indices
d. major diagnostic categories
a. medical necessity.
b. benchmarking.
c. appropriateness.
d. evidence-based medicine.
a. the Stark I Law
b. the Federal Antikickback Statute
c. the False Claims Act
d. the Civil Monetary Penalties Act
a. Potential compensable events
b. Never events
c. Sentinel events
d. Adverse preventable events
a. hypercoding.
b. unbundling.
c. fraud.
d. abuse.
a. the skilled nursing facility prospective payment system
b. long-term care Medicare severity diagnosis-related groups
c. home health resource groups
d. inpatient rehabilitation facility
a. $147.20
b. $192.00
c. $140.80
d. $143.00
b. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) does not match the code used for preadmission services.
a. both diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.
b. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) does not match the code used for preadmission services.
c. diagnostic services.
d. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.
a. Recovery Audit Contractors (RAC)
b. Medicare Code Editors (MCE)
c. Clinical Data Abstraction Centers (CDAC)
d. Quality Improvement Organizations (QIO)
a. qualified discharge.
b. per diem.
c. interrupted stay.
d. transfer.
a. support services.
b. radiological supplies.
c. radiological equipment.
d. physician services.
a. changes in coding productivity.
b. changes in services offered.
c. changes in medical staff composition.
d. changes in coding rules.
a. Capitation
b. Global payment
c. Medicare Physician Fee Schedule (MPFS)
d. Medicare Severity-Diagnosis Related Groups (MS-DRGs)
a. the principal diagnosis.
b. a valid comorbidity.
c. medically necessary.
d. reasonably preventable
a. revenue cycle
b. charge capturing
c. precertification
d. insurance verification
a. code both the comprehensive code and the component code.
b. code only the comprehensive code.
c. code only the component code.
d. do not code either one.
a. cancer hospital
b. psychiatric hospital
c. rehabilitation hospital
d. long-term care hospital
a. pass through
b. hold harmless
c. limiting charge
d. indemnity insurance
a. local contractor’s decisions and national contractor’s decisions.
b. list of covered decisions and noncovered decisions.
c. local covered determinations and noncovered determinations.
d. local coverage determinations and national coverage determinations.
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
This information is printed on the UB-04 claim form to represent the cost center (e.g., lab, radiology, cardiology, respiratory, etc.) for the department in which the item is provided. It is used for Medicare billing.
a. general ledger key
b. charge code
c. HCPCS
d. revenue code
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
This information is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can be available for various financial classes.
a. charge code
b. general ledger key
c. HCPCS code
d. revenue code
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. When possible, the narratives from the HCPCS/CPT book should be utilized.
a. revenue code
b. item description/service description
c. general ledger key
d. HCPCS
Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
This information is the numerical identification of the service or supply. Each item has a unique number with a prefix that indicates the department number (the number assigned to a specific ancillary department) and an item number (the number assigned by the accounting department or the business office) for a specific procedure or service represented on the chargemaster.
a. general ledger key
b. revenue code
c. charge code/service code
d. HCPCS code
Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
This information is used to assign each item to a particular section of the general ledger in a particular facility’s accounting section. Reports can be generated from this information to include statistics related to volume in terms of numbers, dollars, and payer types.
a. HCPCS code
b. revenue code
c. general ledger key
d. charge code
Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date
49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013
49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013
Under APCs, the patient is responsible for paying the coinsurance amount based upon ________ of the national median charge for the services rendered.
a. 80%
b. 20%
c. 50%
d. 15%
a. Medicare Part B
b. Medicaid
c. Medigap
d. Medicare Part A
a. discharged not final billed
b. dollars not fully billed
c. diagnosis not finally balanced
d. days not fiscally balanced
a. 50%.
b. 20%.
c. 10%.
d. 15%.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The nonPAR Medicare fee schedule amount for this service is $190.00.
The patient is financially liable for the coinsurance amount, which is
a. 15%.
b. 20%.
c. 80%.
d. 100%
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The nonPAR Medicare fee schedule amount for this service is $190.00.
If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is
a. $190.00.
b. $218.50.
c. $200.00.
d. $250.00.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The nonPAR Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is
a. $190.00.
b. $218.50.
c. $250.00.
d. $200.00.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The nonPAR Medicare fee schedule amount for this service is $190.00.
If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient’s financial liability (out-of-pocket expense) is
a. $30.00.
b. $160.00.
c. $200.00.
d. $40.00.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The nonPAR Medicare fee schedule amount for this service is $190.00.
a. $152.00.
b. $190.00.
c. $66.50.
d. $38.00.
a. April 1st through March 31 of the next year.
b. July 1st through the June 30 of the next year.
c. October 1st through September 30 of the next year.
d. January 1st through December 31.
a. leaving notes in the chart.
b. calling the physician’s office.
c. e-mailing physicians.
d. using physician query forms.
a. significant procedure, not discounted when multiple.
b. significant procedure, multiple procedure reduction applies.
c. ancillary services.
d. clinic or emergency department visit (medical visits).
a. significant procedure, not discounted when multiple.
b. inpatient procedure.
c. ancillary services.
d. clinic or emergency department visit (medical visits).
a. significant procedure, multiple procedure reduction does not apply.
b. significant procedure, multiple procedure reduction applies.
c. ancillary services.
d. clinic or emergency department visit (medical visits).
a. ancillary services.
b. significant procedure, not discounted when multiple.
c. significant procedure, multiple procedure reduction applies.
d. clinic or emergency department visit (medical visits).
a. ancillary services.
b. significant procedure, not discounted when multiple.
c. significant procedure, multiple procedure reduction applies.
d. inpatient procedures/services.
a. National Practitioner Databank (NPD)
b. National Provider Identifier (NPI)
c. Master Patient Index (MPI)
d. Universal Physician Number (UPN)
a. each service is paid based on the actual charges.
b. capitation involves a group of physicians or an individual physician.
c. capitation means paying a fixed amount per member per month.
d. the volume of services and their expense do not affect reimbursement.
99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
– a detailed or comprehensive history
– a detailed or comprehensive examination and
– medical decision making that is straightforward or of low complexity
99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
– a comprehensive history
– a comprehensive examination and
– medical decision making of moderate complexity
99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
– a comprehensive history
– a comprehensive examination and
– medical decision making of high complexity
a. This code can be used only once per hospitalization.
b. This code can be used by the hospital to bill for facility services.
c. This code can be used for patients admitted to observation status.
d. This code can be used by the admitting physician or consulting physician.
a. the OIG’s Evaluation and Management Documentation Guidelines
b. the OIG’s Workplan
c. the Federal Register
d. the OIG’s Model Compliance Plan
a. cases that have not yet been paid.
b. denials that have been returned to the hospital.
c. cases that have been paid.
d. the amount the hospital was paid.
a. HCPCS/CPT codes
b. none of these
c. both HCPCS/CPT codes and ICD-9-CM codes
d. ICD-9-CM codes
a. HCPCS/CPT codes
b. none of these
c. both HCPCS/CPT codes and ICD-9-CM codes
d. ICD-9-CM codes
a. utilization review coordinator indicating that the patient stay is not medically necessary.
b. provider indicating that Medicare will not pay for certain services.
c. patient indicating whether he/she wants to receive services that Medicare probably will not pay for.
d. physician advisor indicating that the patient’s stay is denied.
a. will receive additional payment for these conditions when they are not present on admission.
b. will not receive additional payment for these conditions when they are present on admission.
c. will receive additional payment for these conditions whether they are present on admission or not.
d. will not receive additional payment for these conditions when they are not present on admission.
a. providers must file all Medicare claims.
b. collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim.
c. fees are restricted to charging no more than the “limiting charge” on nonassigned claims.
d. nonparticipating providers have a higher fee schedule than that for participating providers.
a. the patient has a total of 60 lifetime reserve days.
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.
c. lifetime reserve days are paid under Medicare Part B.
d. lifetime reserve days are usually reserved for use during the patient’s final (terminal) hospital stay.
a. interrelationship diagram.
b. decision tree.
c. case-mix index.
d. grouper hierarchy
a. scrubbers.
b. groupers.
c. pricers.
d. encoders
a. conversion factor.
b. geographic practice cost index.
c. case-mix index.
d. relative weight for the MS-DRG.
a. there are two or more (multiple) procedures that are assigned to status indicator “T.”
b. modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.
c. there are two or more (multiple) procedures that are assigned to status indicator “S.”
d. both there are two or more (multiple) procedures that are assigned to status indicator “T”, and modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.
a. skilled nursing facilities
b. home health agencies
c. inpatient rehabilitation facilities
d. long-term acute care hospitals
a. PACE (Patient Assessment and Comprehensive Evaluation)
b. HHASS (Home Health Agency Software System)
c. HAVEN (Home Assessment Validation and Entry)
d. PEPP (Payment Error Prevention Program)
a. LCD (Local Coverage Determinations)
b. OSHA (Occupational Safety and Health Administration)
c. SI/IS (Severity of Illness/Intensity of Service Criteria)
d. PEPP (Payment Error Prevention Program)
a. HCPCS/CPT codes that are coded by the coders.
b. ICD-9-CM codes that are coded by the coders.
c. HPCS/CPT codes that appear in the hospital’s chargemaster and will be included automatically on the patient’s bill.
d. ICD-9-CM codes that appear in the hospital’s chargemaster and that are automatically included on the patient’s bill.
a. costs
b. reimbursement
c. charges
d. contractual allowance
a. $120.00
b. $ 48.00
c. $ 60.00
d. $ 96.00
a. cost accounting
b. reimbursement
c. charge accounting
d. contractual allowance
a. costs
b. reimbursement
c. charges
d. contractual allowance
a. costs
b. reimbursement
c. charges
d. contractual allowance
a. CPT Code 99291 (critical care)
b. CPT Code 35001 (direct repair of aneurysm)
c. CPT Code 99358 (prolonged evaluation and management service)
d. CPT Code 50300 (donor nephrectomy)
a. remittance advice.
b. DNFB (discharged, no final bill).
c. periodic interim payments.
d. chargemaster.
a. $120.00
b. $57.00
c. $60.00
d. $45.60
a. payment status indicator, HCPCS
b. MS-DRG, CPT
c. CPT code, HCPCS
d. payment status indicator, ICD-9-CM
a. a patient claim may have multiple MS-DRGs.
b. special circumstances can result in an outlier payment to the hospital.
c. the MS-DRG payment received by the hospital may be lower than the actual cost of providing the services.
d. there are several types of hospitals that are excluded from the Medicare inpatient PPS.
a. TRICARE
b. Indian Health Service
c. CHAMPVA
d. workers’compensation
a. will be able to collect his or her total charges.
b. accept, as payment in full, the allowed charge from the PAR fee schedule.
c. agree to charge no more than 15% (limiting charge) over the allowed charge from the nonPAR fee schedule.
d. agree to charge no more than 10% (limiting charge) over the allowed charge from the nonPAR fee schedule.
a. Each facility is accountable for developing and implementing its own methodology.
b. Each facility must use the same methodology used by physician coders based on the history, examination, and medical decision-making components.
c. The level of service codes reported by the facility must match those reported by the physician.
d. Each facility must use acuity sheets with acuity levels and assign points for each service performed.
a. calendar year beginning January 1.
b. month.
c. quarter.
d. fiscal year beginning October 1.
a. geographic practice cost indices.
b. usual and customary fees for the service.
c. national conversion factor.
d. cost of living index for the particular region.
a. none of it is written off
b. $340.00
c. $250.00
d. $391.00
a. episode-of-care (EOC)
b. fee-for-service
c. capitation
d. bundled
a. Medicare Part A
b. Medicare Part C
c. Medicare Part B
d. Medicare Part D
a. prospective, retrospective
b. retrospective, prospective
c. retrospective, concurrent
d. prospective, concurrent
a. a rejected claim is sent back to the provider, errors may be corrected and the claim resubmitted.
b. a rejected claim may be appealed, but a denied claim may not be appealed.
c. a denied claim is sent back to the provider, errors may be corrected and the claim resubmitted.
d. if a procedure or service is unauthorized, the claim will be rejected, not denied.
a. “Technical component” billing.
b. “Assistant” billing.
c. “Incident to” billing.
d. “Assignment” billing.
a. form locator.
b. field box.
c. data field.
d. data locator.
a. surgical procedures
b. clinic/emergency visits
c. clinical lab services
d. radiology/radiation therapy
b. inpatient rehabilitation facilities (IRF).
a. ambulatory surgery centers (ASC).
b. inpatient rehabilitation facilities (IRF).
c. home health agencies (HHA).
d. home health agencies (HHA) and inpatient rehabilitation facilities (IRF).
a. a sentinel event.
b. a hospital acquired condition.
c. a payment status indicator.
d. present on admission.
a. Y = Present at the time of inpatient admission.
b. U = Documentation is insufficient to determine if condition was present at the time of admission.
c. N = Not present at the time of inpatient admission.
d. W = Provider is unable to clinically determine if condition was present at the time of admission.
a. Y = Present at the time of inpatient admission.
b. U = Documentation is insufficient to determine if condition was present at the time of admission.
c. N = Not present at the time of inpatient admission.
d. W = Provider is unable to clinically determine if condition was present at the time of admission
a. Y = Present at the time of inpatient admission.
b. U = Documentation is insufficient to determine if condition was present at the time of admission.
c. N = Not present at the time of inpatient admission.
d. W = Provider is unable to clinically determine if condition was present at the time of admission.
a. Y = Present at the time of inpatient admission.
b. U = Documentation is insufficient to determine if condition was present at the time of admission.
c. N = Not present at the time of inpatient admission.
d. W = Provider is unable to clinically determine if condition was present at the time of admission.
a. principal and secondary, Medicare, inpatient
b. principal and secondary, all, inpatient and outpatient
c. principal, all, inpatient
d. principal, Medicare, inpatient and outpatient