Medical Billing and Reimbursement

a. Resource Utilization Groups (RUGs).
The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called

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).

d. OASIS (Outcome and Assessment Information Set).
The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from

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).

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c. Bill hold
3.

________ 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

b. medical visits.
All of the following items are “packaged” under the Medicare outpatient prospective payment system, EXCEPT for

a. anesthesia.
b. medical visits.
c. recovery room.
d. medical supplies.

b. physician work, practice expense, and malpractice insurance expense.
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are

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.

b. APCs.
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called

a. MS-DRGs.
b. APCs.
c. APGs.
d. RBRVS

d. financially liable for charges in excess of the Medicare fee schedule, up to a limit.
A patient was seen by Dr. Zachary. 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 “balance billing,” which means that the patient is

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
The prospective payment system based on resource utilization groups (RUGs) is used for

a. skilled nursing facilities
b. intermediate care facilities
c. freestanding ambulatory surgery centers
d. hospital-based outpatients

c. remittance advice
The ________ is a statement sent to the provider to explain payments made by third-party payers.

a. acknowledgment notice
b. attestation statement
c. remittance advice
d. advance beneficiary notice

a. 25
How many major diagnostic categories are there in the MS-DRG system?

a. 25
b. 80
c. 100
d. 2,000

d. electronic data interchange (EDI).
The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called

a. health data exchange (HDE).
b. health information exchange (HIE).
c. HIPPA (Health Insurance Portability and Accountability Act).
d. electronic data interchange (EDI).

b. grouper.
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)

a. scrubber.
b. grouper.
c. encoder.
d. case-mix analyzer.

c. UB-04.
The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the

a. CMS-1600.
b. CMS-1491.
c. UB-04.
d. CMS-1500.

d. 100%, 50%
Under ASCs, when multiple procedures are performed during the same surgical session, a payment reduction is applied. The procedure in the highest level group is reimbursed at ________ and all remaining procedures are reimbursed at ________.

a. 100%, 75%
b. 100%, 25%
c. 50%, 25%
d. 100%, 50%

c. Medicare summary notice
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.

a. coordination of benefits
b. advance beneficiary notice
c. Medicare summary notice
d. remittance advice

b. RBRVS
Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient?

a. ASCs
b. RBRVS
c. MS-DRGs
d. APGs

a. The provider is a nonparticipating provider.
Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services?

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%.

b. absorbs the loss.
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

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%
Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group.

a. 150%
b. 200%
c. 50%
d. 100%

d. 1.278
Use the following table to answer the question.

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

c. 247
Use the following table to answer the question.

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

c. 470.
Use the following table to answer the question.

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.

a. It cannot be determined from this information.
Use the following table to answer the question.

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

c. six
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.

a. ten
b. seven
c. six
d. five

c. Fraud
________ is an act that represents a crime against payers or other health care programs (e.g., Medicare), or attempts or conspiracies to commit those crimes.

a. Assault
b. Abuse
c. Fraud
d. Whistle-blowing

a. payment status indicator
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.

a. payment status indicator
b. minimum data set
c. geographic practice cost indices
d. major diagnostic categories

a. medical necessity.
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

a. medical necessity.
b. benchmarking.
c. appropriateness.
d. evidence-based medicine.

a. the Stark I Law
This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of their family has a financial interest.

a. the Stark I Law
b. the Federal Antikickback Statute
c. the False Claims Act
d. the Civil Monetary Penalties Act

b. Never events
________ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.

a. Potential compensable events
b. Never events
c. Sentinel events
d. Adverse preventable events

d. abuse.
When a provider, in order to increase their reimbursement, reports codes to a payer that are not supported by documentation in the medical record, this is called

a. hypercoding.
b. unbundling.
c. fraud.
d. abuse.

c. home health resource groups
What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care?

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
If the Medicare nonPAR approved payment amount is $128.00 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?

a. $147.20
b. $192.00
c. $140.80
d. $143.00

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.

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

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)
A new initiative by the government to eliminate fraud and abuse and recover overpayments 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.

a. Recovery Audit Contractors (RAC)
b. Medicare Code Editors (MCE)
c. Clinical Data Abstraction Centers (CDAC)
d. Quality Improvement Organizations (QIO)

c. interrupted stay.
A discharge in which the patient was discharged from the inpatient rehabilitation facility and returned within three calendar days (prior to midnight on the third day) is called a(n)

a. qualified discharge.
b. per diem.
c. interrupted stay.
d. transfer.

d. physician services.
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

a. support services.
b. radiological supplies.
c. radiological equipment.
d. physician services.

d. changes in coding rules.
Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT

a. changes in coding productivity.
b. changes in services offered.
c. changes in medical staff composition.
d. changes in coding rules.

c. Medicare Physician Fee Schedule (MPFS)
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.

a. Capitation
b. Global payment
c. Medicare Physician Fee Schedule (MPFS)
d. Medicare Severity-Diagnosis Related Groups (MS-DRGs)

d. reasonably preventable
CMS-identified “Hospital-Acquired Conditions” mean that when a particular diagnosis is not “present on admission,” CMS determines it to be

a. the principal diagnosis.
b. a valid comorbidity.
c. medically necessary.
d. reasonably preventable

b. charge capturing
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.

a. revenue cycle
b. charge capturing
c. precertification
d. insurance verification

b. code only the comprehensive code.
The Correct Coding Initiative (CCI) edits contain a listing 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

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
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)

a. cancer hospital
b. psychiatric hospital
c. rehabilitation hospital
d. long-term care hospital

b. hold harmless
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.

a. pass through
b. hold harmless
c. limiting charge
d. indemnity insurance

d. local coverage determinations and national coverage determinations.
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

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.

d. revenue 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 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

c. 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 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

b. item description/service description
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 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

c. charge code/service code
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 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

c. general ledger key
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

b. 20%
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

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%

b. Medicaid
________ is a program that pays for medical assistance to individuals and families with low incomes and limited financial resources.

a. Medicare Part B
b. Medicaid
c. Medigap
d. Medicare Part A

a. discharged not final billed
The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete.

a. discharged not final billed
b. dollars not fully billed
c. diagnosis not finally balanced
d. days not fiscally balanced

d. 15%.
The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the nonPAR fee schedule amount. The limiting charge is

a. 50%.
b. 20%.
c. 10%.
d. 15%.

b. 20%.
Use the following case scenario to answer the question.

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%

c. $200.00.
Use the following case scenario to answer the question.

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.

b. $218.50
Use the following case scenario to answer the question.

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.

d. $40.00.
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 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.

c. $66.50.
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.

a. $152.00.
b. $190.00.
c. $66.50.
d. $38.00.

c. October 1st through September 30 of the next year.
A fiscal year is a yearly accounting period. It is the 12-month period on which a budget is planned. The federal fiscal year is

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.

d. using physician query forms.
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

a. leaving notes in the chart.
b. calling the physician’s office.
c. e-mailing physicians.
d. using physician query forms.

c. ancillary services.
Under APCs, payment status indicator “X” means

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).

d. clinic or emergency department visit (medical visits).
Under APCs, payment status indicator “V” means

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.
Under APCs, payment status indicator “S” means

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).

c. significant procedure, multiple procedure reduction applies.
Under APCs, payment status indicator “T” means

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).

d. inpatient procedures/services.
Under APCs, payment status indicator “C” means

a. ancillary services.
b. significant procedure, not discounted when multiple.
c. significant procedure, multiple procedure reduction applies.
d. inpatient procedures/services.

b. National Provider Identifier (NPI)
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.

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.
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

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.

a. This code can be used only once per hospitalization.
When billing for the admitting physician for a patient who is admitted to the hospital as an inpatient, one must use a CPT Evaluation and Management code based on the level of care provided.

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.

b. the OIG’s Workplan
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’Web site.

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.
Accounts Receivable (A/R) refers to

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.

d. ICD-9-CM codes
The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement.

a. HCPCS/CPT codes
b. none of these
c. both HCPCS/CPT codes and ICD-9-CM codes
d. ICD-9-CM codes

d. ICD-9-CM codes
The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement.

a. HCPCS/CPT codes
b. none of these
c. both HCPCS/CPT codes and ICD-9-CM codes
d. ICD-9-CM codes

c. patient indicating whether he/she wants to receive services that Medicare probably will not pay for
An Advance Beneficiary Notice (ABN) is a document signed by the

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.

d. will not receive additional payment for these conditions when they are not present on admission.
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

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.

d. nonparticipating providers have a higher fee schedule than that for participating providers.
Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT

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.

c. lifetime reserve days are paid under Medicare Part B.
Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT

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.

b. decision tree.
The term used to describe a diagram depicting grouper logic in assigning MS-DRGs is

a. interrelationship diagram.
b. decision tree.
c. case-mix index.
d. grouper hierarchy

a. scrubbers.
Once all data are posted to a patient’s account, the claim can be reviewed for accuracy and completeness. Many facilities have internal auditing systems. The auditing systems run each claim through a set of edits specifically designed for the various third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction. These “internal” auditing systems are called

a. scrubbers.
b. groupers.
c. pricers.
d. encoders

d. relative weight for the MS-DRG.
To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital’s base payment rate by the

a. conversion factor.
b. geographic practice cost index.
c. case-mix index.
d. relative weight for the MS-DRG.

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.
Under the APC methodology, discounted payments occur when

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.

c. inpatient rehabilitation facilities
This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).

a. skilled nursing facilities
b. home health agencies
c. inpatient rehabilitation facilities
d. long-term acute care hospitals

c. HAVEN (Home Assessment Validation and Entry)
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 Web site or on a CD-ROM.

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)
This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda.

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)

c. HPCS/CPT codes that appear in the hospital’s chargemaster and will be included automatically on the patient’s bill.
The term “hard coding” refers to

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.

b. reimbursement
This is the amount collected by the facility for the services it bills.

a. costs
b. reimbursement
c. charges
d. contractual allowance

b. $ 48.00
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 provided is $120.00. Medicare’s PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?

a. $120.00
b. $ 48.00
c. $ 60.00
d. $ 96.00

a. cost accounting
This accounting method attributes a dollar figure to every input required to provide a service.

a. cost accounting
b. reimbursement
c. charge accounting
d. contractual allowance

c. charges
This is the amount the facility actually bills for the services it provides.

a. costs
b. reimbursement
c. charges
d. contractual allowance

d. contractual allowance
This is the difference between what is charged and what is paid.

a. costs
b. reimbursement
c. charges
d. contractual allowance

a. CPT Code 99291 (critical care)
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.

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)

b. DNFB (discharged, no final bill).
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

a. remittance advice.
b. DNFB (discharged, no final bill).
c. periodic interim payments.
d. chargemaster.

d. $45.60
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 nonPAR fee is $57.00. How much reimbursement will the physician receive from Medicare?

a. $120.00
b. $57.00
c. $60.00
d. $45.60

a. payment status indicator, HCPCS
CMS assigns one ________ to each APC and each ________ code.

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.
All of the following statements are true of MS-DRGs, EXCEPT

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
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.

a. TRICARE
b. Indian Health Service
c. CHAMPVA
d. workers’compensation

b. accept, as payment in full, the allowed charge from the PAR fee schedule.
Under Medicare Part B, Medicare participating (PAR) providers

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.
Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true?

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.

d. fiscal year beginning October 1.
CMS adjusts the Medicare Severity DRGs and the reimbursement rates every

a. calendar year beginning January 1.
b. month.
c. quarter.
d. fiscal year beginning October 1.

a. geographic practice cost indices.
In calculating the fee for a physician’s reimbursement, the three relative value units are each multiplied by the

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.

c. $250.00
If a participating provider’s usual fee for a service is $700.00 and Medicare’s allowed amount is $450.00, what amount is written off by the physician?

a. none of it is written off
b. $340.00
c. $250.00
d. $391.00

a. episode-of-care (EOC)
Health plans that use ________ reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time.

a. episode-of-care (EOC)
b. fee-for-service
c. capitation
d. bundled

c. Medicare Part B
________ 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.

a. Medicare Part A
b. Medicare Part C
c. Medicare Part B
d. Medicare Part D

b. retrospective, prospective
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.

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.
The difference between a rejected claim and a denied claim is that

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.

c. “Incident to” billing.
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

a. “Technical component” billing.
b. “Assistant” billing.
c. “Incident to” billing.
d. “Assignment” billing.

a. form locator.
The term used to describe the information-gathering fields on the UB-04 billing form is

a. form locator.
b. field box.
c. data field.
d. data locator.

c. clinical lab services
The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.

a. surgical procedures
b. clinic/emergency visits
c. clinical lab services
d. radiology/radiation therapy

c. home health agencies (HHA).
b. inpatient rehabilitation facilities (IRF).
A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by

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).

d. present on admission.
The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that were not present on hospital admission but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as

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.
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

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.
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

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

c. N = Not present at the time of inpatient admission.
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

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.

b. U = Documentation is insufficient to determine if condition was present at the time of admission.
The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator is

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
The present on admission (POA) indicator is required to be assigned to the ________ diagnosis(es) for ________ claims on ________ admissions.

a. principal and secondary, Medicare, inpatient
b. principal and secondary, all, inpatient and outpatient
c. principal, all, inpatient
d. principal, Medicare, inpatient and outpatient

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