[Radiology examinations] The OPPS used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications.
A medicare patient had two physician office visits, underwent hospital radiology examinations, clinical laboratory tests, and received take-home surgical dressings. What is considerate would be reimbursed under the outpatient prospective payment system OPPS?
Query the physician to determine if the condition was present on admission or not. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity.
In conducting a qualitative review the clinical documentation specialist sees that the nursing staff has documented the patient’s skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician’s documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
Is the supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue(total income produced by a given source).
What is the definition of revenue cycle management?
[The date the bill drops] Accounts receivable manages the amounts of money that owed to facility by patients or their insurance company which will pay later date after the received the services also call Dollars in accounts receivable. The claim is submitted(drop the bill) to third-party payer for reimbursement, the accounts receivable clock begins to tick which is show as a pending claims.
Most facilities begin counting days in accounts receivable at which of the following times?
They are monitored in the [Claims reconciliation/collections] area which is a last component of the Revenue cycle.
In most acute-care setting, the Explanation of Benefits (EOB), Medicare Summary Notice (MSN), and Remittance Advice (RA) Documents (provided by the payer) are monitored in which revenue cycle area?
[Fee-for-service] individuals patient pay for them self after a service was serve.
What is term is used for retrospective cash payments paid by the patient for services rendered by a provider?
[Prospective}
What is term for a payment systems that amount of payment determined before the service is delivered?
Psychiatric, rehabilitation hospitals, long-term care hospitals, children’s hospital, cancer hospitals, and critical access hospitals. They are still paid on the basis of reasonable cost. The reason of excluded from Medicare’s PPS because the PPS diagnosis-related groups do not accurately account for the resource costs for hospital list above.
What types of hospitals are excluded from the Medicare inpatient prospective payment system (PPS)?
[RBRVS] CMS implemented the resource-based relative value scale system for physician’s services such as office visits covered under Medicare Part B. The system reimburses physicians according to a fee schedule based on predetermined values assigned to specific services.
Which of the following is associated with the Medicare fee schedule?
OPPS (the outpatient prospective payment system), the federal government pays hospital outpatient services on a rate-per-service basis depending on the ambulatory payment classification (APC) group that coding assign to HCPCS identifies and groups the services within each APC group.
In processing a Medicare payment for outpatient radiology exams a hospital outpatient services department would receive payment under _____.
Surgical procedures, radiology, clinical visits, ER visits, partial hospitalization services for the mentally ill, chemotherapy, preventative services and screening exams, dialysis for other than ESRD, vaccines, splints, casts, antigens, and certain implantable items.
Under APCs services including _____
Annually by Madicare
Fee schedules are updated ____ by third-party payers.
[Screen 837P or CMS 1500. form 837p submit by via electronic format, it takes place of the CMS-1500 billing form.
What form that health record technician use to perform the billing function for a physician’s office?
[Provider accepts as payment to be made directly to the provider], accepts payment as a full, the allowed charge (from the fee schedule). The provider or supplier is prohibited from balance billing, which means the patient cannot be held responsible for charges in excess of the Medicare fee schedule.
When a provider accepts assignment this means that the____
The provider or supplier agrees to accept assignment for all covered services provided to Medicare patients.
Medicare participation means______.
There is no duplication of benefits paid. Some time patients have more than one insurance policy is necessary to determination which policy is a primary or secondary so is no duplication in payment of benefits.
The coordination of benefits transaction (COB) is important so that____.
MEDPAR is the Medicare Provider Analysis and Review. The MEDPAR file is frequently used for research on topics and it only limitation contains only Medicare patients file.
What is made up of claims data from Medicare claims submitted by acute-care hospitals and skilled nursing facilities?
Healthcare Integrity and Protection Data Bank.
The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of_____.
Name of the federally funded program that pay the medical bills of the spouses or certain former spouses and dependents of persons on active duty in the uniformed services, National Guard and Reserve member, retirees, their families. formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
TRICARE is ____.
[24 days] Inpatient is limited to 90 days in each benefit period. Additional 60 days for lifetime reserve days which is a nonrenewable. So patient is used 36 days lifetime reserve out of 60 days, so patient have 24 days of lifetime reserve left. 60-36=24.
Mr Jones is a 67 year old patient who only had Medicare’s Part A insurance. If Mr Jones used 36 lifetime reserve days, how man does the patient have left to be used at a later date?
is a clam form submitted to the third party payers by inpatient, outpatient, home health care hospice, and long-termcare services.
UB-92 is ___
A statement sent to the PATIENT to explain services provided, amounts billed and payments made by the health plan. Medicare replaced it with Medicare Summary Notice MSN.
The Explanation of Benefits EOB is___
Sent to the provider to explain payments made by third party payers. Available in ANSI ASC X12 835 which is a electronic remittance advice ERA
Remittance Advice RA is____
Part A when the care is medically necessary. Medicare Part A coverage is measured in “benefit periods.” In each benefit period there are limits to the number of days Medicare will pay for inpatient care. Inpatient hospital care is usually limited to 90 days during each benefit period. A benefit period begins on the day of admission and ends when the beneficiary has been out of the hospital for 60 days in a row, including the day of discharge. There is NO limit to the number of benefit periods. When a beneficiary exhausts the 90 days of inpatient hospital care available during a benefit period, a nonrenewable lifetime reserve of up to a total of 60 additional days of inpatient hospital care can be used with in benefit period. Basicly it cover 150 days at a time when patient have new illness the new benefit periods will start even though it in the same year.
Inpatient hospital care is paid for under Medicare Part ___.
Inpatient hospital care, skilled nursing facility (SNF) care, home healthcare, and hospice care
Healthcare services covered under Medicare Part A include _____
Generally provided free of charge to individuals age 65 and over who are eligible for Social Security or Railroad Retirement benefits, people under 65 years old with certain disabilities, and people of all ages with end-stage renal disease. In addition, some otherwise-ineligible aged and disabled beneficiaries who voluntarily pay a monthly premium for their coverage are eligible for Medicare Part A.
Medicare Part A provides hospitalization insurance (HI) that is ____
[100] days. Medicare fully covers the first 20 days in a benefit period from days 21 through 100, a co-payment is required and Medicare will pay up to first 100 days of SNF care.
The number of days Medicare will cover SNF (skilled nursing or rehabilitation services) inpatient care per benefit period is limited to ____
long-term nursing care, custodial care, dentures and dental care, eyeglasses, and hearing aids.
Medicare part A or B does not usually cover____ service.
[Unlimited] as long as with in number of days medicare will pay for inpatient care that is a benefit period normally is 90 days during each benefit period start from the day of admission and ends when patient out of the hospital for 60 days in a row, including the day of discharge.
How many benefit periods are covered by hospital insurance during a Medicare beneficiary’s lifetime?
Medicaid program, Title XIX(19) of the Social Security Act enacted Medicaid in 1965 to provide healthcare coverage to low income individuals and families and limited financial resources
What is the name of the program funded by the federal government to provide medical care to people on low incomes or with limited financial resources?
For people who have both Medicare and Medicaid, Any services covered by Medicare are paid for by the Medicare program first before any payments are made by Medicaid b/c Medicaid is always the PAYER OF LAST RESORT
How individual who have both Medicare and Medicaid makes payments.
Preferred provider organization PPO, Beneficiaries of PPOs select providers such as physicians or hospitals from a list of participating providers who have agreed to furnish healthcare services to the covered population
Which groups of healthcare providers contracts with a self-insured employer or a health insurance carrier to provide healthcare services?
Prospective payment system PPS is an exact amount of the payment is determined before the service is delivered
What is a reimbursement methods pays providers according to charges that are calculated before healthcare services are render or delivered?
Global payments methodology, is a lump sum payments distributed among the physicians who performed the procedure or interpreted its results and the healthcare facility that provided the equipment, supplies, and technical support required that involve professional and technical components.
Which is apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?
[claims processing] is an internal auditing system to ensure claims are error free known as scrubbers. The auditing system runs each claim through a set of edits specifically designed for the third-party payer; identifying data that has failed edits and flags the claim for correction.
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?
[Fiscal intermediary/MAC], Medicare administrative contractor MACs are replacing the claims payment contractors known as fiscal intermediaries.
Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare?
POS is Point-of-Service. This plan was created to increase the flexibility of managed care plans and to allow patients more choice in providers.
What insurance plans that encourages subscribers to select providers from a prescribed network but also allows them to seek healthcare services from providers outside the network at a higher level of copay?
[Medicare], is a health insurance for the aged and disabled. Medicare legislation was enacted as one element of the 1965 amendments to the Social Security Act. It’s for people age 65 and over, eligibility is based on Social Security or Railroad Retirement participation. For people under age 65, eligibility is based on disability. For people who undergo kidney dialysis, eligibility is not dependent on age.
Title XVIII of the Social Security Act Amendment of 1965 is also known as____
[Individual states] that must meet broad national guidelines established by federal statutes, regulations, and policies to qualify for federal matching grants under the Medicaid program. The state also determine the type, amount, duration, and scope of covered services; calculate the rate of payment for covered services; and administer local programs. Different state is different rule.
Which of the following establish eligibility standards for enrollment in Medicaid?
SCHIP refer to Children’s Health Insurance Program, or CHIP. This program cover children up to age 19. It proved additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children.
This program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children
PACE is Programs of all-Inclusive Care for the Elderly. It offers and manages all of the health, medical, and social services needed by a beneficiary and mobilizes other services, as needed, to provide preventive, rehabilitative, curative, and supportive care.
What program provides(day healthcare centers, homes, hospitals, and nursing homes) an alternative to institutional care for individuals 55 years old or older who require a level of care usually provided at nursing facilities.
Medicaid program according to their eligibility category. Additional services may include, for example, hospital, preventive care,nursing facility care beyond the 100-day limit covered by Medicare and other services not covered under Medicare such as dental work, prescriptions, transportation, eyeglasses, and hearing aids
What eligibility additional services will get covered by Medicaid program
The Civilian Health and Medical Program-Veterans Affairs (CHAMPVA) is a healthcare program for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died from service-related conditions, and survivors of military personnel who died in the line of duty
What is CHAMPVA program?
Workers’ compensation programs cover healthcare costs and lost income associated with work-related injuries and illnesses
What is Workers’ compensation programs?
the Federal Employees’ Compensation Act (FECA) which is a workers’ compensation programs, FECA provides federal employees injured in the performance of duty with workers’ compensation benefits. This includes wage-loss benefits for total or partial disability, monetary benefits for permanent loss of use of a body part, medical benefits, and vocational rehabilitation. FECA also provides survivor benefits to eligible dependents if the injury causes the employee’s death
Federal government employees are covered by_____
Medigap is private health insurance that pays, within limits, most of the healthcare service charges not covered by Medicare Parts A and/or B. These policies must meet federal and state laws such as copayments, coinsurance, and deductibles that Medicare doesn’t cover
What is Midigap?
Revenue code (also called the UB-04 code): The revenue code is a three-digit code that describes a classification of a product or service provided to the patient. These revenue or UB-04 codes are required by CMS for reporting services
What is a Revenue code?
Description of service such as evaluation and management visit, observation, or emergency room visit; CPT/HCPCS code or another word is HCPCS level I and II; Revenue code; charge amount(charges for that procedure or service; charge or service code which is a internally assigned number that unique to the facility it identifies each procedure and department or revenue center that charge from such as surgery department, x-ray department; General ledger key which is a two or three digit number that assigns a line item to a section of the general ledger in the hospital’s accounting system; last is activity/status date.
The required elements of a charge description master CDM are____
Healthcare services (and transactions) provided to a patient. Its primary purpose is to allow the provider to accurately charge routine services and supplies to the patient. Services, supplies, and procedures included on the chargemaster generate reimbursement for almost 75 percent of UB-92 claims submitted for outpatient services alone
The chargemaster also called the charge description master (CDM), contains information about____
[TRICARE] known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a healthcare program for active duty service members, National Guard and Reserve members, retirees, their families, survivors and certain former spouses.
Active armed services members and their qualified family members are covered by which of the following healthcare programs?
[CHAMPVA] is the Civilian Health and Medical Program of the Department of Veterans Affairs.
Dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died from service-related conditions, and survivors of military personnel who died in the line of duty.
[IHS, Indian Health Service] is a agency within the HHS. The primary medical services is hospital and ambulatory care, community health services, substance abuse treatment services, and rehabilitative services. Secondary medical care, highly specialized medical services, and other rehabilitative from professional work under contract with the HIS
The agency that responsible for providing healthcare service to American Indians and Alaskan natives?
A deductible is usually an annual expense(cost). Cost sharing with Medicare Part A includes deductibles. A deductible is usually an annual expense. You cover all the costs for your care starting January 1. Once you have spent the deductible amount, then your insurance helps pay your costs for the rest of that calendar year. The cycle starts over on January 1 of the following year. Medicare Part A deductibles are different. You pay a deductible for each “benefit period,” rather than for the year.
Deductible meaning_____
Benefit Period First 60 days patient’s pay $1,100 deductible Medicare pay the rest, Days 61-90 patient’s pay 275 per day Medicare pay the rest, then days 91-150( Reserve days can be used only once in the patient’s lifetime) patient pay 550 per day medicare pay the rest, beyond 150 days patient pay it all. [You pay a Part A deductible for each benefit period. A benefit period begins when you enter the hospital and ends when you are out for 60 days in a row. One benefit period may include more than one hospitalization.]
Example of Benefit Period
[DRG] is assigned a relative weight that is intended to represent the resource intensity of the clinical group.
The most widely used inpatient case-mix system is based on____
Charge code
The unique number that identifies each service or supply in the CDM and links each item to a particular department is know as the____
there are three levels of codes. Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices,[2] and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I).
Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.
Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.
How many levels of HCPCS code_____
Hospital’s case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG. This provides the total weight for each MS-DRG. The sum of all total weights divided by the sum of total patient discharges equals the case-mix index.
What is case-mix index?
[Focused audit] Focused selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-risk areas or other areas of specific concern.
The facility’s Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?
Focused reviews on lower weighted MS-DRGs from triples and pairs. Because lower weighted DRGs could have fewer CC’s and MCC’s which may be the result of a coder missing secondary diagnoses.
The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term?
Record review rate, Query rate, Query response rate, Query agreement rate. The target percentage may need adjustment over time as the CDS staff becomes more familiar with their responsibilities and physician documentation improves.
There are four primary percentages that should be calculated and tracked to assess clinical documentation improvement (CDI) program. This percentages are____
Every 24-48 hours, to check for the physician’s response. If no response is given prior to discharge, the info is requested post discharge. If a response is given and the diagnosis changes the MD-DRG, this change is tracked.
CDI staff should revisit cases___
Balanced Budget Act of 1997 (BBA)
The federal legislation that focused on healthcare fraud and abuse issues, especially as they relate to penalties, was the____
Determined by the facility to be uncollectible. The charges are written off as bad debt after multiple, extensive attempts have been made to collect.
The phrase “bad debt” refers to accounts that include money owed by the patient and are___
[ Physician Index]. The medical staff department is particularly interested in the ICD-9-CM codes associated with each physician. because diagnostic codes can identify untoward events that occur during hospitalization, the quality of physician’s services can be identified through reports called physician reappointment summaries.
A physician does not agree with the number of patients attributed to her for recredentialing purposes. What report is the most useful in validating the data?
Is a summaries outline the number of cases by diagnosis and procedure type, LOS and infection and mortality statistics. At reappointment to facility’s medical staff, code-based reports are required. The medical staff will analysis these reports of each physician’s activities takes place before he or she is reappointed to the staff.
What is the physician reappointment summaries?
[4 days from the date of service/discharge] Bill hold is an established time between the date of service and the date the claim is sent to the payer.
The best practice for a system hold for all charges to be entered into the billing system and all coding to be competed is____
Accounts that have been discharged and have not been billed for a variety of reasons. The DNFB usually hold by HIM department. The reason might be uncoded b/c untimely documentation, misposted charges, registration or the wrong service area, services provided under an incorrect revenue code, lost paperwork.
The “discharge, not final billed (DNFB)” report which is known as discharge, not final bill or accounts not selected for billing includes that types of accounts?
Is a predefined set of edits created by Medicare to check outpatient claims for compliance with the Medicare OPPS. The IOCE will reviews a coded claim for accuracy and send back an edit flag if an error has been detected in the claim, correct it, and then send out a clean claim.
What is the Integrated Outpatient Code Editor (IOCE)? Aportion of the NCCI edits are embedded in the IOCE edits.
