question

Chargemaster also called Charge description master (CDM):

answer

A financial management form that contains information about the organization's charges for the healthcare services it provides to patients.

question

The process for adding new technology into the charge description master (CDS) includes:

answer

1. Reviewing new technology for FDA approval, 2. For OPPS pass-through assignment, 3. And also to have a coding professional check codes from the manufacture for accuracy.

question

Universal protocol:

answer

A written checklist developed by the Joint Commission to prevent errors that can occur when physicians perform the wrong procedure, for example

question

Universal protocol incorporate the principle of eliminating:

answer

wrong-site, wrong-procedure, and wrong-person.

question

Steps involve in universal protocol include:

answer

preoperative verification process, marking of the operative site, and a "time-out" before starting any procedure. (Patient, procedure, site).

question

Discharge not final billed (DNFB):

answer

refers to accounts where the patient has been discharge but the charges have not been procced or billed. Owned by the health information management department (HIM).

question

Uncoded accounts are the result of:

answer

untimely documentation, misposted charge, registration or the wrong service area, services provided under an incorrect revenue code, or lost paperwork.

question

Advance beneficiary notice (ABN):

answer

A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it.

question

National Coverage Determination (NCD):

answer

sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow it.

question

The integrated outpatient code editor (IOCE):

answer

is a predefine set of edits crested by Medicare to check outpatient claims for compliance with the Medicare outpatient prospective payment system (OPPS). Will review a coded claim for accuracy and send an edit flag if an error has been detected in the claim.

question

Most organization all their claim through:

answer

the IOCE prior to sending out to any payer to look for errors, correct them and then send out a clean claim. A portion of the NCCI edits are embedded in the IOCE edit.

question

Clinical documentation improvement (CDI):

answer

The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes.

question

Clinical documentation improvement (CDI) used to:

answer

provide a mechanism for the coding staff to communicate with the physician regarding nonspecific diagnosis statement or when additional diagnosis are suspected but not clearly stated in the records, which helps to avoid assumption coding.

question

All the secondary diagnosis must:

answer

match the definition in the UHDDS

question

If the coder is not clear about a patient:

answer

query the physician and ask him to validate the diagnosis.

question

When developing an internal coding audit review program, One of the elements of the auditing process:

answer

identification of risk area, some major risk areas include chargemaster description, medical necessity, MS-DRG coding accuracy, variation in case mix.

question

Local coverage determination (LCD):

answer

Established by Section 522 of the Benefits Improvement and Protection Act, a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act, which is a determination regarding whether the service is reasonable and necessary. LCDs consist only of reasonable and necessary information. Effective December 7, 2003, CMS's contractors will begin issuing LCDs instead of LMRPs (CMS 2013).

question

Resolving failed edits:

answer

is one of many duties of the health information management (HIM). Various medical department depend on the coding expertise of the HIM to avoid incorrect coding and potential compliance issues.

question

Consultant's report will identify specific issues or causes of coding variation (outcome of coding audit review):

answer

include 1. Issuing queries to physicians to obtain additional information to modify the original coding. 2. Resubmitting claims to payers because the coding has been modifies. 3. Discussing documentation deficiencies with one or more clinicians. Addressing legibility issues with one or more physician, and providing focused education to one or more coders.

question

Error from the coder assignment:

answer

known as soft coding

question

Error from CDM:

answer

known as hard coding. It's important that the error is communicated to the coding staff. If the decision is not communicated effectively, the result could be a duplicated billing which will result in overpayment to the facility.

question

Long-term care hospitals (LTCHS):

answer

must meet state requirements for acute care hospital and must have a provider agreement with Medicare in order to receive Medicare payment.

question

Fiscal intermediaries:

answer

verify that the LTCH meets the required average LOS of greater that 25 days.

question

Coding supervisor:

answer

is responsible for reviewing accounts that have not been final billed because of the errors and removing the code. Education for coders as to which codes are hard-coded will help eliminate those errors.

question

Conditions of Participation:

answer

The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services (CMS 2013); See also Conditions for Coverage.

question

CMS required history and physical examination must be completed:

answer

no more than 30 days before or 24 hours after admission and report must be placed in the record within 24 hours after admission.

question

Hospital's policy that establish time frame for completing the history and physical:

answer

within 24 hours following admission and required that to be completed by the provider who is admitting the patient.

question

For clinical documentation improvement (CDI) to be successful:

answer

medical and clinical staff must be involve in developing the process for documentation improvement. Not required all staff hospital because they do not document in the health record.

question

License:

answer

The legal authorization granted by a state to an entity that allows the entity to provide healthcare services within a specific scope of services and geographical location; Establish by state government, under the direction of state department of health.states license both individual healthcare professionals and healthcare facilities; licensure usually requires an applicant to pass an examination to obtain the license initially and then to participate in continuing education activities to maintain the license thereafter

question

Certification:

answer

1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements.

question

Accreditation:

answer

1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency

question

Optimize the coding process:

answer

the coder attempt to make coding for reimbursement as accurate as passible, reviewing claims to ensure appropriate coding for deserved payment.

question

Optimize the coding process help healthcare facility:

answer

to obtain the highest dollar amount justified within the terms of the government program or the insurance policy involved

question

Participating physicians (PARs):

answer

A doctor or supplier who agrees to accept assignment on all Medicare claims, these individuals will only bill the patient for the Medicare deductible or coinsurance amounts (CMS 2013)

question

Medicare fee schedule (MFS):

answer

A feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers.

question

nonparticipating physicians:

answer

do not sign a participant agreement with Medicare but may or may not accept assignment. Physicians who treat Medicare beneficiaries but do not have a legal agreement with the program to accept assignment on all Medicare services and who, therefore, may bill beneficiaries more than the Medicare reasonable charge on a service-by-service basis.

question

If the non-PAR physician elects to accept assignment:

answer

the provider is paid 95 % (5 % less than participant physician) of Medicare fee schedule (MFS). For example: if the MFS is $200, the PAR provider receive $160 ( 80 % of $200), but the non-PAR providers will receive only (95% of the $160) which $152. In this case the physician is non-participant will receive 95% of the 80% of the MFS.

question

Conversion factor:

answer

A national dollar amount that Congress designates to convert relative value units to dollars; that set the allowance for the relative values - a constant. updated annually.

question

Relative Value Unit:

answer

A number assigned to a procedure that describes its difficulty and expense in relationship to other procedures by assigning weights to such factors as personnel, time, and level of skill; See geographic practice cost index; malpractice; physician work; practice expenses; resource-based relative value scale.

question

Geographic practice cost index (GPCI):

answer

An index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to the national average in the three components of the relative value unit (RVU)

question

three components of the relative value unit (RVU):

answer

physician work, practice expenses, and malpractice coverage; separate GPCIs exist for each element of the RVU and are used to adjust the RVUs, which are national averages, to reflect local costs

question

Formulary:

answer

A listing of drugs, classified by therapeutic category or disease class; in some health plans, providers are limited to prescribing only drugs listed on the plan's formulary. The selection of items to be included in it is based on objective evaluations of their relative therapeutic merits, safety, and cost

question

Formulary is composed of:

answer

medications used for commonly occurring conditions or diagnosis treated in the healthcare organization.

question

Organization accredited by the joint commission are required to maintain:

answer

formulary and document that they review at least annually for a mediation's continued safety and efficacy.

question

Medicare coverage is not identical in different state:

answer

allows states to maintain program adapted to state residents' needs and average income, although state programs must meet coverage requirements for groups such as recipients of adoption assistance and foster care, other type of coverage, such as vision and dental services are determined by the state's Medicaid agencies.

question

One of the internal audit for coding compliance:

answer

is identification of risk areas. Selecting the types of cases to review is also important. The suitable case selection is Medical and surgical MS-DRGs by high dollar and high volume.

question

Resource-based relative value scale (RBRVS):

answer

A scale of national uniform relative values for all physicians' services. The relative value of each service must be the sum of relative value units representing the physicians' work, practice expenses net of malpractice insurance expenses, and the cost of professional liability insurance.

question

Each RBRVS comprises three elements:

answer

physician work, physician practice, and malpractice, each of which is a national average available in the Federal Register.

question

Office of Inspector General (OIG):

answer

Mandated by Public Law 95-452 (as amended) to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs.

question

50. The OIG has a responsibility to report:

answer

To both the Secretary and to the Congress program and management problems and recommendations to correct them.

question

The OIG's duties:

answer

Are carried out through a nationwide network of audits, investigations, inspections, and other mission-related functions performed by OIG components.

question

Office of the Inspector General (OIG) Workplan:

answer

Yearly plan released by the OIG that outlines the focus for reviews and investigations in various healthcare settings.

question

Ares that the OIG is responsible for 70% of bed claims:

answer

1. Insufficient or missing documentation and 2. Failure to document medical necessity.

question

In term of grouping and reimbursement both MS-LTC-DRGs and the acute care MS-DRGs:

answer

are based on the principle diagnosis.

question

Account receivable:

answer

A list of the amounts due from various customers (in this case patient). Payment on the individual amounts is expected within a specified period. A schedule of those expected amounts is prepared in order to track and follow up on payments that are overdue.

question

The accounts receivable collection cycle involve from:

answer

admission to deposit in the bank.

question

Medical identity theft:

answer

is distinguished from other type of identity theft because it creates negative consequences to both the victim's financial status and medical information.

question

Medical identity theft protection program includes:

answer

1. Ensure safeguards are in place to protect the privacy and security of PHI, 2. Balance patient privacy protection with disclosing medical identity theft to victims, 3. Identify resources to assist patient who are victims of medical identity theft.

question

Inpatient rehabilitation facility (IRF):

answer

A healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care, and independence

question

To meet CMS's definition of an IRF:

answer

facilities must have an inpatient population in which at least 60 % of the patient require intensive rehabilitation services and one if the 13 conditions.

question

13 conditions for rehabilitation services for CMS:

answer

stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur, brain injury, neurological disorders, burns, active polyarticular rheumatoid arthritis, systemic vasculitis, sever or advance asteo-arthritis, knee or hip replacement.

question

The first step in improving any problem:

answer

is to identify the root cause of the problem and then develop and take appropriate actions to fit the cause of the problem. For example (determine the type and volume of documentation problem).

question

Query process:

answer

the process in which a healthcare entity addresses the provider documentation issues of legibility, completeness, clarity, consistency, and precision.

question

Case finding:

answer

A method of identifying patients who have been seen or treated in a healthcare facility for the particular disease or condition of interest to the registry

question

Home health prospective payment system (HHPPS):

answer

The case mix reimbursement system developed by the Centers for Medicare and Medicaid Services in 2008, to cover home health services, including therapy visits and different resource costs provided to Medicare beneficiaries.

question

Under the HHPPS:

answer

CMS has accounted for 1. Nonroutine medical supplies, 2. Home health aide visits, 3. Medical social services, 4. Nursing and therapy services.

question

Hospital Outpatient Prospective Payment System (HOPPS):

answer

The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by the Centers for Medicare and Medicaid Services.

question

68. Hospital Outpatient Prospective Payment System (HOPPS):

answer

outpatient services such as recovery room, supplies (other than pass-through), and anesthesia are included in this reimbursement method.

question

Joint commission required medical staff:

answer

fully licensed physicians are permitted by law to provide patient care services.

question

Medical staff bylaws:

answer

provide an organizational structure to ensure communication with the governing body and high-quality patient care. Committees are used to help most medical staffs function. This committee structure is used to make credentialing and clinical privilege decision.

question

The charge description master (CDM):

answer

contains elements such as department and item number, item description, revenue code, HCPCS code, price, and activity status. Procedure and services charge.

question

The claim reconciliation process:

answer

the healthcare facility uses the explanation of benefits, Medicare Summary Notice, and the remittance advice to reconcile accounts.

question

Statistical maintained by the accounts receivable department:

answer

include days in accounts receivable and aging of account.

question

Aging of accounts is maintained:

answer

in 30-day increments (0-30 days, 31-60 days, and so forth).

question

Claims processing:

answer

The process of accumulating claims for services, submitting claims for reimbursement, and ensuring that claims are satisfied.

question

Claims reconciliation and collection uses in acute-care setting:

answer

explanation of benefits (EOB), Medicare summary notice (MSN), and remittance advice (RA), to reconcile account. EOBs and MSN identify the amount owned by the patient to the facility.

question

Collection:

answer

contact the patient to collect outstanding deductibles and copayment.

question

Remittance advice (RA):

answer

indicate rejected or denied items or claims. Facilities can review it and determine where the claim error can be corrected and resubmitted for additional payment.

question

The on-site Joint Commission survey:

answer

utilize a tracer methodology that permits assessment of operational system and processes in relation to the actual experiences of selected patients currently under the organization care. Patients are selected basis of the current census.

question

The surveyor:

answer

identify performance issues or trends in one or more steps of the process or in the interfaces between processes. Patient on subsequent days may be selected on the basis of issues raised.

question

Consistent method to improve communication and documentation:

answer

implement a standardized physician query form so that coders can request clarification from physician about documentation issues.

question

Recovery audit contractor (RAC):

answer

program to reduce improper Medicare payments and prevent future improper payments made of claims of healthcare services to Medicare beneficiaries. Improper payments may be overpayments or underpayments

question

Deemed status:

answer

accrediting bodies such as Joint Commission or American Osteopathic Association can survey facilities for compliance with the Medicare Conditions of Participation for hospitals instead of government.

question

Internal auditing system known as scrubber:

answer

the auditing system runs each claim through a set of edit specifically designed for that third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction.

question

Joint commission required accredited facilities:

answer

to implement system for identifying and addressing sentinel events.

question

According to Joint Commission, the unanticipated death of a full-term infant should be reported as :

answer

Sentinel event

question

Focused reviews ( focused inpatient review):

answer

based on specific problem areas after the initial baseline review has been completed

question

Clinical documentation improvement (CDI):

answer

program based on several different models. Improvement work can be done with retrospective record review and queries, with concurrent record review and queries or with concurrent coding. Although done while the patient is in-house, it does not eliminate the need for post-discharge queries.

question

Federal Trade Commission:

answer

has oversight responsibility for identity theft regulation and requires financial institution and creditors to develop and implement written identity theft prevention program.

question

Program for Evaluation Payment Patterns Electronic Reports (PEPPERs):

answer

to identify those claims that could be targeted by the (RACs). Can be a great tool for RAC preparation because they outline the hospital's Medicare payment patterns compared to other hospital in the state.

question

Ambulatory Payment Classification (APC) an outlier payment is paid:

answer

when the cost of the services is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount.

question

The principal diagnosis:

answer

is governed by the circumstances of admission. The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care (NCVHS 2009); See most significant diagnosis.

question

Focused review (focused patient review):

answer

based on specific problem areas after the initial baseline review has been completed.

question

Medicare summary notice (MSN):

answer

A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided

question

Advance beneficiary notice:

answer

A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it (CMS 2013)

question

Medicare summary notice details:

answer

amount billed by the provider, amount approved by Medicare, how much the Medicare reimburse the provider, and what the patient must pay the provider by way of deductible and copayment.

question

Denial :

answer

define as a payer's refusal to provide payment.

question

Common reason for denial:

answer

billing non-covered services, lack of medical necessity, and beneficiary not covered.

question

The length of multiple laceration:

answer

repairs located in the same classification are added together and one code is assigned.

question

Patient have more than one insurance policy (coordination of benefits):

answer

must determine which policy is primary and which is secondary is necessary so that there is no duplication in payment of benefits.

question

Data mining:

answer

efforts of the recovery audit contractors (RAC) allow them to deney payment without ever reviewing a health record. For example duplicate records. RAC allow to are able to detect improper payment underpayment, overpayments amount can be subject to a automated review.

question

Federal Fair and Accurate Credit Transaction Act (FATCA):

answer

Identity Theft Flags and Address Discrepancy Rule were enacted as part of it. Required financial institutions and creditors to develop and implement written identity theft program that identify, detect, and respond to red flags that may sign the presence of identity theft.

question

Beneficiary incentive program:

answer

encourage Medicare beneficiary to review their bills carefully for discrepancies and report this discrepancies to DHHS.

question

QIO review:

answer

can be promoted Medicare beneficiary through a compliance or a request for appeal, by federal agencies, or as routine review of care and billing patterns under the Medicare program. All of these functions are referred to as "case review".

question

Operation Restore Trust:

answer

A 1995 joint effort of the Department of HHS, OIG, CMS, and AOA to target fraud and abuse among healthcare providers; based on the two-year findings of the project HHS expanded all fraud and abuse prevention activities.

question

MS-DRG grouper:

answer

A computer program that assigns inpatient cases to Medicare severity diagnosis-related groups and determines the Medicare reimbursement rate 107.

question

Tracer methodology

answer

Joint Commission survey methodology involves an evaluation that follows the hospital experience of current patients

Practice Questions Revenue Management: (Domain IV) – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards