Ch. 6 – Assignment Writing – Flashcards
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To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the
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relative weight for the MS-DRG.
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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.
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hold harmless
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Under APCs, payment status indicator "T" means
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ancillary services
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Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT
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changes in coding productivity
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________ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist.
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Fraud
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How many major diagnostic categories are there in the MS-DRG system?
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25
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Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group.
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150%
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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
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U = Documentation is insufficient to determine if condition was present at the time of admission.
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This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).
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inpatient rehabilitation facilities
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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)
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cancer hospital
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All of the following items are "packaged" under the Medicare outpatient prospective payment system, EXCEPT for
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medical visits
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Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true?
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Each facility is accountable for developing and implementing its own methodology.
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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.
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six
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All of the following statements are true of MS-DRGs, EXCEPT
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a patient claim may have multiple MS-DRGs.
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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.
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Medicare Physician Fee Schedule (MPFS)
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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?
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$45.60
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What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care?
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home health resource groups
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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
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scrubbers
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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
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Y = Present at the time of inpatient admission.
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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
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physician services.
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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
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each service is paid based on the actual charges
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Under APCs, payment status indicator "C" means
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inpatient procedures/services
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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
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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.
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The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.
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clinical lab services
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Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are
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physician work, practice expense, and malpractice insurance expense
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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.
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episode-of-care (EOC)
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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.
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CPT Code 99291 (critical care)
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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
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will not receive additional payment for these conditions when they are not present on admission.
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Accounts Receivable (A/R) refers to
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cases that have not yet been paid.
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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
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absorbs the loss.
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The term "hard coding" refers to
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HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.
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Under the APC methodology, discounted payments occur when
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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.
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Under APCs, payment status indicator "V" means
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clinic or emergency department visit (medical visits).
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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.
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the OIG's Workplan
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The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called
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APCs.
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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.
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$66.50.
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Under APCs, payment status indicator "S" means
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significant procedure, multiple procedure reduction does not apply.
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Under APCs, the payment status indicator "N" means that the payment
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is for ancillary services.
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The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called
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Resource Utilization Groups (RUGs).
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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
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October 1st through September 30 of the next year
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The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement.
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ICD-9-CM codes
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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.
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retrospective, prospective
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________ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.
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Never events
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The present on admission (POA) indicator is required to be assigned to the ________ diagnosis(es) for ________ claims on ________ admissions.
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principal and secondary, Medicare, inpatient
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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
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DNFB (discharged, no final bill)
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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
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$200.00.
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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
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$40.00.
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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?
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$250.00
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A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by
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home health agencies (HHA) and inpatient rehabilitation facilities (IRF)
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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
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15%
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When payments can be made to the provider by EFT, this means that the reimbursement is
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sent to the provider by check.
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The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that the patient was not admitted with, but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as
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present on admission
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To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the
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relative weight for the MS-DRG.
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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.
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National Provider Identifier (NPI)
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CMS assigns one ________ to each APC and each ________ code.
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payment status indicator, HCPCS
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This is the amount collected by the facility for the services it bills
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reimbursement
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In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the
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geographic practice cost indices.
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When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called
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abuse.
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This accounting method attributes a dollar figure to every input required to provide a service.
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cost accounting
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CMS adjusts the Medicare Severity DRGs and the reimbursement rates every
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fiscal year beginning October 1
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Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient?
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RBRVS
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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.
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LCD (Local Coverage Determinations)
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Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT
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lifetime reserve days are paid under Medicare Part B.
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Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services?
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The provider cannot bill the patients for the balance between the MPFS amount and the total charges
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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
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local coverage determinations and national coverage determinations.
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A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. 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
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financially liable for charges in excess of the Medicare fee schedule, up to a limit
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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 receive is
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$218.50
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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. DNFB is an acronym for ________.
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discharged not final billed
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When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a
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Corporate Integrity Agreement
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The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from
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OASIS (Outcome and Assessment Information Set)
