HIM2350C FINAL EXAM

HCPCS, CPT level I

Physician work (WORK), physician practice expenses (PE), and malpractice (MP)RVU=Relative Value Units: Physician Work + Practice Expense +Malpractice Costs

An adjustment component, geographic practice cost index (GPCI), reflects local costs, and the WORK, PE, and MP elements of the RVU have their own GPCIs. Both the RVUs and GPCIs are included in the payment calculation

The conversion factor (CF) is the control (constant) CMS raises or lowers annually to adjust physician payments. The sum of RVUs and GPCIs are multiplied times the conversion factor to arrive at the national allowance, 80 percent of which is the actual reimbursement payment (once the Part B deductible is met).

Levels are dependent on the complexity of service performed (basic versus specialty care), the EMT's level of training required to perform the service, and the type of transport involved (land vehicle versus helicopter).

FALSE - no mileage billable

The rule establishes that the median cost of the most expensive procedure or service in the APC cannot be more than two times greater than the median cost of the least expensive procedure or service in the same group.

TRUE

FALSE

A well-defined set of specific clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment, and are utilized before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Wage index adjustment Permanent hold harmless add-on payment Rural sole community hospital add-on payment

Medicare moved to a PPS for hospital inpatient services to help control increasing healthcare costs and Medicare expenditures; August 1, 2000; They are paid via APC (Ambulatory Payment Classifications (APCs)) - Hospital outpatient prospective payment system. The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group); Changed the Mammography payment from HOPPS to a fee schedule-based payments.; Not for physicians but for facilities

Payment methodology is modified for certain device-intensive procedures

Section 153(b) of Pub. L. 110-275, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA

wage index adjustment, low-volume adjustment

Consolidated Health Care Act of 1996

FALSE, FQHC requires a sliding scale - RHC does not

Tax Equity and Fiscal Responsibility Act of 1982 (FEFRA)

FALSE

Consolidated billing include: Therapist, Lab test, X-ray, and pharmacy/medicines Consolidated billing exclude: Emergency services, inpatient care, extended services, and radiation therapy

Per diem rates for SNF PPS patients are determined for various cases by using the RUG classification system. This system uses the nursing component, therapy component, and noncase-mix-adjusted component to drive the rates.

25 or more days

MS-LTC-DRGs are determined by the principal diagnosis, up to eight additional diagnoses, up to six procedures, sex, and discharge status.

functional status, assessment table

False

TRUE

Home assistance validation and entry (HAVEN).

DME is excluded from the per-episode HHPPS reimbursement system and is reimbursed under the DME fee schedule.

The home health HIPPS code is called an "intelligent" code because each number or letter in the code provides information depending on its position. The first position is the payment grouping step for episode (numeric). The second, third, and fourth positions are clinical, functional, and service dimensions (alphabetic). The fifth position is severity of nonroutine medical supplies (alphanumeric).

The provider order entry system that is usually more reliable is electronic because the charge for the service or supply is entered at the point of service and automatically transferred to the patient account and posted to the patient claim. The paper system leaves more room for error

One source of new codes is the CMS release of updates to codes and billing guidance; the other is performance of new services at the healthcare provider that require line items to be added to the system

compliance violations and lost reimbursements, Overpayment Underpayment ,undercharging for services

Administrative Simplification, Developement and implementation of standardized health-related financial and administrative activities electronically and implementation of privace and security procedures to prevent the misuse of health information by ensuring confidentiality

1.to make sure the EOBs and the MSNs are provided to the facility. 2. is that the EDI reports claim rejections, denials, and payments to the facility

The ways that discrepancies between submitted charges and paid charges can be reconciled is by the provider contacting the patient to collect the outstanding deductible or copayment. In addition the facility needs to determine whether the claim can be corrected and resubmitted, if it cannot the facility has to write it off or make an adjustment on the patients account.When batches of EOBs, MSNs, and RAs are received via the 835A or 835B electronic format, accounting personnel check the amount owed by the patient (listed as not covered on the EOB or MSN), and collections personnel contact the patient to collect deductibles, copayments, and charges remaining. Accounting personnel also check RAs for denied claims to determine whether corrected claims should be submitted to the insurer. When they cannot receive further payment from insurers or insureds, billing personnel write off the patients' accounts and the revenue cycle ends.

Providers define optimal performance for units of the facility by establishing key performance indicators (KPI) which represent the areas that need to be improved. And by setting a standard for each indicator which can be measured to gauge performance improvement.

Some key performance indicators a provider's RCM team could use to learn the reasons for the surge in unpaid balances could be the days from discharge to coded, the percentage of denials from the third party payers, percentage of late charges, percentage of returned claims for corrections.

sources of errors that can cause claim denials are invalid procedure, invalid revenue code, the code is not recognized or service unit out of range for procedure and data entry mistakes

FALSE

Reimbursement (incentives, rewards) Performance Quality

-Wide-spread movement toward quality and safety -Pay for performance (P4P) and value-based purchasing (VBP) emerge as way to align payment incentives and quality - These systems were created for the health care system as an incentive linked to payment, performance and quality.

Attribution is the determination of who rendered care so that the care's outcomes can be linked to its provider and that provider receives the reward or penalty. Other terms for attribution are enrollee assignment or beneficiary assignment.

FALSE

FALSE

Australia, Canada, Great Britain

TRUE

Deficit Reduction Act of 2005

CMS allows a facility to maintain the full payment for services when it successfully participates in a quality-measure reporting program. CMS wants to promote efficiency in resource use while providing high-quality care, established hospital-acquired conditions provision in the acute care delivery

Beginning in FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs.