Question 1

DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g., BlueCross BlueShield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.

Accepted Answer

All-Patient diagnosis-related group (AP-DRG)

Question 2

adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded original DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of physiological decompensation or organ system loss of function) and risk of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, and (4) extreme.

Accepted Answer

All-Patient Refined diagnosis-related group (APR-DRG)

Question 3

maximum fee a provider may charge.

Accepted Answer

allowable charge

Question 4

payment system for ambulance services provided to Medicare beneficiaries. the balanced budget act of 1997 2002 was phased in over 5 years replacing a retrospedtive reasonable cost payment system.

Accepted Answer

ambulance fee schedule

Question 5

for OPPS, all services are paid according to ________ which group services according to similar clinical characteristics and in terms of resources required. Hospitals can be paid for more than one APC

Accepted Answer

ambulatory payment classificaton

Question 6

state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must accept assignment on Medicare claims.

Accepted Answer

ambulatory surgical center (ASC)

Question 7

predetermined amount for which ASC services are reimbursed, at 80 percent after adjustment for regional wage variations.

Accepted Answer

ambulatory surgical center payment rate

Question 8

billing beneficiaries for amounts not reimbursed by payers (not including copayments and coinsurance amounts); this practice is prohibited by Medicare regulations.

Accepted Answer

balance billing

Question 9

the types and categories of patients treated by a health care facility or provider.

Accepted Answer

case mix

Question 10

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility\'s patient accounting system, and charges are automatically posted to the patient\'s bill (UB-04).

Accepted Answer

charge description master (CDM) also called chargemaster

Question 11

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility\'s patient accounting system, and charges are automatically posted to the patient\'s bill (UB-04).

Accepted Answer

chargemaster

Question 12

process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.

Accepted Answer

chargemaster maintenance

Question 13

jointly shares the responsibility of updating and revising the chargemaster to ensure its accuracy and consists of representatives of a variety of departments, such as coding compliance financial services, health information management, information services, other departments, and physicians.

Accepted Answer

chargemaster team

Question 14

data set based on local fee schedules (for outpatient clinical diagnostic laboratory services).

Accepted Answer

clinical laboratory fee schedule

Question 15

a registered nurse licensed by the state in which services are provided, has a master\'s degree in a defined clinical area of nursing from an accredited educational institution, and is certified as a CNS by the American Nurses Credentialing Center.

Accepted Answer

clinical nurse specialist (CNS)

Question 16

communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS Internet-only program manual.

Accepted Answer

CMS program transmittal

Question 17

an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or cancelled, and new or revised manual instructions.

Accepted Answer

CMS Quarterly Provider Update (QPU)

Question 18

dollar multiplier that converts relative value units (RVUs) into payments.

Accepted Answer

conversion factor

Question 19

clinical lab DMEPOS physician fee schedule skilled nursing facility ambulance fee schedule ambulatory surgica center payment rates

Accepted Answer

cost based

Question 20

tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

Accepted Answer

data analytics

Question 21

each discahrge is catagorized into a ______ which is based on the patient\'s principal and secondary diagnosis. as well as procedures

Accepted Answer

diagnosis related group

Question 22

classifies mental health disorders and is based on ICD; published by the American Psychiatric Association.

Accepted Answer

Diagnostic and Statistical Manual (DSM)

Question 23

policy in which hospitals that treat a high percentage of low-income patients receive increased Medicare payments.

Accepted Answer

disproportionate share hospital (DSH) adjustment

Question 24

Medicare reimburses DMEPOS dealers according to either the actual charge or the amount calculated according to formulas that use average reasonable charges for items during a base period from 1986 to 1987, whichever is lower.

Accepted Answer

durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) fee schedule

Question 25

contributed to by an employer or employee pay-all plan; provides coverage to employees and dependents without regard to the enrollee\'s employment status (i.e., full-time, part-time, or retired).

Accepted Answer

employer group health plan (EGHP)

Question 26

bundles end-stage renal disease (ESRD) drugs and related laboratory tests with the composite rate payments, resulting in one reimbursement amount paid for ESRD services provided to patients; the rate is case-mix adjusted to provide a mechanism to account for differences in patients\' utilization of health care resources (e.g., patient\'s age).

Accepted Answer

End-Stage Renal Disease (ESRD) composite payment rate system

Question 27

determines appropriate group (e.g., diagnosis-related group, home health resource group, and so on) to classify a patient after data about the patient is input.

Accepted Answer

grouper software

Question 28

Five-digit alphanumeric codes that represent case-mix groups about which payment determinations are made for the HH PPS.

Accepted Answer

health insurance prospective payment system (HIPPS) code set

Question 29

data entry software used to collect OASIS assessment data for transmission to state databases.

Accepted Answer

Home Assessment Validation and Entry (HAVEN)

Question 30

classifies patients into one of 80 groups, which range in severity level according to three domains: clinical, functional, and service utilization.

Accepted Answer

home health resource group (HHRG)

Question 31

Medicare regulation which permitted billing Medicare under the physician\'s billing number for ancillary personnel services when those services were incident to a service performed by a physician.

Accepted Answer

incident to

Question 32

approved teaching hospitals receive increased Medicare payments, which are adjusted depending on the ratio of residents-to-beds (to calculate operating costs) and residents-to-average daily census (to calculate capital costs).

Accepted Answer

indirect medical education (IME) adjustment

Question 33

system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge.

Accepted Answer

inpatient prospective payment system (IPPS)

Question 34

implimentation of a per diem patient classification system that reflects differences in patient resources use and cost SCHIP balanced budget refinement act of 1999 replaced a resonable cost based system

Accepted Answer

inpatient psychiatric facility prospective payment system (IPF PPS)

Question 35

software used as the computerized data entry system by inpatient rehabilitation facilities to create a file in a standard format that can be electronically transmitted to a national database; data collected is used to assess the clinical characteristics of patients in rehabilitation hospitals and rehabilitation units in acute care hospitals, and provide agencies and facilities with a means to objectively measure and compare facility performance and quality; data also provides researchers with information to support the development of improved standards.

Accepted Answer

Inpatient Rehabilitation Validation and Entry (IRVEN)

Question 36

relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease.

Accepted Answer

intensity of resources

Question 37

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient\'s inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

Accepted Answer

IPPS 3-day payment window

Question 38

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient\'s inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

Accepted Answer

IPPS 72-hour rule

Question 39

any patient with a diagnosis from one of ten CMS-determined DRGs, who is discharged to a post acute provider, is treated as a transfer case; this means hospitals are paid a graduated per diem rate for each day of the patient\'s stay, not to exceed the prospective payment DRG rate.

Accepted Answer

IPPS transfer rule

Question 40

provided by an employer that has 100 or more employees or a multiemployer plan in which at least one employer has 100 or more full- or part-time employees.

Accepted Answer

large group health plan (LGHP)

Question 41

maximum fee a provider may charge. Non-Par doctors usually report only the _______ as their fee

Accepted Answer

limiting charge

Question 42

classifies patients according to long-term (acute) care DRGs, which are based on patients\' clinical characteristics and expected resource needs; replaced the reasonable cost-based payment system. BBRA of 1999 aurthorized implementation of per discharge DRG  for cost reporting periods begining oct. 1 2002 (2008 medicare severity long term care diagnosis related groups were adopted for LTCH PPS

Accepted Answer

long-term (acute) care hospital prospective payment system (LTCH PPS)

Question 43

organizes diagnosis-related groups (DRGs) into mutually exclusive categories, which are loosely based on body systems (e.g., nervous system).

Accepted Answer

major diagnostic category (MDC)

Question 44

payment system that reimburses providers for services and procedures by classifying services according to relative value units (RVUs); also called resource-based relative value scale (RBRVS) system. 1992 - RBRVS)

Accepted Answer

Medicare physician fee schedule (MPFS)

Question 45

situations in which the Medicare program does not have primary responsibility for paying a beneficiary\'s medical expenses.

Accepted Answer

Medicare Secondary Payer (MSP)

Question 46

adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs; bases DRG relative weights on hospital costs and greatly expanded the number of DRGs; reevaluated complications/comorbidities (CC) list to assign all ICD-10-CM codes as non-CC status (conditions that should not be treated as CCs for specific clinical conditions), CC status, or major CC status; handles diagnoses closely associated with patient mortality differently depending on whether the patient lived or expired.

Accepted Answer

Medicare severity diagnosis-related groups (MS-DRGs)

Question 47

previously called an Explanation of Medicare Benefits or EOMB; notifies Medicare beneficiaries of actions taken on claims.

Accepted Answer

Medicare Summary Notice (MSN)

Question 48

standards of measurement, such as those used to evaluate an organization\'s revenue cycle to ensure financial viability.

Accepted Answer

metrics

Question 49

has two or more years of advanced training, has passed a special exam, and often works as a primary care provider along with a physician.

Accepted Answer

nurse practitioner (NP)

Question 50

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

Accepted Answer

Outcomes and Assessment Information Set (OASIS)

Question 51

hospitals that treat unusually costly cases receive increased Medicare payments; the additional payment is designed to protect hospitals from large financial losses due to unusually expensive cases.

Accepted Answer

outlier

Question 52

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

Accepted Answer

outpatient encounter

Question 53

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

Accepted Answer

outpatient visit

Question 54

classifies patients into IRF PPS (inpatient rehabilitation facility) groups based on clinical characteristics and expected resources needs

Accepted Answer

patient assesment instrument

Question 55

reimbursement method the federal government uses to compensate providers for patient care.

Accepted Answer

payment system

Question 56

has two or more years of advanced training, has passed a special exam, works with a physician, and can do some of the same tasks as the doctor.

Accepted Answer

physician assistant (PA)

Question 57

IPPS Inpatienet psychiatric facility PPS home health  hospital inpatient long term care pps

Accepted Answer

Priced based

Question 58

rates established in advance, but based on reported health care costs (charges) from which a prospective per diem rate is determined.

Accepted Answer

prospective cost-based rates

Question 59

rates associated with a particular category of patient (e.g., inpatients) and established by the payer (e.g., Medicare) prior to the provision of health care services.

Accepted Answer

prospective price-based rates

Question 60

payment components consisting of physician work, practice expense, and malpractice expense.

Accepted Answer

relative value units (RVUs)

Question 61

data entry system used to enter MDS data about SNF patients and transmit those assessments in CMS-standard format to individual state databases.

Accepted Answer

Resident Assessment Validation and Entry (RAVEN)

Question 62

distribution of financial resources among competing groups (e.g., hospital departments, state health care organizations).

Accepted Answer

resource allocation

Question 63

uses data analytics to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources, such as appropriately expending budgeted amounts as well as conserving resources and protecting assets while providing quality patient care.

Accepted Answer

resource allocation monitoring

Question 64

payment system that reimburses physicians practices expenses based on relative values for three components of each physicians services: physician work, practice expence, and malpractice insurance expense

Accepted Answer

resource based relative value (RBRVS) system

UHI Ch 9: CMS Reimbursement Methodologies – Flashcards

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