CIC Quiz Chapter 1

In the hospital outpatient facility, all facility services must be:

Billed on a UB-04 claim form. All outpatient hospital facility services are reported on the UB-04 claim form.

Which department in a facility generates claims?

. Business office The business office is generally a separate department responsible for claim generation, processing of remittance documents, filing incomplete or rejected claim forms, payment posting, appeals, and a number of other reimbursement issues.

What is a requirement under the HIPAA privacy rule?

. Employees must be trained to understand the privacy rules. The HIPAA Privacy Rule requires: notifying patients about their privacy rights and how their information can be used; adopting and implementing privacy procedures for its practice, hospital, or plan; training employees so they understand the privacy procedures; and designating an individual to be responsible for seeing that the privacy procedures are adopted and followed.

The following are included in the facility APC reimbursement:

. Nursing personnel The facility component includes costs incurred for nursing personnel, room costs (operating, treatment, cast, etc.).

A type A emergency department includes:

24-hours per day, 7 days a week access for patient's requiring immediate, urgent, or emergent care. Type A Emergency Departments are open 24 hours per day, 7 days per week for immediate, urgent, and emergent care.

A critical access hospital is:

A facility in a rural area used for for emergency services, acute inpatient care, and may offer inpatient rehabilitation and/ or psychiatric services. Medicare beneficiaries in rural areas can receive services from critical access hospitals. CAHs offer emergency services, inpatient rehabilitation, and psychiatric services.

What is a chargemaster?

A listing of everything that can be reported if performed in the hospital. A chargemaster is a master inventory list of everything that can be reported or performed in the hospital.

An outpatient patient is defined by CMS as:

A person who has not been admitted by the hospital as an inpatient but is registered in the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH. Outpatient is defined by Centers for Medicare & Medicaid Services (CMS) as, "a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH."

An example of personal supervision is:

A physician is physically present during a colonoscopy performed by a resident Personal supervision: The physician must be in attendance in the room during the performance of the service or procedure.

What constitutes a consultation?

A qualified provider seeks advice from another qualified provider. A consultation is the advice or opinion rendered at the request of another qualified provider.

A nonpatient is defined as:

A specimen is processed, but the patient has not registered as a hospital patient Services rendered to a patient not admitted as an inpatient or outpatient at the hospital. This term typically refers to laboratory tests performed on samples sent to the hospital laboratory from an outside source to process. The account is established, but the services are rendered on the specimen rather than to a patient seen at the hospital.

Payment for surgeries in a hospital outpatient facility is based on

APC assignment. The reimbursement for outpatient hospital surgeries is based on the ambulatory payment classification (APC).

Payment for surgeries in a hospital outpatient facility is based on:

APC assignment. The reimbursement for outpatient hospital surgeries is based on the ambulatory payment classification (APC).

The department that registers patients for inpatient services is referred to as:

Admitting office Any time a patient presents for any care (eg, emergency, inpatient, outpatient, the admitting office, or other entity) the admitting office is notified to obtain information from the patient personally or through hospital personnel (eg, nursing staff, hospital unit coordinators).

Teaching facilities are:

Affiliated with a medical school Teaching hospitals are affiliated with medical schools to train physicians.

Ambulatory surgical centers include:

An independent ASC Independent ASCs offer ambulatory surgical services or same-day surgeries to patients who only require services with immediate postoperative care. When the ASC is owned by the hospital, it is generally considered to be an extension of the physical hospital and the same as any other outpatient department. In general, an independent ASC must be financially independent from the hospital, not be included on the hospital's cost reports and have a unique provider number for insurance purposes.

Additional requirements to be certified as a critical access hospital (CAH) can be found on the:

CMS website Services provided by CAHs are reimbursed based on the Standard Payment Method unless it elects to be paid under the Optional Payment Method.

Which code set is used to report procedures for outpatient facility services?

CPT® CPT and HCPCS Level II codes are utilized for the professional services performed by physicians and nonphysician practitioners and outpatient hospital services.

Which code set is used to report procedures for physician services?

CPT® CPT and HCPCS Level II codes are utilized for the professional services performed by physicians and nonphysician practitioners and outpatient hospital services.

How are codes selected for claim submission?

Coders review the medical documentation to assign codes or inpatient department personnel, such as X-ray technologists or charge specialists, select codes using the facility chargemaster. There are different methods for code selection. In some departments, the charge for the service is selected by a technician performing the test (eg, X-ray technician performing a CT scan) or it is selected by the secretary for the department by using the facility chargemaster. Admissions, surgical procedures and emergency department encounters are selected by coders.

The department that is not open 24-hours a day but provides emergent care is called:

Emergency department Type B A Type B emergency department is a facility meeting specific licensing requirements for emergent or urgent care patients not open 24 hours per day.

What is the average length of stay in long term care hospitals?

Greater than 25 days CMS defines an LTCH as "a hospital which has an average inpatient length of stay of greater than 25 days.

The department responsible for coding procedures and services in the hospital facility is:

HIM Department The health information department includes sections for coding, chart construction or organization, transcriptions (some hospitals and facilities contract with transcription companies), release of information, birth and death certification, scanning or filing to input information into charts, and other sections required to maintain a consistent flow of patient information throughout the hospital or facility.

The department responsible for coding procedures and services in the hospital facility is:The department responsible for coding procedures and services in the hospital facility is:

HIM department The health information department includes sections for coding, chart construction or organization, transcriptions (some hospitals and facilities contract with transcription companies), release of information, birth and death certification, scanning or filing to input information into charts, and other sections required to maintain a consistent flow of patient information throughout the hospital or facility.

Which code set is used to report procedures for inpatient facility services?

ICD-10-PCS Rationale: ICD-10-PCS are procedure codes that are currently used for inpatient surgical procedures. ICD-10-CM are the code set to report diagnosis coding.

Under General Supervision, the physician must be:

Immediately available. General supervision: the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician is not required to be present in the room where the procedure is performed or within any other physical boundary as long as he or she is immediately available.

Where are critical access hospitals located?

In rural areas To be certified by Medicare as a CAH, a facility must (among other requirements): be located in a rural area or is treated as rural; and be located more than a 35-mile drive from a hospital or another healthcare facility; and be certified by the state as being a necessary provider of healthcare services to residents in the area.

MS-DRG payments are made by Medicare for:

Inpatient hospital stays Medicare Part A payments are made for inpatient hospital stays through Medicare's Inpatient Prospective Payment System (IPPS), utilizing the Medicare Severity Diagnosis Related Group Methodology (MS-DRG). MS-DRG is a classification system that groups similar clinical conditions or diagnoses, and the procedures furnished by the hospital during the patient's stay.

Which of the following providers are in their first year of residency?

Intern Rationale: Interns are usually in their first year following graduation from medical school and are completing a one-year rotation in various specialty departments of the teaching facility.

How is payment determined for acute care facilities?

MS-DRGs Medicare Part A payments are made for inpatient hospital stays through Medicare'sInpatient Prospective Payment System, utilizing the Medicare Severity Diagnosis Related Group Methodology (MS-DRG).

The Privacy Rule under HIPAA is managed by:

Medical Records The Privacy Rule under HIPAA is managed in the medical records department. The department must protect individuals' health information. It must also process requests for copies of patient medical records and ensure the disclosures follow the mandates of the HIPAA Privacy Rule.

Services provided by residents in the graduate medical education program are reimbursed by:

Medicare Part A Teaching settings receive direct Medicare graduate medical education (GME)program payments for residents' services. The direct payments include resident salaries, fringe benefits, and teaching physician compensation for services not payable on a fee schedule. These payments are made on a per-resident basis and are hospital-specific. Medicare Part A payments are made for inpatient hospital stays through a prospective payment system, better known as Medicare Severity Diagnosis Related Group (MS-DRG) payments.

MS-DRG payments are made by Medicare for:

Medicare Part A payments are made for inpatient hospital stays through Medicare's Inpatient Prospective Payment System (IPPS), utilizing the Medicare Severity Diagnosis Related Group Methodology (MS-DRG). MS-DRG is a classification system that groups similar clinical conditions or diagnoses, and the procedures furnished by the hospital during the patient's stay.

Outpatient Services are covered under:

Medicare Part B Outpatient services are covered under Medicare Part B, and include the rental or purchase of DME prescribed by a doctor for use in the home; devices, other than dental, to replace all or part of an internal body organ; certain ambulance services; laboratory services; X-ray and other radiology services; ER and outpatient clinic services; medical supplies, splints, and casts; other diagnostic services; physical, occupational therapies, and speech pathology services; dialysis in the facility or home and outpatient surgery.

CAHs have:

No more than 25 inpatient beds used for either inpatients or swing bed services CAHs can have no more than 25 inpatient beds used for either inpatient or swing bed services.

Which of the following services is included in inpatient hospital services?

Nursing services and other related services Inpatient hospital services do not include the following types of services: posthospital SNF care furnished by a hospital or a critical access hospital that has a swing bed approval.; nursing facility services that may be furnished as a Medicaid service under title XIX of the Act in a swing bed hospital that has an approval to furnish nursing facility services; physician services for payment on a fee schedule basis; physician assistant services defined in 1861(Ii) of the Act; nurse practitioner and clinical nurse specialist services; certified nurse mid-wife services; qualified psychologist services; services of an anesthetist.

All of the following are examples of facilities that may provide outpatient services except:

OPPS OPPS stands for outpatient prospective payment system. This is a payment system and not a type of facility.OPPS stands for outpatient prospective payment system. This is a payment system and not a type of facility.

The admitting office is responsible for:

Obtaining demographic information, insurance information, recording the patient's type of service, establishing an account, and obtaining consent for treatment Rationale: Insurance information, demographics, and the type of services the patient requires are recorded. The patient's insurance card is generally copied for verification purposes. An account is established through a computerized system that transfers patient information for hospital-wide availability during patient care. The admitting office is also responsible for obtaining consent for treatment or surgical services from the patient as well as other pertinent information required for patient management. Answer B is incorrect because referral information is usually gathered in a physician's office to refer a patient to another physician. Answer C is incorrect because the admitting department does not record the outcomes of treatment.

When a patient has multiple procedures, such as an X-ray, diagnostic testing, and a stress test, performed in a single visit, how are the charges billed for the outpatient hospital facility?

One claim is generated for each date of service and reported on a UB-04 form Although the patient may present at different departments for services in the hospital, one claim is generated for each date of service. All of the departments report the services performed and all charges are consolidated on one claim (UB-04) for the date of service.

What is needed from the physician for a facility to perform a diagnostic test?

Order The facility must have an order from the physician to perform a diagnostic test. The order needs to include the test to be performed and the reason for the tests (diagnosis).

Which of the following payment classification categories is used for skilled nursing facilities' payment?

PDPM Medicare Part A payments are made for inpatient hospital stays through Medicare's Skilled Nursing Facility Prospective Payment System, utilizing the Resource Utilization Groups (RUGs) payment classification.

The business office in the outpatient facility is commonly referred to as:

Patient Financial Services The business office is commonly referred to as patient financial services.

Which level of supervision requires the physician's physical presence in the room while the services are rendered?

Personal supervision Personal supervision: the physician must be in attendance in the room during the performance of the service or procedure.

Which of the following services can be performed in a CORF?

Physical therapy Covered services for a CORF include provider services related to administration, physical therapy, occupational therapy, speech therapy, respiratory therapy, social and psychological services, prosthetic or orthopedic devices, supplies, and drugs and biological that cannot be self-administered.

Which of the following medical professionals is considered a non-physician practitioner?

Physician Assistant Non-physician practitioners (NPP) include physician assistants (PA), nurse practitioners (NP), certified registered nurse anesthetists (CRNA), clinical nurse specialists (CNS), certified nurse-midwives, clinical psychologists, and licensed clinical social workers (LCSW).

Which of the following is NOT considered an inpatient service by CMS:

Physician assistant services. Inpatient hospital services do not include the following types of services: posthospital SNF care furnished by a hospital or a critical access hospital that has a swing-bed approval; nursing facility services that may be furnished as a Medicaid service under title XIX of the Act in a swingbed hospital that has an approval to furnish nursing facility services; physician services for payment on a fee schedule basis; physician assistant services ; nurse practitioner and clinical nurse specialist services; certified nurse mid-wife services; qualified psychologist services; services of an anesthetist.

Teaching physicians oversee:

Residents providing patient care Teaching physicians oversee residents providing patient care. Teaching settings receive direct Medicare GME payments for residents' services.

For an inpatient admission to be considered medically necessary, the admission requires a physician order and generally which of the following?

Services requiring a length of stay of "two midnights" Rationale: For Medicare patients, the inpatient hospital admission is generally considered appropriate when the patient is expected to need two or more midnights of medically necessary hospital care. A patient who has a procedure on the inpatient only list will be admitted as an inpatient. However, such a procedure is not required for the stay to be considered an inpatient.

A hospital Type A emergency department must provide:

Services that are hospital-based and open 24-hours a day 7 days a week for patients who need immediate attention and emergent or urgent care Type A emergency departments meet the traditional definition of an emergency department as they are hospital based, open 24-hours per day, 7 days per week, for immediate, urgent, and emergent care.

Which services are covered under Medicare Part A?

Skilled nursing facilities Medicare Part A covers inpatient hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Physician services are covered under Medicare Part B.

Which payment methodology applies to critical access hospitals?

Standard payment method Services provided by CAHs are reimbursed based on the Standard Payment Method unless it elects to be paid under the Optional Payment Method.

Which of the following statement is true regarding an ED encounter?

Two claims are generated: one for the facility and one for the physician. When providers perform procedures in the outpatient facility, two bills (claims) are generated. One claim is for the physician services, which are submitted on a CMS-1500 claim form. The other is for the facility services, which are submitted on a UB-04 claim form. This includes emergency department services.

Which of the following statements is true regarding an inpatient stay?

Two types of claims are generated: one for the facility and one for the physician. Rationale: When providers perform procedures in the inpatient facility, two bills (claims) are generated. One claim is for the facility services which are submitted on a UB-04 or CMS 1450 paper claim form, or electronically using the 837I (institutional) claim form. While the other claim is for the physician services which are submitted on a CMS-1500 paper claim form, or electronically using the 837P (professional) claim form.

Which claim form is used to submit hospital facility charges?

UB-04 Rationale: When providers perform procedures in the outpatient facility, two bills (claims) are generated. One claim is for the facility services which are submitted on a UB-04 or CMS 1450 paper claim form, or electronically using the 837I (institutional) claim form. While the other claim is for the physician services which are submitted on a CMS-1500 paper claim form, or electronically using the 837P (professional) claim form.

When does the reimbursement process begin?

When a patient presents to a facility or outpatient hospital department. The reimbursement process begins when a patient presents to a facility or outpatient hospital department.

A list of surgeries that can be performed in an ASC is released:

Yearly by CMS in the Outpatient Prospective Payment System (OPPS) Final Rule Medicare publishes a list of approved procedures in the ASC and a list of nonapproved (out of scope) procedures considered higher risk, which might require a hospital stay. This list is updated yearly in the OPPS Final Rule for ASCs.