Week 7: Domain 2 Reimbursement Quiz

Assume the patient has already met their deductible and that the physician is a Medicare participating (PAR) provider. The physician's standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00. How much reimbursement will the physician receive from Medicare? $ 48.00 $120.00 $ 96.00 $ 60.00

$ 48.00 The provider is a PAR and therefore limited to charge $60.00. Medicare's policy is an 80/20 coinsurance plan. Therefore, Medicare will reimburse the provider $48.00 (60 x 0.80), and the patient will need to pay the other 20% ($12.00).

Use the following case scenario to answer the question. 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 non-PAR 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 amount the physician will receive is $250.00. $200.00. $218.50. $190.00.

$218.50. If a physician is a nonparticipating physician who does not accept assignment, he can collect a maximum of 15% (the limiting charge) over the non-PAR Medicare Fee Schedule amount. In this case, the non-PAR Medicare Fee Schedule amount is $190.00 and 15% over this amount is $28.50; therefore, the total that he can collect is $218.50.

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 non-PAR 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 amount of the patient's financial liability (out-of-pocket expense) is $190.00. $38.00. $152.00. $66.50.

$66.50. Limiting charge is the maximum charge that a non-PAR can charge a Medicare beneficiary (115% of the reduced MPFS). MPFS amount is $200. As a non-PAR, this physician is entitled to: $200 minus 5% ($10) = $190.00. Multiply this by the limiting charge = 190 x 1.15% = $218.50. Medicare will pay 80% of the $190.00 = $152.00. In this case, balance billing is permitted, so the patient must pay the rest: $218.50 minus $152.00 = $66.50.

The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the non-PAR fee schedule amount. The limiting charge is 50%. 20%. 15%. 10%.

15%. Limiting charge is the maximum charge that a non-PAR can charge a Medicare beneficiary (15%).

Under ASC PPSs, bilateral procedures are reimbursed at _______ of the payment rate for their group. 200% 50% 150% 100%

150% The correct answer is 150%: 100% for the first side + 50% for the second side.

Terminally ill patients with life expectancies of ______ may opt to receive hospice services. 6 months to a year 1 year or more 1 year or less 6 months or less

6 months or less Hospice services are covered for those determined to have 6 months or less life expectancies.

The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the National Library of Medicine. World Health Organization. Agency for Healthcare Research and Quality. Centers for Medicare and Medicaid Services.

Agency for Healthcare Research and Quality. A major initiative for the Agency for Healthcare Research and Quality (AHRQ) has been the Healthcare Cost and Utilization Project (HCUP). HCUP uses data collected at the state level from either claims data from the UB-04 or discharge-abstracted data, including UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers.

The outpatient method for reimbursement from CMS for Medicare is Usual, Customary, Reasonable (UCR). Ambulatory Patient Classification (APC). Resource-Based Relative Value Scale (RBRVS). Diagnosis-related Groups (DRGs).

Ambulatory Patient Classification (APC). APCs or Ambulatory Payment Classifications are the government's method of paying facilities for outpatient services for the Medicare program.

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 Fraud Prevention Memorandum of Understanding. Corporate Integrity Agreement. Recovery Audit Contract. Noncompliance Agreement.

Corporate Integrity Agreement. Corporate Integrity Agreement is a contract between the federal government and health care providers as part of a settlement of federal health care program regulations. This is the correct answer. Incorrect answers: Fraud Prevention Memorandum of Understanding is used by the Immigrant and Employee Right section of the Department of Justice. Noncompliance Agreement—health care providers and payers should never agree to break the law. Recovery Audit Contract is an agreement between CMS and a company to audit claims paid to search for overpayment and underpayments.

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 periodic interim payments. DNFB (discharged, not final billed). chargemaster. remittance advice.

DNFB (discharged, not final billed). Discharged, not final billed (DNFB) is a list of funds that have been earned because the patient has been discharged; however, the final claim form has not yet been generated or submitted. This is the correct answer. Incorrect answers: Chargemaster is a database of all procedures, services, and treatments provided in this facility, along with the amount to be charged for that item. Periodic interim payments is when a patient is in the hospital for a very long time, the facility is permitted to file an interim claim for services provided to date, even though the patient has not been discharged yet. Remittance advice is a statement from a third-party payer, itemizing the reimbursement amount.

______ classifies inpatient hospital cases into groups that are expected to consume similar hospital resources. IPPS DRG CMS MAC

DRG DRG stands for Diagnosis-Related Group, an episode of care methodology for reimbursement based on the standard of care for inpatients by principal and secondary diagnosis codes. This is the correct answer. Incorrect answers: CMS stands for Centers for Medicare and Medicaid Services, an agency of the federal government. IPPS stands for Inpatient Prospective Payment Services, which determine reimbursement allowed amounts for procedures, services, and treatments provided. MAC stands for Medicare Administrative Contractor, which processes claims and provides program integrity tasks for providers under Part A and B, as well as DMEPOS.

This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes are listed in the memoranda. OSHA (Occupational Safety and Health Administration) SI/IS (Severity of Illness/Intensity of Service Criteria) PEPP (Payment Error Prevention Program) LCD (Local Coverage Determinations)

LCD (Local Coverage Determinations) Local Coverage Determination (LCD) is the official statement of diagnoses (ICD-10-CM) and procedures (CPT and ICD-10-PCS) that is covered by a specific Medicare policy. This is the correct answer. Incorrect answers: Occupational Safety and Health Administration (OSHA) is the federal agency responsible for overseeing workplace safety. Payment Error Prevention Program (PEPP) is designed to achieve measurable improvements in processes and outcomes of payment errors by the federal government. Severity of Illness/Intensity of Service Criteria (SI/IS) is used to determine the validity of a hospital admission.

Which of the following is a federal program, state administered that provides health care coverage to low-income populations and certain aged and disabled individuals? Medicaid Medicare Part B Medicare Part A TRICARE

Medicaid Medicaid is a federal program managed by each state to financially support health care services to low-income individuals. This is the correct answer. Incorrect answers: Medicare Part A is a federal program managed by each state to financially support inpatient health care services for those who are 65 years old and older, as well as those with permanent disabilities. Medicare Part B is a federal program managed by each state to financially support outpatient health care services for those who are 65 years old and older, as well as those with permanent disabilities. TRICARE is a federal program that financially supports health care services for those who are in the armed services and their families.

The ________________________ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider. remittance advice Medicare Summary Notice Advance Beneficiary Notice coordination of benefits

Medicare Summary Notice Medicare Summary Notice is CMS's version of an Explanation of Benefits (EOB). This is the correct answer. Incorrect answers: Advance Beneficiary Notice is required by Medicare to be provided to the patient prior to the procedure or service to acknowledge the patient's responsibility for payment because it is expected that Medicare will not cover the cost. Coordination of benefits is a customer service representative who helps patients get the most from their coverage. Remittance advice is a statement from a third-party payer itemizing the reimbursement amount.

The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from the UACDS (Uniform Ambulatory Core Data Set). OASIS (Outcome and Assessment Information Set). MDS (Minimum Data Set). UHDDS (Uniform Hospital Discharge Data Set).

OASIS (Outcome and Assessment Information Set). Outcome and Assessment Information Set (OASIS) is a database containing key components for the assessment for an adult home care patient. OASIS forms the basis for measuring patient outcomes and determines agency reimbursement. This is the correct answer. Incorrect answers: Minimum Data Set (MDS) is a clinical assessment of all residents in Medicare and Medicaid-certified nursing homes, mandated by the federal government. Uniform Ambulatory Core Data Set (UACDS) involves evaluations of the provisions of ambulatory care, including the reasons for the encounter, patient's living arrangements, and marital status. The UACDS is recommended, not mandatory. Uniform Hospital Discharge Data Set (UHDDS) is a data set containing minimum descriptions of a hospital episode or admission, recommended upon discharge for all hospital stays reimbursed under Medicare and Medicaid.

This initiative was instituted by the government to eliminate fraud and abuse and recover overpayments, and involves the use of ______________. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government. Clinical Data Abstraction Centers (CDAC) Medicare Code Editors (MCE) Quality Improvement Organizations (QIO) Recovery Audit Contractors (RAC)

Recovery Audit Contractors (RAC) Recovery Audit Contractors (RAC) are companies hired by CMS to audit claims submitted to look for overpayments and underpayments. This is the correct answer. Incorrect answers: Clinical Data Abstraction Centers (CDAC) is responsible for validating quality data submitted by health care facilities to comply with the Hospital Quality Alliance. Medicare Code Editors (MCE) is a software that is programmed to detect and report coding errors in inpatient (hospital) claims submitted to Medicare. Quality Improvement Organizations (QIO) is a group of experts in health care quality, along with clinicians and consumers who focus on ways to improve the quality of health care delivered to Medicare beneficiaries.

The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called Resource Utilization Groups (RUGs). Resource Based Relative Value System (RBRVS). Ambulatory Patient Classifications (APCs). Medicare Severity Diagnosis Related Groups (MS-DRGs).

Resource Utilization Groups (RUGs). Resource Based Relative Value System [RBRVS] is a formula used to determine reimbursement for Medicare providers. MS-DRGs are used to determine reimbursement to hospitals for services provided to Medicare beneficiaries. APCs are used to determine reimbursement to outpatient facilities.

The medical coder's query stated, "Dr. Jones, I noticed that the patient has had elevated blood pressure during his last three visits. Shouldn't he be diagnosed with hypertension and prescribed medication?" What do you observe about this query? The query should state the specific medication. The query should suggest specific diagnoses since the patient had elevated blood pressure for the last 3 visits. The coder correctly suggests the physician prescribe a medication in the query. The query is leading Dr. Jones and is insulting to the physician.

The query is leading Dr. Jones and is insulting to the physician. A legal query should never lead the physician to a conclusion, nor should it ever include, a suggested diagnosis or treatment. This question is leading Dr. Jones to a conclusion through specifically asking if the patient should be diagnosed with hypertension and prescribed medication.

The query asked, "Do you agree that the edema in the patient's legs were caused by his previous diagnosis of malnutrition?" A legal version of this question would be: Please add to the documentation the connection between the edema and the patient's nutrition. Did the malnutrition cause the patient's edema? Lower extremity bilateral edema is usually caused by malnutrition. Do you agree? What is the cause of the patient's edema?

What is the cause of the patient's edema? "What is the cause of the patient's edema?" is a legal version of the prior question because it is open-ended and does not make any suggestions about the diagnosis. Queries must not lead the physician to a conclusion. The other answer choices are all improper because they make suggestions about the diagnosis. The question "Lower extremity bilateral edema is usually caused by malnutrition. Do you agree?" is specifically worded so that the physician need only answer yes or no, which indicates that the question is leading.

A 47-year-old female came for an initial appointment with a neurologist. She was diagnosed with relapsing-remitting multiple sclerosis (RRMS) two years ago. She states that she was initially diagnosed after experiencing acute blurred vision and pain in her left eye, urinary incontinence, and numbness in her arms and legs on several occasions. Her primary care physician ordered a magnetic resonance imaging (MRI) which revealed several demyelinating lesions in the right frontal cerebral white matter as well as her cervical spinal cord. She expressed that, over the last year, she has had acute attacks which were treated with corticosteroids by her primary care physician. At this time, I am prescribing interferon (IFN)β-1a (30 mcg weekly by IM injection) as a long-term disease-modifying therapy. Based on this, I suspect progressive multifocal leukoencephalopathy (PML), and want to perform a lumbar puncture to analyze her cerebrospinal fluid using a quantitative polymerase chain reaction (PCR) assay. A query sent to the neurologist asked if the PML was a new diagnosis, a differential diagnosis, or a replacement diagnosis. Was this a legal query? Yes, because the question enables coding at a

Yes, because there is no influence presented. This is a legal query because there is no influence presented. Legal queries may not have any influence or hint toward an answer. While this means that a query should be open-ended, presenting multiple choices of answers is also acceptable. The question "Is the PML a new diagnosis, a differential diagnosis, or a replacement diagnosis?" does not promote up-coding and coders are required, by law, to query physicians when there is missing, contradictory, or ambiguous documentation.

A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) CMS-1500 claim form. advance beneficiary notice. explanation of benefits. remittance advice.

advance beneficiary notice. An Advance Beneficiary Notice (ABN) is a written notice (CMS-R-131) a patient receives from a provider before receiving a service or item when the provider expects Medicare will deny payment for that service or item. The ABN notifies the patient that payment will likely be denied by Medicare and that the patient will be responsible for payment if Medicare denies payment.

Which of the following could influence a facility's case mix? changes in DRG weights accuracy of coding all answers apply changes in the services offered by a facility

all answers apply Changes in services offered by a facility, changes in DRG weights, and/or the accuracy of coding could influence a facility's case mix.

Under APCs, payment status indicator "X" means significant procedure, not discounted when multiple. ancillary services. significant procedure, multiple procedure reduction applies. clinic or emergency department visit (medical visits).

ancillary services. APC status indicator "X" states ancillary services. Clinic or emergency department visit = PSI VSignificant procedure, not discounted when multiple = PSI SSignificant procedure, multiple procedure reduction applies = PSI T

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). psychiatric hospital long-term care hospital rehabilitation hospital cancer hospital

cancer hospital Cancer hospitals are eligible to receive a waiver from CMS and to be excluded from the IPPS. This is the correct answer. Incorrect answers: Long-term care hospital is reimbursed under the Long-Term Care Hospital Prospective Payment System (LTCH PPS). Psychiatric hospital is a residential behavioral health facility that would be reimbursed under IPPS. Rehabilitation hospital is reimbursed under the Inpatient Rehabilitation Prospective Payment System.

Regardless of how much is charged, this is the maximum amount the third-party will pay. costs contractual allowance reimbursement customary

contractual allowance Contractual allowance, also known as the allowed amount, is the maximum a third-party payer will reimburse for a service, procedure, or treatment. This is the correct answer. Incorrect answers: Costs is what the facility pays, out-of-pocket, for a product. Customary is the amount charged for a procedure by other, equally qualified providers in the same geographic area. Reimbursement is the payment for services already provided.

If a claim is returned as denied or rejected due to an error, the best thing to do is write the loss off as unrecoverable. resubmit the same claim form, with no changes, to hope for a different outcome. correct the claim and resubmit in accordance with the third-party payer. send a bill to the patient.

correct the claim and resubmit in accordance with the third-party payer. When errors are found on a denied or rejected claim, the errors should be corrected and the claim resubmitted, and marked as a Corrected Claim. Marking the new claim this way will prevent any suspicions of duplicate billing.

This accounting method attributes a dollar figure to every input required to provide a service. reimbursement cost accounting charge accounting contractual allowance

cost accounting Cost accounting is the method of calculations of products based on out-of-pocket expenses. This is the correct answer. Incorrect answers: Charge accounting is the master set of books organized by the amount billed. Contractual allowance is an amount, agreed upon between facility and third-party payer, for a specific procedure or service. Reimbursement is the payment for services already provided.

When payments can be made to the provider by EFT, this means that the reimbursement is combined with all other payments from the third-party payer. directly deposited into the provider's bank account. sent to the patient, who then pays the provider. sent to the provider by check.

directly deposited into the provider's bank account. EFT stands for Electronic Funds Transfer—a process of moving money from one person or organization to another by wire, from one's bank to another's bank. Also known as direct deposit.

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 therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services. diagnostic and therapeutic services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services. diagnostic services. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) does not match the code used for preadmission services.

diagnostic and therapeutic services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services. The 72-hour rule covers any preadmission diagnostic and therapeutic services provided by a hospital within 3 days prior to the admission will be covered by the inpatient PPS, under the condition that the principal diagnosis code is the same for the preadmission and inpatient services.

The question or questions in a query must be written to be: either open-ended or multiple choice. close-ended. open-ended. multiple-choice.

either open-ended or multiple choice. The legal guidelines state that the question can be either open-ended or multiple choice but cannot be closed-ended or leading in any way.

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 over a specific period of time for a particular reason. bundled episode of care (EOC) fee-for-service capitation

episode of care (EOC) Episode of care (EOC) reimbursement is based on the standard-of-care's treatment plan as per the diagnosis. This is the correct answer. Incorrect answers: Bundled is creating a group of procedures or services that are commonly provided together into one reportable event. Capitation is the amount paid to a primary care provider, monthly, for each patient assigned to that provider. Fee-for-service reimbursement is based on each procedure, service, or treatment provided during an encounter.

A Medicare patient was seen by Dr. Zamora, 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. Zamora does not accept assignment. The office manager will apply a practice termed as "balance billing," which means that the patient is financially liable for charges in excess of the Medicare Fee Schedule, up to a limit. financially liable for the Medicare Fee Schedule amount. not financially liable for any amount. financially liable for only the deductible.

financially liable for charges in excess of the Medicare Fee Schedule, up to a limit. Participating Providers (PAR) must accept assignment, to be reimbursed according the Medicare Physician Fee Schedule (MPFS). Not Participating Providers (non-PAR) can accept assignment; however, this physician does not accept assignment. Therefore, Dr. Zamora cannot charge more than the "limiting charge" (115% of the reduced MPFS - 5% lower than PAR). Therefore, the correct answer is the patient is "financially liable for charges in excess of the Medicare Fee Schedule, up to a limit" (the limiting charge).

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the cost of living index for the particular region. geographic practice cost indices. usual and customary fees for the service. national conversion factor.

geographic practice cost indices. Once the relative value units (RVU) are determined for a specific procedure codes, for each location, the total is adjusted by multiplying it by the geographic practice cost indices. The national conversion factor translates the total number of RVUs, after the geographic adjustment, into U.S. dollars.

The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis. This is called grouping. mapping. soft coding. hard coding.

hard coding. The charge master, or charge description master (CDM), is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. It helps to make the process of charge capture and billing smoother. The main purpose is to try to capture the costs of the hospital for performing these services.

When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n) per diem. qualified discharge. transfer. interrupted stay.

interrupted stay. Interrupted stay is the term used to describe a patient who was discharged from an inpatient rehabilitation facility and then readmitted within 72 hours later (prior to midnight on the third day. This is the correct answer. Incorrect answers: Per diem—for each day Qualified discharge—a patient who has met the criteria to be released from the facility Transfer—when a patient is discharged from one facility to be directly admitted into another facility

Under APCs, the payment status indicator "N" means that the payment is packaged into the payment for other services. is for ancillary services. is discounted at 50%. is for a clinic or an emergency visit.

is packaged into the payment for other services. In the front of your HCPCS Level II book, you can find a list of the OPPS Status Indicators. Status indicator N states "items and services packaged into APC rates." Incorrect answers: Ancillary services are not reported with a specific status indicator. A clinic or emergency visit would be reported with a Place of Service (POS) code. A 50% discount would not be reported with an APC indicator.

Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay. lifetime reserve days are paid under Medicare Part B. lifetime reserve days are not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges. the patient has a total of 60 lifetime reserve days.

lifetime reserve days are paid under Medicare Part B. Lifetime reserve days may only be applied to hospital inpatient stays, which are reimbursed under Medicare Part A, not Part B.

Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT nonparticipating providers have a higher fee schedule than that for participating providers. fees are restricted to charging no more than the "limiting charge" on nonassigned claims. collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim. providers must file all Medicare claims.

nonparticipating providers have a higher fee schedule than that for participating providers. Non-PAR (nonparticipating) providers are permitted an additional 15% above the Medicare Physician Fee Schedule (MPFS). PAR (participating) providers must accept the MPFS-allowed amounts.

An Advance Beneficiary Notice (ABN) is a document signed by the utilization review coordinator indicating that the patient stay is not medically necessary. provider indicating that Medicare will not pay for certain services. physician advisor indicating that the patient's stay is denied. patient indicating whether he/she wants to receive services that Medicare probably will not pay for.

patient indicating whether he/she wants to receive services that Medicare probably will not pay for. Advance Beneficiary Notice is required by Medicare to be provided to the patient prior to the procedure or service to acknowledge the patient's responsibility for payment because it is expected that Medicare will not cover the cost.This document is about the notification to the patient about the potential of financial responsibility for an upcoming procedure. Therefore, the patient, not the provider, the utilization review coordinator, nor a physician advisor would have the authority to sign.

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 radiologic technicians. radiological equipment. radiological supplies. physician's services.

physician's services. Physician services are the professional components of a procedure, service, or treatment. This is the correct answer. Incorrect answers: Radiological equipment are part of the technical component of a service or treatment. Radiologic supplies are part of the technical component of a service or treatment. Radiologic technicians' services are part of the technical component.

A legal query must be written using precise language that will be understood. specific language so that the physician only needs to answer yes or no. vague language so the physician is not influenced. innuendo so as not to reveal PHI.

precise language that will be understood. A legal query must use precise language that will be understood by the provider. The language should NOT be vague. The query must make it clear exactly what information is needed to complete the documentation in the record. However, to specifically word the query so the physician only needs to answer yes or no indicates that the question is leading, and this would not be proper or legal. An innuendo (a suggestion or hint) would also not be proper or legal. It may be advisable to reveal the appropriate amount of PHI in order for the physician to identify the patient.

Procedure-to-Procedure (PTP) Edits review claims for codes that report procedures that cannot or should not be provided to the same patient on the same day. durable medical equipment without medical necessity. diagnosis codes that have been deleted. post-operative therapies.

procedures that cannot or should not be provided to the same patient on the same day. Procedure-to-Procedure (PTP) edits identify codes for procedures that cannot, or should not, be provided to the same patient on the same date of service. Post-operative therapies help speed recovery. The key goals are to improve movement and range of motion, strengthen muscles, and help you learn how to safely resume daily activities. Different experts help with different parts of rehab. Examples: physiatrist, physical therapist, occupational therapist, dietitian, speech therapist, and nurses. Durable medical equipment is considered without medical necessity when it does not meet the definition of medical necessity included in the following criteria: Durable Medical Equipment (DME) meets the definition of medical necessity when ALL the following criteria are met: The equipment provides therapeutic benefit to the member who has certain medical conditions or illnesses The DME is prescribed by a physician The DME does not serve primarily as a comfort or convenience item The equipment does not have significant non-medical uses (e.g., environmental control equipment) The technology must have final approval from the appropriate government regulatory bodies (e.g., the U.S. Food and Drug Administration (FDA)).

The documentation under History of Present Illness [HPI] states, "The patient denies any sore throat or coughing." In the last paragraph, under Plan, it states "The patient was given a prescription for Tessalon." Tessalon is a cough suppressant. The coder should: code an adverse reaction to Tessalon. query the physician about the contradiction. query the physician to amend the notes to include report of a cough. code a chronic cough.

query the physician about the contradiction. The coder should query the physician about the contradiction between the HPI stating the patient had no cough and a cough suppressant being prescribed. There is no mention of an adverse reaction to the medication and there is no documentation of a chronic cough; therefore, the coder should NOT code an adverse reaction to Tessalon or code a chronic cough. It would not be appropriate to code a diagnosis unless or until the record provides documentation for correct coding. Queries are used to collect information to correct or complete the documentation of the record. Then the coder can report the proper diagnosis. The coder is also not permitted to direct the physician to change the documentation in any specific way. Therefore, the coder cannot query the physician to amend the notes to include report of a cough. The coder is not allowed to lead the physician to a specific code.

The chart included, "The nail bed, left hand third finger, was infected. Local treatment was applied, and a bandage was provided." The coder should: query, "Is follow-up required?" report the infection with an Incision and Drainage [I&D]. query, "What specific treatment was provided?" report the infection with an E/M only.

query, "What specific treatment was provided?" The "local treatment" must be described in detail so it can be accurately reported. Reporting the infection with an E/M code only could be throwing away earned reimbursement. Therefore, the coder should query, "What specific treatment was provided?" The coder does not need to query whether follow-up is required because this would not be coded. Reporting the infection with an Incision and Drainage [I&D] would not be proper because there is currently no documentation of an I&D being provided.

Your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with MEDPAR representatives. recovery audit contractors. QIO physicians. the OIG.

recovery audit contractors. The RAC program is mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program. Office of Inspector General (OIG); Medicare Provider Analysis and Review (MEDPAR ); Quality Improvement Organization (QIO).

Accreditation by Joint Commission is a voluntary activity for a facility, and it is conducted in each facility annually. required for state licensure in all states. considered unnecessary by most health care facilities. required for reimbursement of certain patient groups.

required for reimbursement of certain patient groups. The correct answer is: Required for reimbursement of certain patient groups. Wrong answers: 1) Considered unnecessary by most health care facilities: advantages of accreditation are numerous and include financial and legal incentives. 2) Required for state licensure in all states: state licensure is required for accreditation but not the reverse. 3) Conducted in each facility annually Joint Commission conducts unannounced on-site surveys approximately every 3 years.

The process by which health care facilities and providers ensure their financial viability by increasing revenue, improving cash flow, and enhancing the patient's experience is called auditing. revenue cycle management. accounts receivable. patient orientation.

revenue cycle management. Revenue cycle management is the process of ensuring the efficiency and effectiveness of all work involved in obtaining earned revenue. This is the correct answer. Incorrect answers: Accounts receivable are the funds that have been earned and billed for, yet not received. Auditing is an official review of work performed. Patient orientation is the process of helping patients, at admission, to understand the environment and upcoming events.

A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by home health agencies (HHA) and ____. physical therapy (PT) centers and inpatient rehabilitation facilities (IRFs) ambulatory surgery centers (ASCs) and physical therapy (PT) centers skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) ambulatory surgery centers (ASCs) and skilled nursing facilities (SNFs)

skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) Skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are paid under Health Insurance Prospective Payment System (HIPPS). Ambulatory surgical centers and physical therapy centers are covered under APC.

Under the APC methodology, discounted payments occur when there are two or more (multiple) procedures that are assigned to status indicator "T." pass-through drugs are assigned to status indicator "K." modifier -78 is used to indicatean unplanned return to the operating room by the same physician there are two or more (multiple) procedures that are assigned to status indicator "S."

there are two or more (multiple) procedures that are assigned to status indicator "T." APC status indicator "T" states "procedure or service, multiple procedure reduction applies," designating a discount on additional reimbursement will be provided when more than one of the exact same procedure is provided (typically bilaterally). PSI "S" = significant procedure, not discounted when multipleModifier 78 reports an unplanned return to the Operating RoomPSI "K" reports non-pass through drugs

The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as optimizing. unbundling. upcoding. downcoding.

upcoding. The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as upcoding.