Ch.10
12. Critical pathways usually focus on one discipline and provide guidelines for standards of care.
b. False
15. Upcoding is the assignment of a DRG that does not match documentation and for the purpose of increasing outpatient reimbursement.
b. False
20. CPT is the abbreviation for current procedure terms.
b. False
3. ICD-10-CM is published by the American Medical Association (AMA) and provides numerical codes for procedures.
b. False
4. The standard classification for mental disorders is Current Procedure Terminology (CPT).
b. False
6. Medicaid is a joint federal and state program that provides health care coverage to individuals age 65 and older.
b. False
7. Workers' compensation is federally mandated insurance program that reimburses health care costs and lost wages for employees injured on the job.
b. False
8. Medicare legislation prohibits physicians from referring patients to an entity with which the physician or family member(s) have a financial relationship.
b. False
9. Diagnosis-related group (DRG) grouper software is used to assign ICD-10-CM codes inpatient cases.
b. False
31. In 1948, Happy Hospital was able to secure federal grant funds to update its surgical units. This funding was established by:
b. Hill-Burton Act
44. The goal of the Recovery Audit Contractor program is to:
b. Identify improper payments made on claims of health care services provided to Medicare beneficiaries
33. Polly's job responsibilities include collecting outcome and assessment information set (OASIS) data and entering the data set into Home Assessment Validation Entry (HAVEN) data-entry software. She most likely works at a:
b. The Home Health Agency
57. HCPCS Level || or ____________ codes classify medical equipment, injectable drugs, and other services not classified in CPT.
NATIONAL
58. Pharmacies use _____________ to report pharmacy transactions.
NATIONAL DRUG CODES
61. Errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients are referred to as
NEVER EVENTS.
48. Pre-established reimbursement rates for health care services are part of a(n)
PROSPECTIVE PAYMENT SYSTEM
54. Dr. James Read developed ____________ to record clinical summaries in general practice
READ CODES
45. A third-party payer is an organization that processes claims for ___________ covered by a health care plan.
REIMBURSEMENT
67. Describe when a veteran's dependents may receive benefits from the CHAMPVA program.
A veteran's dependents may receive benefits when the veteran is rated as 100% permanently and totally disabled as a result of service-connected conditions, when the veteran died as a result of service-connected conditions, or when the veteran died on duty with fewer than 30 days of active service.
68. Define and state the purpose of an APC. Describe how the APC payment rate is applied to payment.
An APC (ambulatory payment classification) organizes similar health care services clinically and according to resources required. A payment rate is established for each APC and, depending on services provided, hospitals can be paid for more than one APC per encounter, with second and subsequent APCS discounted at 50%.
70. Explain why case-mix analysis should be performed by health care facilities.
Analyzing the case mix can forecast health care trends unique to individual settings, ensure that facilities continue to provide appropriate services to their patient populations, and help facilities recognize that different patients require different resources for care.
43. The End-Stage Renal Disease Composite Payment Rate System was established by the:
C. Medicare Prescription Drug, Improvement and Modernization Act of 2003
49. In the early 1900s, most patients paid for health care services by _____________ or bartering.
CASH
51. Hospitals use a _________ to record encounter data about ambulatory care.
CHARGEMASTER
66. Summarize disability insurance, stating the percentage of income covered and the waiting period.
Disability insurance replaces 40-60% of an individual's gross income if an illness or injury prevents the individual from earning an income. Policies usually require a 90-day waiting period from onset of disability before the individual can apply for disability benefits.
62. The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) required adoptlon of two types of code sets for encoding data elements. Describe the large code sets.
Diseases, injuries, impairments, other health-related problems, and their manifestations Causes of injury, disease, impairment, or other health-related problems Actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments Substances, equipment, supplies, or other items used to perform actions.
47. A retrospective payment system or _____________ plan bills payers after health care services are provided to the patient.
FEE-FOR-SERVICE
46. Private health insurance consists of a(n) ___________- which cover individuals for certain health care expenses.
INDEMNITY PLAN
52. ICD-10-CM and ICD-10-PCS codes are assigned to ______________ diagnoses and procedures and entered into automated abstracting software.
INPATIENT
50. The Correct Coding Initiative was implemented to reduce ___________ expenditures by detecting inappropriate coding on claims.
MEDICARE
59. Third-party payers often adopt payment systems and fee schedules after _____________ has implemented them.
MEDICARE
60. Payers that process both Medicare Part A and Part B claims are known as
MEDICARE ADMINISTRATIVE CONTRACTORS
53. The Military Health System (MHS) provides health care services and support to
MEMBERS OF THE UNIFORMED SERVICES AND THEIR FAMILIES
65. Describe the activities that are coded by SNOMED.
SNOMED codifies all activities within the patient record, including medical diagnoses and procedures, nursing diagnoses and procedures, patient signs and symptoms, occupational history, and the many causes and etiologies of diseases.
64. State the name of the organization that developed the Systematized Nomenclature of Pathology (SNOP) and the purpose of the nomenclature.
SNOP was developed by the College of American Pathologists. It includes a four-axis system of terms and related codes for use by pathologists interested in storage and retrieval of medical data.
56. A health care enrollee is known as a(n)
SUBSCRIBER
71. Define severity of illness, and summarize the basis of severity of illness scores.
Severity of illness is the physiologic complexity that comprises the extent and interactions of a patient's disease(s) as presented to medical personnel. Severity of illness scores are based on physiologic measures of the degree of abnormality of individual signs and symptoms of a patient's disease(s). The more abnormal the signs and symptoms, the higher the score.
69. Summarize the services that are reimbursed by the Medicare Resource Based Relative Value System (RBRVS), now called the Physician Fee Schedule (PFS).
The services reimbursed by PFS include physician services covered by Medicare Part B.
1. A medical nomenclature organizes diseases and procedures into numeric and alphabetic characters.
b. False
55. The purpose of the ________________ is to aid in the development of systems to help retrieve and integrate electronic biomedical information from a variety of sources.
UNIFIED MEDICAL LANGUAGE SYSTEM
10. The national limitation amount serves as a ceiling on the amount that third-party payers can pay for clinical laboratory tests.
b. False
42. In 2008, Medicare implemented ambulatory payment classifications (APCS) and relative payment weights to reimburse__________ for surgical procedures performed.
a. Ambulatory Surgery Centers
28. Sally is a coder for a dentist and needs to purchase updated coding books. Should she purchase:
a. CDT
38. The standard institutional claim submitted by hospitals and skilled nursing facilities to payers to obtain reimbursement for health care services is called:
a. CMS-1450
34. Barb is completing a report for the hospital governing board. The board wants to review the types and categories of patients treated. Barb should use which data to prepare the report?
a. Case Mix
37. Each year the business office, ancillary departments, and health information management (HIM) department update the charges and codes for all procedures, services, and supplies. This information is entered into the computer system to create a:
a. Chargemaster
39. Which characteristic of electronic of electronic data interchange (EDI) below is incorrect?
a. It determines claim status within 14 hours
11. Paying for surgery performed on the wrong body part is not consistent with the goals of Medicare payment reforms.
a. True
13. Chargemasters should undergo annual reviews.
a. True
14. Revenue codes classify hospital categories of service by revenue cost center.
a. True
16. A subscriber is a health plan enrollee.
a. True
17. Codes are reported to third-party payers for reimbursement and to external agencies for data collection; they are also used internally for education and research.
a. True
18. The intent of standard coding guidelines is to simplify claims submission for health care providers.
a. True
19. HCPCS Level Il codes are in the public domain, and they are not copyrighted.
a. True
2. A clearinghouse is an entity that processes health information received from another entity.
a. True
5. Commercial health insurance payers include private and employer-based health insurance plans.
a. True
36. Interdisciplinary guidelines developed by hospitals to facilitate the management and delivery of quality clinical care are called:
b. Critical Pathways
24. Which is a standard classification of mental disorders published by the American Psychiatric Association (APA)?
b. DSM
29. Sue has just taken a new job at the Pentagon. Part of her benefits include health insurance coverage through:
b. FEP
40. Which organization publishes CPT?
c. AMA
32. The inpatient prospective payment system (IPPS) 72-hour rule requires that outpatient preadmission services provided by a hospital up to three days prior to a patient's inpatient admission be covered by the DRG payment for:
c. Diagnostic and therapeutic services with the same principal diagnosis code
21. A durable medical equipment company would classify medical equipment using:
c. HCPCS Level Il codes
35. University medical students are reviewing research to determine the death rates of hospital patients admitted for pneumonia. Which system would be helpful in their study?
c. MMPS
30. Hospital reimbursement based on a retrospective payment system that issues payment based on daily charges is called:
c. Per Diem
25. Sally works in a pathology laboratory, gathering information for staff pathologists. Which nomenclature does she use in her job?
c. SNOMED
23. Which of the following is not an example of a never event?
c. Severe pressure ulcer present on admission
41. The Medicare Severity DRG was implemented by CMS in:
d. 2007
22. National Drug Codes are managed by the:
d. Food and Drug Administration
27. Which of the following is not an example of a hospital-acquired condition?
d. Heart attack 24 hours after admission updated
26. Sue has just accepted a position at the National Library of Medicine to retrieve and process electronic biomedical information for health care universities. Her supervisor informs her that she will be receiving coding training for:
d. UMLS
63. List the code sets proposed by HIPAA
• International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) • Current Procedural Terminology (CPT) • HCPCS Level II (National Codes) • Current Dental Terminology (CDT) • National Drug Codes (NDC)
