Domain 4 Revenue Cycle Management Test Prep 10th edition

385. All of the following are examples of identity theft red flags categories except: a. Alerts or notification from a consumer reporting agency b. Suspicious documents c. Alerts or notification from AHIMA d. Suspicious personally identifying information

C Alerts or notification from a consumer reporting agency, suspicious documents, suspicious personally identifying information, patient's reporting, are examples of identity red flag categories (Palkie 2020b, 304).

334. Which of the following is typically the responsibility of the contract management team? a. Marketing of new services to affiliated clinics b. Determining whether services are set up to reflect the proper CPT/HCPCS codes and revenue codes on the billing claim c. Analyzing whether discount rates are providing financial incentives that steer the patient population d. Conducting a SWOT analysis to maintain the facility's competitive advantage

C One of the responsibilities of the contract management team is to analyze whether discount rates are providing financial incentives that steer the patient population (Handlon 2020, 267).

352. Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service

If a service is hard-coded into the charge description master (CDM), it is important that this decision is communicated to the coding staff. If the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and White 2021, 145).

296. David was admitted to the hospital following an automobile accident in which he suffered a fractured femur. Two days after surgery to repair the fracture, he developed pneumonia and was transferred to the ICU. Because the pneumonia was not present at the time of admission to the hospital, it is considered a: a. Healthcare-associated infection b. Hospital sickness c. Community-acquired infection d. Community sickness

a A healthcare-associated infection (HAI) is an infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or it is the remainder of an infection acquired during a previous admission (Shaw and Carter 2019, 177).

337. In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has COPD d. Assign a code from the abnormal findings to reflect the condition

a A query is routine communication and education tool used to advocate for complete and compliant documentation. The intent is to clarify what has been recorded, not to call into question the provider's clinical judgment or medical expertise. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS and whether the COPD does is not clear (Hunt and Kirk 2020, 285-287).

359. The physician marked his superbill for a moderate level of care for every patient based on the concept that historically, on average, his reimbursements for all patients have been at that level. Additionally, he considered that he would save time, both for himself and his biller, by not having to figure out the actual time spent and level of complexity of medical decision-making required to assign the actual CPT E/M level for the case. His biller is curious and asks you whether this is appropriate. Your response is: a. Systematic, intentional miscoding of cases is fraud, and he should not do this. b. This is a great time saver, and you will consider doing the same for ED cases in the hospital. c. Although this is a violation of CPT coding rules, it will not affect his reimbursement, so it is okay. d. This is abuse of the reimbursement system, and he should not do this.

a Although historically his cases came out to the moderate level of care average, the physician is ignoring accurate coding rules as well as payer mix. The physician's reimbursement might be middling on average, but that does not mean every payer's reimbursements to him came out that way. Further, his intentional miscoding is inherently fraud. Based on this rationale, all of the other answers are incorrect. Answer d is incorrect because there is intention, which makes the physician's actions fraud (Davis and Doyle 2016, 62-64).

328. Which of the following processes are financial counselors typically responsible for? a. Determining whether the patient is eligible for charity care b. Verifying whether the patient's insurance plan is in network or out of network c. Determining whether scheduled services will be covered by the insurance plan d. Understanding which procedures require preauthorization

a Assessing the patient's ability to pay for services is the primary responsibility of a financial counselor; the other listed processes are typically performed by a registration staff member (Handlon 2020, 248-249).

309. Which of the following occurs when the organization assumes potential losses associated with a given risk and makes plans to cover the financial consequences. a. Corporate integrity agreements (CIAs) b. Risk assessment c. Risk retention d. Contingency planning

a CIAs may last for many years and are imposed when serious misconduct (fraud and abuse) is discovered through an audit or self-disclosure. Remediation initiatives, such as training or designation of a compliance officer, are part of the CIA. Remediation activities are intended to offer providers another chance to prove they are worthy of participating in federal healthcare programs (Palkie 2020b, 307).

331. Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. a. 54401, Insertion of penile prosthesis; inflatable (self-contained) b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir c. 54440, Plastic operation of penis for injury d. 54400, Insertion of penile prosthesis, non-inflatable (semi-rigid)

a Code 54401 is correct because the prosthesis is self-contained (Huey 2021, 24).

307. Being excluded from participating in Medicare or other federal programs is significant because _____. a. The government is the largest purchaser of healthcare services in the country b. Jailtime always accompanies exclusion c. Those excluded are covicted of fraud, not abuse d. Facilties or individuals excluded from federal programs must undergo extensive offender training

a Exclusion is significant as the government is the largest purchaser and provider of services in the country (Hunt and Kirk 2020, 293-294).

369. Anywhere Hospital is implementing a new clinical documentation improvement (CDI) program. As part of the program, the clinical staff is educated on the components and procedures of the program. Which of the following would not be true about the CDI program? a. The need for postdischarge queries will be eliminated. b. Physicians will be consulted about nonspecific documentation while patients are still in-house. c. Effective communication between clinical staff and CDI specialist is vital. d. CDI reviewers will be on the inpatient units to review clinical documentation concurrently.

a Facilities may design a clinical documentation improvement (CDI) program based on several different models. Improvement work can be done with retrospective record review and queries, with concurrent record review and queries, or with concurrent coding. Although much of the CDI process is often done while the patient is in-house, it does not eliminate the need for post-discharge queries (Schraffenberger and Kuehn 2011, 363).

299. Which term is used for retrospective reimbursement charges submitted by a provider for each service rendered? a. Fee-for-service b. Deductible c. Actuarial d. Prospective

a Fee-for-service reimbursement is based on the principle that there is a charge for each service rendered by a provider (Hazelwood 2020, 225).

304. When radiological and other procedures that include professional and technical components are paid as a lump sum that is to be divided between the physician and the healthcare facility, this is called a: a. Global payment b. Professional payment c. Unbundled payment d. Fee-for-service payment

a Global payments are lump-sum payments for an entire event. These may be distributed among different physicians or between physicians and facilities. For many radiological procedures, the physician is paid for the professional component of the procedure while the facility is paid for the technical component (supplies, technician, equipment, and the like). Unbundled payments should not occur, and fee-for-service is payment for each individual component of a service and not a lump sum (Hazelwood 2020, 226-227).

363. The process in which a healthcare entity addresses the provider documentation issues of legibility, completeness, clarity, consistency, and precision is called: a. Query process b. Release of information process c. Coding process d. Case-finding process

a Healthcare entities should consider a policy in which queries may be appropriate when documentation in the patient record fails to meet one of the following five criteria: legibility, completeness, clarity, consistency, and precision (Hunt and Kirk 2020, 285-287).

374. A payer has advised your hospital that it is auditing records from last year due to a suspected payment error. Your hospital's first action should be to: a. Review the contract to determine whether this is a violation of the look-back period clause b. Request a list of the records to be reviewed and make sure the payer is requesting records that are specifically associated with that payer only c. Ask the payer to specifically identify the suspected payment error d. Notify HIM of the request for release of information

a If the review is a violation of the look-back period clause, all of the other answers are irrelevant (Davis and Doyle 2016, 159).

325. In which of the following documents can regulatory requirements and revisions regarding national and local coverage determinations (NCDs and LCDs) be found? a. Medicare billing manuals b. Official ICD-10 coding guidelines c. Local managed care contract language d. Notice of privacy practices

a Local managed contracts, official coding guidelines, and notice of privacy practices are documents in which NCDs and LCDs requirements and revisions are not found. Medicare billing manuals would include these items (Handlon 2020, 247-248)

349. Which of the following is an example of internal medical identity theft? a. Sue in her role as a patient registration clerk uses a patient's insurance information to see a specialist for cosmetic surgery. b. Joe uses a patient's information obtained through hacking the healthcare facility system. c. Joan, an ICU nurse accesses the record of the patient she is currently treating. d. Bob introduces a virus into the facility's health information system.

a Medical identity theft can be the result of either internal or external forces. Electronic health records have improved the ability to share information, but this has also increased exposure to data making it more vulnerable. Internal medical identity theft is committed by organization insiders, such as clinical or administrative staff with access to patient information. External threats are causing a greater risk for healthcare organizations due to increased threats of ransomware, malware, and denial-of-service (DOS) attacks (Olenik and Reynolds 2017, 290).

347. Which of the following is a reason to deliver a hospital-issued notice of noncoverage (HINN) to a Medicare beneficiary? a. Service is not medically necessary b. Service was preauthorized c. Service was delivered in the most appropriate setting d. Service is provided in the emergency room

a The hospital-issued notice of noncoverage (HINN) may be provided to patients when an inpatient service has been deemed non-covered due to medical necessity (Handlon 2020, 248).

339. Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? a. $228 b. $240 c. $285 d. $300

a Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians) of the Medicare fee schedule (MFS). For example, if the MFS amount is $200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider receives only $152 (95 percent of $160). In this case the physician is nonparticipating so he or she will receive 95 percent of the 80 percent of the MFS or 80 percent of 300, which is $240; 95 percent of the $240 is $228 (Casto and White 2021, 125).

377. There has been a recent increase in errors regarding the posting of the admitting diagnosis. Correction of this error falls to the coding staff. With which department will HIM have to partner in order to identify and eliminate this recurring error? a. Patient access b. Patient financial services c. Case management d. Medical staff

a Patient access staff are responsible for entering this data; therefore, it is with that department that HIM needs to work (Davis and Doyle 2016, 4).

364. Which of the following terms describes the requirement for a healthcare provider to obtain permission from the health insurer in order to provide predefined services to the patient? a. Preauthorization b. Coordination of benefits c. Informed consent d. Preassessment

a Preauthorization is a term that describes the requirement for a healthcare provider to obtain permission from the health insurer in order to provide predefined services to the patient (Handlon 2020, 247).

330. A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension

a Present on admission is defined as present at the time the order for inpatient admission occurs—conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission. This patient was not admitted with a catheter-associated urinary infection, so that condition cannot be coded as present on admission (POA). The patient was admitted with symptoms of a stroke and diagnoses of COPD and hypertension. The CVA was documented after admission, but the symptoms of the stroke were POA, so this condition would be coded as POA (Hazelwood 2020, 230).

324. Which of the following is considered a type of registration issue affecting the revenue cycle? a. Patient registered with more than one medical record number b. Accurately recording the patient's guarantor and employer information c. Excessive wait time for patients in the registration area d. Completion of insurance verification

a Registering a patient with more than one medical record number is an issue that affects the revenue cycle. Although excess wait time is frustrating for patients, it is not a guarantee of an issue with the revenue cycle. Ensuring the patient's guarantor and employer and completing insurance verification would help the revenue cycle process (Handlon 2020, 249).

342. Understanding adjustments in payment to the provider and then utilizing the information to determine subsequent revenue audit and recovery efforts initiate from which of the following? a. Remittance advice b. Claim form 837 c. Adverse determination d. Accounts receivable Use the following figure for questions 343 and 344:

a Remittance advice (RA) files are sent to the provider from the payer with final individual claim adjudication and payment information. RAs provide explanation through itemized claims processing decision information about any adjustments made regarding payment, adjustments, etc. (Handlon 2020, 265).

297. The goal of revenue integrity is to produce a claim that is __________. a. Clean, complete, and compliant b. Complete, accurate, and timely c. Clean, timely, and includes modifiers d. Compliant, clean, and includes diagnosis

a Revenue integrity is performing revenue cycle duties to obtain operational efficiency, compliance adherence, and legitimate reimbursement. A claim that is clean, complete, and compliant meets the goals of revenue integrity (Casto and White 2021, 9-10).

367. The Red Flags Rule ________ an organization to implement a protection program that identifies warnings that alert the organization that potential identity theft has occurred or is occurring. a. Requires b. Does not require c. Sometimes requires d. Recommends as best practice

a The Red Flags Rule requires many businesses and organizations to implement a written identity theft prevention program designed to detect the "red flags" of identity theft in day-to-day operations, take steps to prevent the crime, and mitigate its damage (Palkie 2020b, 304-305).

350. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? a. Conversion factor b. RVU c. GPCI d. Weighted discount

a The conversion factor is an across-the-board multiplier that sets the allowance for the relative values—a constant (Casto and White 2021, 123).

301. A patient is treated in observation and fell out of his bed. An x-ray shows a femoral fracture. The patient is admitted as an inpatient to treat the hip fracture. What is the POA indicator for the fracture for the inpatient admission? a. Y b. N c. U d. W

a The correct answers is "Y=Yes" as the condition is present on admission. When the patient was admitted from observation, the hip fracture was present (Hazelwood 2020, 230-231).

305. If an organization has an average daily gross patient service revenue of $230,000 along with 120 patient preregistered encounters, 150 scheduled encounters, and $100,000 in gross dollars in discharged, not final billed accounts, what is the DNFB rate? a. 43.5% b. 52.1% c. 2.3% d. 80.0%

a The formula for measuring the days in total discharged, not final billed is calculated with a numerator of gross dollars in discharged not filled billed and a denominator of average daily gross patient service revenue (Handlon 2020, 269).

366. Gladys Johnson was admitted to the skilled nursing facility for 30 days. If the current Medicare coverage for SNF care is: First 20 days = 100% of approved amount Days 21-100 = all but $170.50 per day Beyond 100 days = Nothing What is Gladys' total financial responsibility for the SNF stay? a. $1,705.00 b. $5,115.00 c. $170.50 d. Nothing, Medicare pays for all 30 days

a The patient's first 20 days of care are paid at 100 percent. Days 21-30 are paid all but $170.50 per day; the patient's responsibility is $1,705.00 (10 days x $170.50 per day) (Hazelwood 2020, 213).

343. From the figure, determine whether the plan covers Gill F. White, Jane's spouse. a. No, the card states "Employee-Only" b. Yes, the policy number includes "S" c. Yes, the group is "State" d. Cannot be determined

a The policy information provided states this is a single policy or employee-only policy, so the member's spouse is not covered (Casto and White 2021, 16-17).

326. A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? a. K43.9, R00.1, Z53.09, 0WJG0ZZ b. K43.9, I97.191, R00.1, 0WJG0ZZ c. K43.9, 0WQF0ZZ d. K43.9, Z53.09, 0WQF0ZZ

a The repair of the hernia is not coded because it was not performed; however, code 0WJG0ZZ is assigned to describe the extent of the procedure, inspection of the peritoneal cavity based on ICD-10-PCS Guideline B3.3. The Z53.09 is also used to indicate the cancelled procedure due to the contraindication. The code R00.1 is also added for the bradycardia that the patient developed during the procedure (Kuehn and Jorwic 2023, 43; Schraffenberger and Palkie 2022, 701).

361. To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? a. Brain injury b. Chronic myelogenous leukemia c. Acute myocardial infarction d. Cancer

a To meet the CMS's definition of an IRF, facilities must have an inpatient population in which at least 75 percent of the patients require intensive rehabilitation services and one of the following conditions: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur, brain injury, neurological disorders, burns, rheumatoid arthritis, systemic vasculitides, osteo-arthritis, polyarthritis, or knee or hip replacement (Hazelwood 2020, 238).

348. Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors

a When coders "optimize" the coding process, they attempt to make coding for reimbursement as accurate as possible. In this way, the healthcare facility can obtain the highest dollar amount justified within the terms of the government program or the insurance policy involved (Hunt and Kirk 2020, 296).

394. Given of the following data elements in the charge master, which value will not transfer to the billing claim form? a. G0379 b. 760211 c. $1,179.00 d. 762

b 760211 is the charge code which is a unique identifier to specify the service or supply. The number is only meaningful to the organization and does not appear on the billing claim form (Handlon 2020, 256).

314. If your hospital's net days in accounts receivable is 62 and the local peer hospital's net days in accounts receivable is 46, your hospital's A/R value compared to the local peer hospital would be considered _____. a. Favorable b. Unfavorable c. Average d. Insignificant

b A low A/R value is favorable (Handlon 2020, 263).

390. A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? a. Code congestive heart failure, respiratory failure, mechanical ventilation, and intubation b. Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis c. Query the attending physician about the adding the symptom of shortness of breath as a secondary diagnosis d. Code shortness of breath, congestive heart failure, mechanical ventilation, and intubation

b As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity. In this situation the reason for the mechanical ventilation and intubation, most likely, is respiratory failure and the physician would need to be queried for validation of that diagnosis in order for it to be coded (Hunt and Kirk 2020, 285-287).

391. Automated review efforts of recovery audit contractors (RAC) allow them to deny payments without ever reviewing a health record based on the information they gather without having access to the record. Which of the following would be an example of a potential denial based on information the RAC contractor would have without the health record? a. A coder assigning the wrong DRG for a patient b. Billing for two colonoscopies on the same day for the same Medicare beneficiary c. An inaccurate principal diagnosis d. A principal procedure code

b Automated reviews by recovery audit contractors (RACs) allow them to deny payments without ever reviewing a health record. For example, duplicate billing, such as billing for two colonoscopies on the same day for the same Medicare beneficiary, is easy to identify as a potential improper payment. Underpayment and overpayment amounts can be subject to an automated review (Casto and White 2021, 206).

327. Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32408, Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)

b Begin with the main term: Biopsy, artery, temporal (Huey 2021, 24).

387. Which of the following is the principal goal of internal auditing programs for billing and coding? a. Increase revenues b. Protect providers from sanctions or fines c. Improve patient care d. Limit unnecessary changes to the chargemaster

b Ongoing evaluation is critical to successful coding and billing for third-party payer reimbursement. The goal of internal auditing is to protect providers from sanctions or fines (Palkie 2020b, 308).

322. A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? a. A41.89, K57.32, R10.9 b. A41.01, K57.32 c. A41.89, K57.32, B95.61 d. A41.9, K57.32

b Sepsis is a serious medical condition caused by the body's immune response to an infection. Code A41.01 is for sepsis with methicillin-susceptible Staphylococcus aureus. Because abdominal pain is a symptom of diverticulitis, only the diverticulitis of the colon is coded (Schraffenberger and Palkie 2022, 43-44, 119-120).

317. Improving account collections while creating a positive consumer experience can be accomplished through a recognized method of _____. a. Denying service at the pre-registration process b. Electronic payment options through a patient portal c. Auditing the EOB with the patient to determine if payment is necessary d. Using a threshold to determine account review and then sending account to third-party collection agency

b Since obtaining the patient portion can be a significant challenge for many organizations, permitting electronic payment options through a patient portal is an increasingly popular approach with collections and follow-up (Handlon 2020, 263-264).

383. The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit

b The HIM department can plan focused reviews based on specific problem areas after the initial baseline review has been completed. This would be called a focused inpatient review or focused audit (Schraffenberger and Kuehn 2011, 314-315).

384. During a recent coding audit, the coding manager identified the following error made by a coder. The coder assigned the following codes for a female patient who was admitted for stress incontinence and a urethral suspension without mesh was performed: What error was made by the coder? a. The coder assigned the correct diagnosis and procedure codes. b. The coder assigned the correct diagnosis code but assigned the incorrect root operation for the procedure. c. The coder assigned the correct procedure code but the incorrect diagnosis code. d. The coder assigned the correct diagnosis code but selected the incorrect device character for the procedure code.

b The coder assigned the correct diagnosis code. The coder did not assign the correct procedure because the root operation for this procedure is reposition, not supplement. Reposition is moving to its normal location or other suitable location all or a portion of a body part, whereas supplement is defined as putting in or on biological or synthetic material that physically reinforces or augments the function of the portion of a body part (Kuehn and Jorwic 2023,

319. Which of the following reimbursement methods pays providers according to charges that are calculated before the healthcare services are rendered? a. Fee-for-service reimbursement b. Prospective payment c. Retrospective payment d. Resource-based payment

b The concept of a prospective payment system is that charges are calculated before healthcare services are actually provided. The charges are based on historical data on patients with like conditions and procedures. Retrospective payment is payment for the actual cost of services provided (Hazelwood 2020, 225).

318. A patient is admitted for an appendectomy. Postoperatively, the patient develops a pulmonary embolism. What is the POA indicator for the pulmonary embolism? a. Y b. N c. U d. W

b The correct answer is "N=No" as the condition was not present on admission. The pulmonary embolism developed after admission to the hospital (Hazelwood 2020, 230-231).

344. From the figure, determine which entity that has purchased the insurance policy. a. 1234567890 b. STATE c. ABC Premiere Health Plan d. Jane B. White

b The insured is the organization that has purchased the insurance policy. In this case, STATE has purchased the insurance coverage for subscriber Jane B. White (Casto and White 2021, 16-17).

379. A patient is scheduled for elective services, and preregistration has determined that insurance does not cover all of the reimbursement for the procedure. What does the registrar do first? a. Demand payment in advance b. Offer financial counseling services c. Cancel the services d. Call the physician to explain the situation

b The purpose of a financial counselor is to assist the patient in understanding their financial obligations and working out a method of payment. This would be the first step (Davis and Doyle 2016, 96-97).

373. The purpose of this program is to reduce improper Medicare payments and prevent future improper payments made on claims of healthcare services: a. Medicare provider analysis and review b. Recovery audit contractors c. Medicare Conditions of Participation d. Health Insurance Portability and Accountability Act

b The purpose of the recovery audit contractors (RAC) program is to reduce improper Medicare payments and prevent future improper payments made of claims of healthcare services to Medicare beneficiaries. Improper payments may be overpayments or underpayments (Rinehart-Thompson 2017e, 258).

310. A newborn is treated for pulmonary valve stenosis, with stretching of the valve opening accomplished via a percutaneous balloon pulmonary valvuloplasty. In ICD-10-PCS, what root operation would be coded for this procedure? a. Alteration b. Dilation c. Repair d. Restriction

b Though the term valvuloplasty in the index leads to Repair, Replacement, or Supplement, this procedure was performed as a percutaneous Dilation. The root operation Dilation is expanding an orifice or the lumen of a tubular body part (Kuehn and Jorwic 2021).

351. The provider staff who are involved with communicating adverse determinations to patients and their families are considered: a. Financial counselors b. Utilization management staff c. Registration staff d. Patient financial services staff

b Utilization management staff work with payers and convey the decision of denial of payment information from commercial payers to patients and families (Handlon 2020, 252)

313. _____ results when someone without authorization obtains healthcare services under someone else's name or purchases insurance coverage based on someone else's clean bill of health. a. Red Flags Rule b. Medical identity theft c. HIPAA Violation d. Whistleblowing

b When identity theft occurs in the context of medical care, it is known as medical identity theft. Medical identity theft is the inappropriate or unauthorized use of a person's identity to obtain medical goods or services or to falsify claims to fraudulently bill insurance companies (Palkie 2020b, 304).

380. When someone without authorization obtains healthcare services under someone else's name or purchases insurance coverage based on someone else's clean bill of health, this is called: a. Red Flags Rule b. Medical identity theft c. HIPAA Violation d. Whistleblowing

b When identity theft occurs in the context of medical care, it is known as medical identity theft. Medical identity theft is the inappropriate or unauthorized use of a person's identity to obtain medical goods or services or to falsify claims to fraudulently bill insurance companies (Palkie 2020b, 304).

308. When a payer questions a clinical aspect of an admission, such as length of stay of the admission, the level of service, if the encounter meets medical necessity parameters, the site of the service, or if clinical validation is not passed, this is called a/an: a. Administrative denial b. Clinical trial c. Clinical denial d. Administrative trial

c A clinical denial is issued when the insurance provider questions a clinical aspect of the admission, such as the LOS of the admission, the level of service, if the encounter meets medical necessity parameters, the site of the service, or if clinical validation is not passed (Casto and White 2021, 219).

382. An internal coding audit at Community Hospital shows that the cause of improper coding is lack of proper physician documentation to support reimbursement at the appropriate level. Coders have found that coding issues result because physician documentation needs clarification. The HIM department staff has met periodically with each clinical specialty to improve communication and provide targeted education, but documentation problems still persist. Which of the following actions would be the most reliable and consistent method to improve communication and documentation? a. Revise medical staff bylaws to include documentation requirements. b. Suspend medical staff privileges after a specified number of documentation problems have occurred. c. Implement a standardized physician query form so that coders can request clarification from physicians about documentation issues. d. Allow coders to make clinical judgments i

c Answer c is the only option that provides a consistent and reliable method to improve communication and documentation. Options a and b do not provide any communication avenues that will improve documentation or provide coders with necessary information to assign accurate codes. Option d is not appropriate in any case because coders should not be making clinical judgments (Hunt and Kirk 2020, 289).

356. Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? a. Request that the CEO write a memorandum to all hospital staff b. Give the chairperson of the CDI committee authority to fire employees who do not improve their clinical documentation c. Include ancillary clinical staff and medical staff in the process d. Request a letter of support from the Joint Commission

c Because clinical documentation improvement (CDI) involves the medical and clinical staffs, it is more likely that the CDI project will be successful if these staff are included in developing the process for documentation improvement. Because all hospital staff do not document in the health record, a memorandum from the CEO to all staff would not be efficient or necessarily effective. The chairperson of the CDI project does not have line authority for employee evaluation. The Joint Commission performs oversight activities but would not be involved in direct operational tasks such as this (Schraffenberger and Kuehn 2011, 360).

336. Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems

c Each Resource-Based Relative Value Scale (RBRVS) comprises three elements: physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register (Casto and White 2021, 122-123).

395. The HHS OIG publishes a yearly work plan that outlines _____. a. A schedule of audits to be undertaken b. Proposed targets of reviews by geographic region c. Projects that are planned and the areas identified for review d. New compliance measures for public facilities

c Each year, the HHS OIG publishes the projects that are planned and the areas identified for review. These published workplans cover CMS and the Administrations for Children and Families and Administration on Aging. The workplan can be found on the HHS OIG website (Hunt and Kirk 2020, 296).

371. There are several physicians on staff who continue to write "urosepsis" in the patient charts. The term "urosepsis" has no meaning in the ICD-10-CM code set. Coders repeatedly have to query the physicians to ask for a definitive diagnosis. What is the most efficient way to solve the problem? a. The HIM director should speak to the physicians and tell them to write "urinary tract infection" instead of "urosepsis." b. Patient financial services should meet with the physicians to educate them. c. CDI staff should be alert to this documentation issue so they can query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation. d. The physicians should be placed on suspension until they learn to document correctly.

c Educating physicians regarding documentation issues that affect coding is the function of the CDI team. Therefore, that is the best answer (Davis and Doyle 2016, 108).

393. Which of the following payment methods reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness? a. Managed fee-for-service b. Capitation c. Episode-of-care d. Point of service

c Episode-of-care payment is a single payment for all care delivered within a defined period of time. This may be an inpatient hospitalization or perhaps outpatient surgery (Hazelwood 2020, 226).

303. Which of the following assists with identifying issues involving data elements to ensure clean claims to be submitted to the payers? a. Clinical documentation improvement program b. Claims management follow up software c. APC grouper or claim scrubber software d. Order tracking and management system

c The scrubber reviews the claim for errors using predetermined criteria prior to sending to the payer for payment (Handlon 2020, 262).

323. A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? a. E08.52, I96 b. E10.52, I96 c. E10.8 d. E10.52

d The ICD-10-CM index entry for Diabetes, type 1, with gangrene provides E10.52 as the correct code, so the peripheral angiopathy is presumed when gangrene is present (Schraffenberger and Palkie 2022, 43-44).

362. AS director of patient access services. Mary Smith 35 is calling she received a bill from the hospital for services rendered last month that her insurance did not reimburse. Mary does not use your hospital and tells you that her primary care physician is associated with an entirely different hospital. Upon review of the patient file, you confirm that Mary's patient data is correct in your system. What is the problem, and what should you do? a. Mary is confused and does not remember the visit. You should ask to speak to a family member who can explain the situation to her. b. Mary is trying to get out of paying the bill. You should refer her to patient financial services and transfer the call. c. Mary is possibly a victim of medical identity theft. You should alert your security and compliance departments. d. Mary is confused. You should offer to send her the medical records to demonstrate that she was there.

c Even if the patient is possibly confused or trying to get out of paying the bill, it is in the best interests of the patient and the organization to take her concern seriously and take appropriate measures. This is a potential instance of medical identity theft and the security and compliance departments should be notified so that they can investigate this claim (Davis and Doyle 2016, 82-83).

389. Which of the following requires financial institutions to develop written medical identity theft programs? a. HIPAA Security Rule b. HITECH Act c. Fair and Accurate Credit Transactions Act d. HIPAA Privacy and Security Rule

c In 2007, Identity Theft Red Flags and Address Discrepancy Rules were enacted as part of the Federal Fair and Accurate Credit Transactions Act (FATCA) of 2003. The FATCA requires financial institutions and creditors to develop and implement written identity theft programs that identify, detect, and respond to red flags that may signal the presence of identity theft (Olenik and Reynolds 2017, 291).

320. A patient has HIV with disseminated candidiasis. What is the correct code assignment? a. B20, B37.0 b. B37.7, B20 c. B20, B37.7 d. B20, B37.89, B37.7

c Patients who are admitted for an HIV-related illness should be assigned a minimum of two codes in the following order: code B20 to identify the HIV disease and additional codes to identify the related diagnosis, which in this case is disseminated candidiasis code B37.7 (Schraffenberger and Palkie 2022, 129).

340. When a procedure is performed by visualizing the operative field via an orifice, without using instrumentation, which ICD-10-PCS approach value is correct? a. Open b. Percutaneous endoscopic c. External d. Via natural or artificial opening endoscopic

c Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach External in the ICD-10-PCS coding system (Kuehn and Jorwic 2023, 54).

333. Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Utilization management b. Patient access c. Health information management d. Patient accounts

c Resolving failed edits is one of many duties of the health information management (HIM) department. Various medical departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Schraffenberger and Kuehn 2011, 237-238).

360. The lead coder in the HIM department is an acknowledged coding expert and is the go-to person in the healthcare entity for coding guidance. As the HIM director you learn that she is not following proper coding guidelines and her coding practices are not compliant. As the HIM director, the best steps to take would be which of the following? a. Report to the coder to the OIG and terminate the coder b. Notify the compliance officer and suspend the employee c. Review the coding errors and counsel the employee d. Ignore the coding errors

c Reviewing and auditing through internal audits enables healthcare facilities to ensure accurate coding and compliance. In this situation, the coding errors made by the lead coder need to be identified and discussed with the lead coder (Casto and White 2021, 208).

311. If the whistleblower is an employee, which of the following actions can the employer take against the employee? a. Termination b. Suspension c. No action is taken d. Demotion

c The False Claims statute also protects whistleblowers. Protections are provided to employees against discharge, demotion, harassment, or discrimination against an employee (Palkie 2020b, 304).

375. Charges for items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures are called: a. Insurance code mappings b. Charge codes c. Exploding charges d. Revenue Codes

c The charge description master can provide a method for grouping items that are frequently reported together. Items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures, are called exploding charges (Schraffenberger and Kuehn 2011, 227).

388. You are the coding manager and are completing a review of a new coder's work. The case facts are that the patient was treated in the emergency department for two forearm lacerations that were both repaired with simple closure. The new coder assigned one CPT code for the largest laceration. Which of the following would be the correct CPT code assignment for this case? a. One CPT code for the largest laceration b. Two CPT codes, one for each laceration c. One CPT code adding the lengths of the lacerations together d. One CPT code for the most complex closure

c The length of multiple laceration repairs located in the same classification are added together and one code is assigned (Huey 2021, 82-83).

321. A patient was admitted for removal of the left lobe of the liver via laparotomy due to metastasis from a colon carcinoma. What is the correct ICD-10-PCS procedure code for this operation? a. 0FB20ZZ b. 0FB24ZZ c. 0FT20ZZ d. 0FT24ZZ

c The root operation performed was resection—cutting out or off, without replacement, all of a body part. Even though the entire liver was not removed, the correct root operation is resection based on coding guideline B3.8. PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs and liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part. The correct code is 0FT20ZZ. The section is Medical and Surgical—character 0; Body System is Hepatobiliary and Pancreas—character F; Root Operation is Resection—character T; Body Part is Liver, Left Lobe—character 2; Approach is Open—character 0; No Device—character Z; and No Qualifier—character Z (Kuehn and Jorwic 2023, 30, 46, 79).

300. George Benson, age 72, was admitted to the hospital on March 1st and was discharged on May 15th. He has not met his benefit period deductible. He also has not used his reserve days. If the current Medicare rates for the patient's responsibility are: Benefit period deductible: $1,364 Days 61-90: $341 per day Days 91-150: $682 per day What is George's financial responsibility for this inpatient visit? a. $1,364 b. $6,479 c. $6,820 d. $25,916

c The total out-of-pocket patient responsibility for this inpatient stay is $6,820. The patient must pay the deductible for the benefit period which is $1,364. Days 1-60 are covered by deductible. The remaining 16 days of care are charged at $341 per day, or $5,456. (March 1-March 31 is 31 days of care; April 1-April 30 is 30 days of care; May 1-May 15 is 15 days of care for a total of 76 days of care). The total charge for this hospital stay is $6,820 ($5,456 + $1,364) (Hazelwood 2020, 213).

376. Identity theft is primarily a financial crime. However, ________ can impact an individual's ability to obtain health care and health insurance coverage. a. The False Claims Act b. The Red Flags Rule c. Medical identity theft d. Whistleblowing

c There is a difference between identity theft and medical identity theft and the impact it has on patients. This includes financial and safety concerns regarding care (that is, medical record documentation) (Palkie 2020b, 304).

345. When attempting to build patient relations and customer service in the revenue cycle related to the patient's financial obligations, providers should focus which of the following approaches? a. Consumer-centric approach b. Patient engagement approach c. Transparency approach d. Payment variance approach

c Transparency approach involves providing financial information in a user-friendly format along with all relevant past and current patient obligations (Handlon 2020, 267).

354. In the HHPPS system, which home healthcare services are consolidated into a single payment to home health agencies? a. Home health aide visits, routine and nonroutine medical supplies, durable medical equipment b. Routine and nonroutine medical supplies, durable medical equipment, medical social services c. Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits d. Nursing and therapy services, durable medical equipment, medical social services

c Under the home health prospective payment system (HHPPS), CMS has accounted for nonroutine medical supplies, home health aide visits, medical social services, and nursing and therapy services (Hazelwood 2020, 237).

338. Which of the following is most applicable to describing utilization management functions? a. Begins only after patient admission b. Provides criteria to monitor for the continued appropriateness of the supplies and patient convenience items c. Screens for the appropriate use of hospital services and resources d. Applies criteria to determine medications that should be prescribed

c Utilization management may begin prior to the patient's elective or prescheduled admission or occur after the patient is discharged. Utilization management can be incorporated into all stages of the revenue cycle process through prospective, concurrent, and retrospective reviews. However, most often, utilization management does support the middle-process, but does not ONLY begin after patient admission. Utilization management provides supervision of resources to ensure appropriate utilization of those resources focusing on improving quality and reducing costs. Utilization management incorporates criteria to determine readiness for discharge (Handlon 2020, 252).

358. The accounts receivable collection cycle involves the time from: a. Discharge to receipt of the money b. Admission to billing the account c. Admission to deposit in the bank d. Billing of the account to deposit in the bank

c When an organization has delivered goods or services, payment for the same is expected. Because the revenue has been accrued upon delivery or provision of the goods and services, the organization must have some way to keep track of what is owed to them as a result. Accounts receivable then is merely a list of the amounts due from various customers (in this case, patients). Payment on the individual amounts is expected within a specified period. A schedule of those expected amounts is prepared in order to track and follow up on payments that are overdue (late) (Revoir 2020, 812).

346. A clinical documentation improvement (CDI) program facilitates accurate coding and helps coders avoid: a. NCCI edits b. Upcoding c. Coding without a completed face sheet d. Assumption coding

d A CDI program provides a mechanism for the coding staff to communicate with the physician regarding nonspecific diagnostic statements or when additional diagnoses are suspected but not clearly stated in the record, which helps to avoid assumption coding (Hess 2015, 42).

370. In a typical acute-care setting, the explanation of benefits, Medicare summary notice, and remittance advice documents (provided by the payer) are monitored in which revenue cycle area? a. Preclaims submission b. Claims processing c. Accounts receivable d. Claims reconciliation

d A component of the revenue cycle is claims reconciliation. The healthcare facility uses the explanation of benefits (EOB), Medicare summary notice (MSN), and remittance advice (RA) to reconcile accounts. EOBs and MSNs identify the amount owed by the patient to the facility. Collections can contact the patient to collect outstanding deductibles and copayments. RAs indicate rejected or denied items or claims. Facilities can review the RAs and determine where the claim error can be corrected and resubmitted for additional payment (Casto and

392. Daniel's supervisor is requiring him to code inpatient Medicare charts with a diagnosis of pneumonia as having mechanical ventilation provided, whether or not the chart supports this. Daniel has voiced his concerns about this practice but nothing has changed. Daniel makes a call to the OIG to report this practice, and an audit is forthcoming. In this case, Daniel is acting as a(n) _________________: a. Arbitrator b. Mediator c. Ombudsman d. Whistleblower

d A person who reports discriminatory acts or other illegal activity is called a whistleblower. A whistleblower is protected by both a specific federal statute, the Whistleblower Protection Act of 1989, and provisions within individual legislation (Kelly and Greenstone 2020, 111).

357. A financial counselor assumes responsibility for which of the following? a. Ensuring appropriate and timely care is provided b. Identifies barriers to patient progression through healthcare services c. Connects with patients after they leave the provider d. Determines sources of payment for healthcare services rendered

d All other functions are that of a case manager. Financial counselors are staff dedicated to helping patients and physicians determine sources of reimbursement for healthcare services (Handlon 2020, 248-249).

332. Assign the correct CPT code for the following procedure: Patient is admitted to move the skin pocket for their pacemaker. a. 33223, Relocation of skin pocket for implantable defibrillator b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) c. 33212, Insertion of pacemaker pulse generator only; with existing single lead d. 33222, Relocation of skin pocket for pacemaker

d Begin with the main term Relocation; skin pocket; pacemaker (Huey 2021, 24).

306. Determinations of medical necessity reflect the efficient and cost-effective application of patient care for which of the following? a. Positive patient interactions b. Previous medical conditions c. Physician restrictions d. Diagnostic testing

d Determinations of medical necessity must reflect the efficient and cost-effective application of patient care including, but not limited to, diagnostic testing, therapies (including activity restriction, after-care instructions, and prescriptions), disability ratings, rehabilitating an illness, injury, disease or its associated symptoms, impairments or functional limitations, procedures, psychiatric care, levels of hospital care, extended care, long-term care, hospice care, and home healthcare (Handlon 2020, 248).

335. Patient accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should: a. Bill the patients for these accounts b. Contact the patients to obtain an ABN c. Write off the accounts to contractual allowances d. Write off the failed charges to bad debt and bill Medicare for the clean charges

d Edits are used to review a coded claim for accuracy and send back a flag if an error has been detected in the claim. Most organizations run all their claims through edits prior to sending out to any payer to look for errors, correct them, and then send out a clean claim. In this instance the facility has determined to write-off the failed charges because an ABN notice was not signed by the patients (Schraffenberger and Kuehn 2011, 465).

312. The following are the most common reasons for claim denials except: a. Billing noncovered services b. Lack of support for medical necessity c. Untimely filing d. Coverage not in effect for date of service

d Effective dates of coverage are usually resolved in the front end of the revenue cycle or prior to submission of the bill to payers (Handlon 2020, 264).

386. The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies would be most likely to correct this problem in the long term? a. Focused reviews on changes in MS-DRGs b. Facility top 10 to 15 DRGs by volume and charges c. Contracting with a larger consulting firm to do audits and education d. Development and implementation of a CDI program

d Facilities may design a clinical documentation improvement (CDI) program based on several different models. Improvement work can be done with retrospective record review and queries, with concurrent record review and queries, or with concurrent coding. Although much of the CDI process is often done while the patient is in-house, it does not eliminate the need for post-discharge queries (Schraffenberger and Kuehn 2011, 314-315).

341. Hospital-issued notices of noncoverage (HINNs) can be issued at any of the following times except: a. Prior to admission b. At admission c. At any point during the hospital stay d. After discharge

d HINNs may not be issued to a patient after a service is rendered (Handlon 2020, 248).

302. The insurance verification process involves confirming the patient is a member of the insurance plan and this fact is communicated to the provider. Which of the following statements involving insurance verification reflects the most common time when insurance verification occurs for an unscheduled patient? a. Prior to medical screening b. During or directly after preregistration c. After the patient is released from care d. After medical screening

d Many organizations create policies to follow reasonable registration procedures and occur after medical screening (Handlon 2020, 246).

329. The insurance verification process involves confirming the patient is a member of the insurance plan communicated to the provider. Which of the following describes the most common time when insurance verification occurs for an unscheduled patient? a. Prior to medical screening b. During or directly after preregistration c. After the patient is released from care d. After medical screening

d Many organizations create policies to follow reasonable registration procedures and occur after medical screening (Handlon 2020, 246).

298. What is the maximum number of days that Medicare will cover skilled nursing facility inpatient care? a. 21 b. 30 c. 60 d. 100

d Medicare allows for 100 skilled days of care per calendar year (Hazelwood 2020, 213-214).

316. Which of the following tools is typically used to support the processes in the back end of the revenue cycle? a. Chargemaster maintenance software b. Preregistration c. Charge capture d. Automated claim status and cash posting

d Preregistration is completed in the front-end process of the revenue cycle. Chargemaster maintenance software and charge capture are utilized in the middle revenue cycle process. Automated claim status and cash posting occur in the back-end processes of the revenue cycle (Handlon 2020, 259).

353. Which of the following is true about the advance beneficiary notification of noncoverage? a. Estimates patient's financial out-of-pocket financial responsibility b. Supports patients with financial assistance applications c. May be issued when an inpatient service has been regarded noncovered due to medical necessity d. Required to be issued when outpatient service is considered not likely to be covered by Medicare

d The ABN's primary purpose is to inform the patient of financial responsibility for outpatient services when it is not likely Medicare will cover due to NCD or LCD requirements (Handlon 2020, 248).

378. With what agency may patients file a complaint if they suspect medical identity theft violations? a. Internal Revenue Service b. Office of Civil Rights c. Centers for Medicare and Medicaid Services d. Federal Trade Commission

d The Federal Trade Commission has oversight responsibility for identity theft regulations and requires financial institutions and creditors to develop and implement written identity theft prevention programs (Biederman and Dolezel 2017, 406).

381. A patient is admitted with coughing and fever. X-rays show bilateral pneumonia. She is not responding to antibiotics and is admitted to the ICU with severe sepsis. The physician documents that he is not sure whether the sepsis was present on admission or not. What is the POA indicator for the sepsis? a. Y b. N c. U d. W

d The correct answer is "W=Clinically Undetermined". The physician is unable to clinically determine whether the sepsis was present on admission or not (Hazelwood 2020, 230-231).

315. Which of the following individuals assists in communicating with and educating medical staff as part of the CDI program? a. Medical officer b. Chief of staff c. Department chairperson d. Physician champion

d The physician champion, also known in some organizations as the physician advisor, is an individual who assists in communicating with and educating medical staff in areas such as documentation procedures for accurate billing and EHR procedures (Hunt and Kirk 2020, 277).

372. The health record review process and what other aspect allow for the highest level of quality in clinical documentation? a. Training on the revenue cycle b. Medical necessity c. Training on basics of coding d. Physician queries

d The primary operational components of the CDI program are the record review and the query process. The review process and the physician query process allow for the highest level of quality in clinical documentation (Hess 2015, 158).

368. Who assumes the risk of loss in caring for a patient who is covered under a capitation contract? a. Patient b. Policy holder c. Payer d. Provider

d The risk of loss in a capitation arrangement rests with the provider. This includes specialists, for example, who provide services upon referral. Without an appropriate referral, the specialist will not be reimbursed. The payer's financial obligation is, for the most part, discharged with the period fixed payments to the provider. On the provider's side, the fixed payments provide a predictable revenue stream. However, because the revenue is not entirely linked to services, the provider is at risk if an unpredicted percentage of the panel (the patients assigned to that provider) uses the provider's services at a high rate (Davis and Doyle 2016, 57).

355. The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following? a. Upcoding b. Complex coding c. Query d. Unbundling

d Unbundling occurs when individual components of a complete procedure or service are billed separately instead of using a combination code (Bowman 2017, 440).

365. Which of the following items are packaged under the Medicare hospital outpatient prospective payment system (OPPS)? a. Recovery room and medical visits b. Medical visits and supplies (other than pass-through) c. Anesthesia and ambulance services d. Supplies (other than pass-through) and recovery room

d Under the Medicare hospital outpatient prospective payment system (OPPS), outpatient services such as recovery room, supplies (other than pass-through), and anesthesia are included in this reimbursement method (Casto and White 2021, 107).