Medical Billing and Reimbursement

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 nonPAR Medicare fee schedule amount for this service is $190.00. If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is a. $30.00. b. $160.00. c. $200.00. d. $40.00.

d. $40.00. The PAR Medicare Fee Schedule amount is $200.00. The patient has already met the deductible. Of the $200.00, the patient is responsible for 20% ($40.00). Medicare will pay 80% ($160.00). Therefore, the total financial liability for the patient is $40.00.

Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's nonPAR fee is $57.00. How much reimbursement will the physician receive from Medicare? a. $120.00 b. $57.00 c. $60.00 d. $45.60

d. $45.60 Since the physician is a nonparticipating physician, he will receive the nonPAR fee. The Medicare nonPAR fee is $57.00. Medicare will pay 80% of the nonPAR fee ($57.00 x 0.80 = $45.60). The patient will pay 20% of the nonPAR fee ($57.00 x 0.20 = $11.40). Since the physician is accepting assignment on this claim, he cannot charge the patient any more than the 20% co-payment. Therefore, the physician will receive $45.60 directly from Medicare.

Use the following table to answer the question. MS-DRG Description Number of Patients CMS Relative Weight 470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871 392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121 194 Simple pneumonia & pleurisy w CC 1,150 1.0235 247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255 293 Heart failure & shock w/o CC/MCC 850 0.8765 313 Chest pain 650 0.5489 292 Heart failure & shock w CC 550 1.0134 690 Kidney & urinary tract infections w/o MCC 400 0.8000 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145 871 Septicemia w/o MV 96+ hours w MCC 250 1.7484 The case-mix index (CMI) for the top 10 MS-DRGs above is a. 1.097. b. 0.782. c. 1.164. d. 1.278

d. 1.278 12781.730/10,000 = 1.278

Under ASCs, when multiple procedures are performed during the same surgical session, a payment reduction is applied. The procedure in the highest level group is reimbursed at ________ and all remaining procedures are reimbursed at ________. a. 100%, 75% b. 100%, 25% c. 50%, 25% d. 100%, 50%

d. 100%, 50%

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

d. 15%.

Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient? a. ASCs b. RBRVS c. MS-DRGs d. APCs

d. APCs

The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement. a. Revenue codes b. both HCPCS/CPT codes and ICD-10-CM/ICD-10-PCS codes c. both HCPCS/CPT codes and ICD-9-CM codes d. ICD-10-CM/ICD-10-PCS codes

d. ICD-10-CM/ICD-10-PCS codes

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

d. OASIS (Outcome and Assessment Information Set). REFERENCE: Green, p 423

When a provider, in order to increase their reimbursement, reports codes to a payer that are not supported by documentation in the medical record, this is called a. hypercoding. b. unbundling. c. fraud. d. abuse.

d. abuse.

Under the APC methodology, discounted payments occur when a. there are two or more (multiple) procedures that are assigned to status indicator "T." b. modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started. c. there are two or more (multiple) procedures that are assigned to status indicator "S." d. both there are two or more (multiple) procedures that are assigned to status indicator "T", and modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.

d. both there are two or more (multiple) procedures that are assigned to status indicator "T", and modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started. Discounts are applied to those multiple procedures identified by CPT codes with status indicator "T." REFERENCE: Green, pp 1007-1008

Under APCs, payment status indicator "V" means a. significant procedure, not discounted when multiple. b. inpatient procedure. c. ancillary services. d. clinic or emergency department visit (medical visits).

d. clinic or emergency department visit (medical visits). Under the APC system, there exists a list of status indicators (also called service indicators, payment status indicators, or payment indicators). This indicator is provided for every HCPCS/CPT code and identifies how the service or procedure would be paid (if covered) by Medicare for hospital outpatient visits.

This is the difference between what is charged and what is paid. a. costs b. reimbursement c. charges d. contractual allowance

d. contractual allowance

The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called a. health data exchange (HDE). b. health information exchange (HIE). c. HIPPA (Health Insurance Portability and Accountability Act). d. electronic data interchange (EDI).

d. electronic data interchange (EDI).

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

d. financially liable for charges in excess of the Medicare fee schedule, up to a limit. Sayles, pp 295-297

CMS adjusts the Medicare Severity DRGs and the reimbursement rates every a. calendar year beginning January 1. b. month. c. quarter. d. fiscal year beginning October 1.

d. fiscal year beginning October 1.

Under APCs, payment status indicator "C" means a. ancillary services. b. significant procedure, not discounted when multiple. c. significant procedure, multiple procedure reduction applies. d. inpatient procedures/services.

d. inpatient procedures/services.

LCDs and NCDs are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors. LCD and NCD are acronyms that stand for a. local contractor's decisions and national contractor's decisions. b. list of covered decisions and noncovered decisions. c. local covered determinations and noncovered determinations. d. local coverage determinations and national coverage determinations.

d. local coverage determinations and national coverage determinations.

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

d. nonparticipating providers have a higher fee schedule than that for participating providers. Under Medicare Part B, Congress has mandated special incentives to increase the number of health care providers signing PAR (participating) agreements with Medicare. One of those incentives includes a 5% higher fee schedule for PAR providers than for non-PAR (nonparticipating) providers.

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 a. support services. b. radiological supplies. c. radiological equipment. d. physician services.

d. physician services.

CMS-identified "Hospital-Acquired Conditions" mean that when a particular diagnosis is not "present on admission," CMS determines it to be a. the principal diagnosis. b. a valid comorbidity. c. medically necessary. d. reasonably preventable

d. reasonably preventable

To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the a. conversion factor. b. geographic practice cost index. c. case-mix index. d. relative weight for the MS-DRG.

d. relative weight for the MS-DRG.

Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 This information is printed on the UB-04 claim form to represent the cost center (e.g., lab, radiology, cardiology, respiratory, etc.) for the department in which the item is provided. It is used for Medicare billing. a. general ledger key b. charge code c. HCPCS d. revenue code

d. revenue code

There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by a. leaving notes in the chart. b. calling the physician's office. c. e-mailing physicians. d. using physician query forms.

d. using physician query forms.

CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital a. will receive additional payment for these conditions when they are not present on admission. b. will not receive additional payment for these conditions when they are present on admission. c. will receive additional payment for these conditions whether they are present on admission or not. d. will not receive additional payment for these conditions when they are not present on admission.

d. will not receive additional payment for these conditions when they are not present on admission.

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 nonPAR 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 a. $190.00. b. $218.50. c. $250.00. d. $200.00.

b. $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.

HCPCS Code Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 Under APCs, the patient is responsible for paying the coinsurance amount based upon ________ of the national median charge for the services rendered. a. 80% b. 20% c. 50% d. 15%

b. 20%

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 nonPAR Medicare fee schedule amount for this service is $190.00. The patient is financially liable for the coinsurance amount, which is a. 15%. b. 20%. c. 80%. d. 100%

b. 20%. REFERENCE: Green and Rowell, p 498

The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called a. MS-DRGs. b. APCs. c. APGs. d. RBRVS

b. APCs.

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 a. remittance advice. b. DNFB (discharged, no final bill). c. periodic interim payments. d. chargemaster.

b. DNFB (discharged, no final bill).

________ is a program that pays for medical assistance to individuals and families with low incomes and limited financial resources. a. Medicare Part B b. Medicaid c. Medigap d. Medicare Part A

b. Medicaid

This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms. a. National Practitioner Databank (NPD) b. National Provider Identifier (NPI) c. Master Patient Index (MPI) d. Universal Physician Number (UPN)

b. National Provider Identifier (NPI)

________ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. a. Potential compensable events b. Never events and Sentinel events d. Adverse preventable events

b. Never events and Sentinel events

When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital a. can bill Medicare for the difference. b. absorbs the loss. c. makes a profit. d. can bill the patient for the difference.

b. absorbs the loss.

Under Medicare Part B, Medicare participating (PAR) providers a. will be able to collect his or her total charges. b. accept, as payment in full, the allowed charge from the PAR fee schedule. c. agree to charge no more than 15% (limiting charge) over the allowed charge from the nonPAR fee schedule. d. agree to charge no more than 10% (limiting charge) over the allowed charge from the nonPAR fee schedule.

b. accept, as payment in full, the allowed charge from the PAR fee schedule.

This process involves the gathering of charge documents from all departments within the facility that have provided services to patients. The purpose is to make certain that all charges are coded and entered into the billing system. a. revenue cycle b. charge capturing c. precertification d. insurance verification

b. charge capturing

The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled "comprehensive codes" and "component codes." According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service a. code both the comprehensive code and the component code. b. code only the comprehensive code. c. code only the component code. d. do not code either one.

b. code only the comprehensive code. REFERENCE: Green, p 1024

The term used to describe a diagram depicting grouper logic in assigning MS-DRGs is a. interrelationship diagram. b. decision tree. c. case-mix index. d. grouper hierarchy

b. decision tree.

A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n) a. scrubber. b. grouper. c. encoder. d. case-mix analyzer.

b. grouper.

These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments. a. pass through b. hold harmless c. limiting charge d. indemnity insurance

b. hold harmless REFERENCE: Green, p 989

Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. When possible, the narratives from the HCPCS/CPT book should be utilized. a. revenue code b. item description/service description c. general ledger key d. HCPCS

b. item description/service description

All of the following items are "packaged" under the Medicare outpatient prospective payment system, EXCEPT for a. anesthesia. b. medical visits. c. recovery room. d. medical supplies.

b. medical visits.

Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are a. conversion factor, CMS weight, and hospital-specific rate. b. physician work, practice expense, and malpractice insurance expense. c. geographic index, wage index, and cost of living index. d. fee-for-service, per diem payment, and capitation.

b. physician work, practice expense, and malpractice insurance expense. REFERENCE: Green, p 1011

This is the amount collected by the facility for the services it bills. a. costs b. reimbursement c. charges d. contractual allowance

b. reimbursement

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS'Web site. a. the OIG's Evaluation and Management Documentation Guidelines b. the OIG's Workplan c. the Federal Register d. the OIG's Model Compliance Plan

b. the OIG's Workplan Sayles, p 305

Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services? a. The provider is a nonparticipating provider. b. The provider cannot bill the patients for the balance between the MPFS amount and the total charges. c. The provider is reimbursed at 15% above the allowed charge. d. The provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus 10%.

b.The provider cannot bill the patients for the balance between the MPFS amount and the total charges. Since the provider accepts assignment, he will accept the Medicare Physician Fee Schedule (MPFS) payment as payment in full.

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 nonPAR Medicare fee schedule amount for this service is $190.00. If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is a. $190.00. b. $218.50. c. $200.00. d. $250.00.

c. $200.00 If a physician is a participating physician who accepts assignment, he will receive the lesser of "the total charges" or "the PAR Medicare Fee Schedule amount." In this case, the Medicare Fee Schedule amount is less; therefore, the total received by the physician is $200.00

If a participating provider's usual fee for a service is $700.00 and Medicare's allowed amount is $450.00, what amount is written off by the physician? a. none of it is written off b. $340.00 c. $250.00 d. $391.00

c. $250.00 The participating physician agrees to accept Medicare's fee as payment in full; therefore, the physician would write off the difference between $700.00 and $450.00, which is 250.00.

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 nonPAR Medicare fee schedule amount for this service is $190.00. a. $152.00. b. $190.00. c. $66.50. d. $38.00.

c. $66.50.

Use the following table to answer the question. MS-DRG Description Number of Patients CMS Relative Weight 470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871 392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121 194 Simple pneumonia & pleurisy w CC 1,150 1.0235 247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255 293 Heart failure & shock w/o CC/MCC 850 0.8765 313 Chest pain 650 0.5489 292 Heart failure & shock w CC 550 1.0134 690 Kidney & urinary tract infections w/o MCC 400 0.8000 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145 871 Septicemia w/o MV 96+ hours w MCC 250 1.7484 Which individual MS-DRGs has the highest reimbursement? a. 293 b. 871 c. 247 d. 470

c. 247 Sayles, p 269

Use the following table to answer the question. MS-DRG Description Number of Patients CMS Relative Weight 470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871 392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121 194 Simple pneumonia & pleurisy w CC 1,150 1.0235 247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255 293 Heart failure & shock w/o CC/MCC 850 0.8765 313 Chest pain 650 0.5489 292 Heart failure & shock w CC 550 1.0134 690 Kidney & urinary tract infections w/o MCC 400 0.8000 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145 871 Septicemia w/o MV 96+ hours w MCC 250 1.7484 Based on this patient volume, during this time period, the MS-DRG that brings in the highest "total" reimbursement to the hospital is a. 871. b. 392. c. 470. d. 247.

c. 470. Sayles, p 296

3. ________ indicates that the claim is suspended in the billing system awaiting late charges, diagnoses/procedure codes that are soft coded by the coders, and/or insurance verification. a. Bill drop b. Concurrent review c. Bill hold d. Accounts receivables

c. Bill hold

________ is an act that represents a crime against payers or other health care programs (e.g., Medicare), or attempts or conspiracies to commit those crimes. a. Assault b. Abuse c. Fraud d. Whistle-blowing

c. Fraud

Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS Web site or on a CD-ROM. a. PACE (Patient Assessment and Comprehensive Evaluation) b. HHASS (Home Health Agency Software System) c. HAVEN (Home Assessment Validation and Entry) d. PEPP (Payment Error Prevention Program)

c. HAVEN (Home Assessment Validation and Entry)

Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 This information is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can be available for various financial classes. a. charge code b. general ledger key c. HCPCS code d. revenue code

c. HCPCS code

The term "hard coding" refers to a. HCPCS/CPT codes that are coded by the coders. b. ICD-9-CM codes that are coded by the coders. c. HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill. d. ICD-9-CM codes that appear in the hospital's chargemaster and that are automatically included on the patient's bill.

c. HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.

This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service. a. Capitation b. Global payment c. Medicare Physician Fee Schedule (MPFS) d. Medicare Severity-Diagnosis Related Groups (MS-DRGs)

c. Medicare Physician Fee Schedule (MPFS) The Medicare Physician Fee Schedule (MPFS) reimburses providers according to predetermined rates assigned to services. REFERENCE: Green, p 1011

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. a. coordination of benefits b. advance beneficiary notice c. Medicare summary notice d. remittance advice

c. Medicare summary notice

A fiscal year is a yearly accounting period. It is the 12-month period on which a budget is planned. The federal fiscal year is a. April 1st through March 31 of the next year. b. July 1st through the June 30 of the next year. c. October 1st through September 30 of the next year. d. January 1st through December 31.

c. October 1st through September 30 of the next year.

The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the a. CMS-1600. b. CMS-1491. c. UB-04. d. CMS-1500.

c. UB-04. The UB-04 is used by hospitals. The CMS-1500 is used by physicians and other noninstitutional providers and suppliers. The CMS-1491 is used by ambulance services.

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

c. ancillary services. Under the APC system, there exists a list of status indicators (also called service indicators, payment status indicators, or payment indicators). This indicator is provided for every HCPCS/CPT code and identifies how the service or procedure would be paid (if covered) by Medicare for hospital outpatient visits.

HCPCS Code Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 This information is the numerical identification of the service or supply. Each item has a unique number with a prefix that indicates the department number (the number assigned to a specific ancillary department) and an item number (the number assigned by the accounting department or the business office) for a specific procedure or service represented on the chargemaster. a. general ledger key b. revenue code c. charge code/service code d. HCPCS code

c. charge code/service code

HCPCS Code Charge Code Item Description General Ledger Key Medicare Medicaid Charges Revenue Code Activity Date 49683105 CT scan; head; w/out contrast 3 70450 70450 500.00 0351 1/1/2013 49683106 CT scan; head; with contrast 3 70460 70460 675.00 0351 1/1/2013 This information is used to assign each item to a particular section of the general ledger in a particular facility's accounting section. Reports can be generated from this information to include statistics related to volume in terms of numbers, dollars, and payer types. a. HCPCS code b. revenue code c. general ledger key d. charge code

c. general ledger key

What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care? a. the skilled nursing facility prospective payment system b. long-term care Medicare severity diagnosis-related groups c. home health resource groups d. inpatient rehabilitation facility

c. home health resource groups

This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs). a. skilled nursing facilities b. home health agencies c. inpatient rehabilitation facilities d. long-term acute care hospitals

c. inpatient rehabilitation facilities

A discharge in which the patient was discharged from the inpatient rehabilitation facility and returned within three calendar days (prior to midnight on the third day) is called a(n) a. qualified discharge. b. per diem. c. interrupted stay. d. transfer.

c. interrupted stay.

Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT a. the patient has a total of 60 lifetime reserve days. 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. c. lifetime reserve days are paid under Medicare Part B. d. lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay.

c. lifetime reserve days are paid under Medicare Part B. Lifetime reserve days are applicable for hospital inpatient stays that are payable under Medicare Part A, not Medicare Part B. REFERENCE: Green and Rowell, pp 528-529

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

c. patient indicating whether he/she wants to receive services that Medicare probably will not pay for

The ________ is a statement sent to the provider to explain payments made by third-party payers. a. acknowledgment notice b. attestation statement c. remittance advice d. advance beneficiary notice

c. remittance advice

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

c. significant procedure, multiple procedure reduction applies. Under the APC system, there exists a list of status indicators (also called service indicators, payment status indicators, or payment indicators). This indicator is provided for every HCPCS/CPT code and identifies how the service or procedure would be paid (if covered) by Medicare for hospital outpatient visits. Payment Status Indicator (PSI) "T" means that if a patient has more than one CPT code with this PSI, the procedure with the highest weight will be paid at 100% and all others will be reduced or discounted and paid at 50%.

The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ________ years, unless state law specifies a longer period. a. ten b. seven c. six d. five

c. six

If the Medicare nonPAR approved payment amount is $128.00 for a proctoscopy, what is the total Medicare approved payment amount for a doctor who does not accept assignment, applying the limiting charge for this procedure? a. $147.20 b. $192.00 c. $140.80 d. $143.00

a. $147.20 The limiting charge is 15% above Medicare's approved payment amount for doctors who do NOT accept assignment ($128.00 X 1.15 = $147.20).

Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group. a. 150% b. 200% c. 50% d. 100%

a. 150%

How many major diagnostic categories are there in the MS-DRG system? a. 25 b. 80 c. 100 d. 2,000

a. 25

When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service. a. CPT Code 99291 (critical care) b. CPT Code 35001 (direct repair of aneurysm) c. CPT Code 99358 (prolonged evaluation and management service) d. CPT Code 50300 (donor nephrectomy)

a. CPT Code 99291 (critical care) When a patient meets the definition of critical care, the hospital must use CPT Code 99291 to bill for outpatient encounters in which critical care services are furnished. This code is used instead of another E&M code.

Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true? a. Each facility is accountable for developing and implementing its own methodology. b. Each facility must use the same methodology used by physician coders based on the history, examination, and medical decision-making components. c. The level of service codes reported by the facility must match those reported by the physician. d. Each facility must use acuity sheets with acuity levels and assign points for each service performed.

a. Each facility is accountable for developing and implementing its own methodology. REFERENCE: Green, p 538

The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement. a. ICD-10-CM/ICD-10-PCS codes b. HCPCS/CPT codes c. NPI codes d. both HCPCS/CPT codes and ICD-10-CM/ICD-10-PCS codes

a. ICD-10-CM/ICD-10-PCS codes REFERENCE: Green, pp 1002-1004 Sayles, p 267

Use the following table to answer the question. MS-DRG Description Number of Patients CMS Relative Weight 470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 1.9871 392 Esophagitis, gastroent & misc. digestive disorders w/o MCC 2,200 0.7121 194 Simple pneumonia & pleurisy w CC 1,150 1.0235 247 Perc cardiovasc proc 2 drug-eluting stent w/o MCC 900 2.1255 293 Heart failure & shock w/o CC/MCC 850 0.8765 313 Chest pain 650 0.5489 292 Heart failure & shock w CC 550 1.0134 690 Kidney & urinary tract infections w/o MCC 400 0.8000 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.8145 871 Septicemia w/o MV 96+ hours w MCC 250 1.7484 Based on this patient volume, the MS-DRG that brings in the highest total profit to the hospital is a. It cannot be determined from this information. b. 392. c. 470. d. 247

a. It cannot be determined from this information. Total profit cannot be determined from this information alone. A comparison of the total charges on the bills and the PPS amount (reimbursement amount) that the hospital would receive for each MS-DRG could identify the total profit.

This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda. a. LCD (Local Coverage Determinations) b. OSHA (Occupational Safety and Health Administration) c. SI/IS (Severity of Illness/Intensity of Service Criteria) d. PEPP (Payment Error Prevention Program)

a. LCD (Local Coverage Determinations)

A new initiative by the government to eliminate fraud and abuse and recover overpayments 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. a. Recovery Audit Contractors (RAC) b. Medicare Code Editors (MCE) c. Clinical Data Abstraction Centers (CDAC) d. Quality Improvement Organizations (QIO)

a. Recovery Audit Contractors (RAC)

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

a. Resource Utilization Groups (RUGs).

This program, formerly called CHAMPUS (Civilian Health and Medical Program—Uniformed Services), is a health care program for active members of the military and other qualified family members. a. TRICARE b. Indian Health Service c. CHAMPVA d. workers'compensation

a. TRICARE

Once all data are posted to a patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have internal auditing systems. The auditing systems run each claim through a set of edits specifically designed for the various third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction. These "internal" auditing systems are called a. scrubbers. b. groupers. c. pricers. d. encoders

a. scrubbers.

Under APCs, payment status indicator "S" means a. significant procedure, multiple procedure reduction does not apply. b. significant procedure, multiple procedure reduction applies. c. ancillary services. d. clinic or emergency department visit (medical visits).

a. significant procedure, multiple procedure reduction does not apply.

The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ____________for patients with Medicare. a. skilled nursing facilities b. intermediate care facilities c. freestanding ambulatory surgery centers d. hospital-based outpatients

a. skilled nursing facilities REFERENCE: Green, pp 1006-1007

This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of their family has a financial interest. a. the Stark I Law b. the Federal Antikickback Statute c. the False Claims Act d. the Civil Monetary Penalties Act

a. the Stark I Law

Assume the patient has already met his or her 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? a. $120.00 b. $ 48.00 c. $ 60.00 d. $ 96.00

b. $ 48.00 If the physician is a participating physician (PAR) who accepts the assignment, he will receive the lesser of the "total charges" or the "PAR amount" (on the Medicare Physician Fee Schedule). Since the PAR amount is lower, the physician collects 80% of the PAR amount ($60.00) x .80 =$48.00, from Medicare. The remaining 20% ($60.00 x .20 = $12.00) of the PAR amount is paid by the patient to the physician. Therefore, the physician will receive $48.00 directly from Medicare.

When billing for the admitting physician for a patient who is admitted to the hospital as an inpatient, one must use a CPT Evaluation and Management code based on the level of care provided. 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a detailed or comprehensive history - a detailed or comprehensive examination and - medical decision making that is straightforward or of low complexity 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history - a comprehensive examination and - medical decision making of moderate complexity 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history - a comprehensive examination and - medical decision making of high complexity a. This code can be used only once per hospitalization. b. This code can be used by the hospital to bill for facility services. c. This code can be used for patients admitted to observation status. d. This code can be used by the admitting physician or consulting physician.

a. This code can be used only once per hospitalization.

All of the following statements are true of MS-DRGs, EXCEPT a. a patient claim may have multiple MS-DRGs. b. special circumstances can result in an outlier payment to the hospital. c. the MS-DRG payment received by the hospital may be lower than the actual cost of providing the services. d. there are several types of hospitals that are excluded from the Medicare inpatient PPS.

a. a patient claim may have multiple MS-DRGs.

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 a. both diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services. b. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) does not match the code used for preadmission services. c. diagnostic services. d. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.

a. both diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.

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) a. cancer hospital b. psychiatric hospital c. rehabilitation hospital d. long-term care hospital

a. cancer hospital Cancer hospitals can apply for and receive waivers from the Centers for Medicare and Medicaid Services (CMS) and are therefore excluded from the inpatient prospective payment system (MS-DRGs). Rehabilitation hospitals are reimbursed under the Inpatient Rehabilitation Prospective Payment System (IRF PPS). Long-term care hospitals are reimbursed under the Long-Term Care Hospital Prospective Payment System (LTCH PPS). Skilled nursing facilities are reimbursed under the Skilled Nursing Facility Prospective Payment System (SNF PPS).

Accounts Receivable (A/R) refers to a. cases that have not yet been paid. b. denials that have been returned to the hospital. c. cases that have been paid. d. the amount the hospital was paid.

a. cases that have not yet been paid.

Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT a. changes in coding productivity. b. changes in services offered. c. changes in medical staff composition. d. changes in coding rules.

a. changes in coding productivity.

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

a. cost accounting

The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. a. discharged not final billed b. dollars not fully billed c. diagnosis not finally balanced d. days not fiscally balanced

a. discharged not final billed

In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation," EXCEPT a. each service is paid based on the actual charges. b. capitation involves a group of physicians or an individual physician. c. capitation means paying a fixed amount per member per month. d. the volume of services and their expense do not affect reimbursement.

a. each service is paid based on the actual charges.

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

a. geographic practice cost indices. The three relative value units are physician work, practice expense, and malpractice expense. These are adjusted by multiplying them by the geographical practice cost indices. Then, this total is multiplied by the national conversion factor.

The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is a. medical necessity. b. benchmarking. c. appropriateness. d. evidence-based medicine.

a. medical necessity.

These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid. a. payment status indicator b. minimum data set c. geographic practice cost indices d. major diagnostic categories

a. payment status indicator

CMS assigns one ________ to each APC and each ________ code. a. payment status indicator, HCPCS b. MS-DRG, CPT c. CPT code, HCPCS d. payment status indicator, ICD-9-CM

a. payment status indicator, HCPCS REFERENCE: Green, pp 1007-1008