Cengage-Module 4 Test Medical Billing and Reimbursement Systems (RHIA & RHIT) Flashcards
Use the following case scenario to answer the question.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The non-PAR Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount of the patient’s financial liability (out-of-pocket expense) is
$152.00.
$190.00.
$38.00.
$66.50.
$66.50.
The process by which health care facilities and providers ensure their financial viability by increasing revenue, improving cash flow, and enhancing the patient’s experience is called
auditing.
revenue cycle management.
patient orientation.
accounts receivable.
revenue cycle management.
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
e-mailing physicians.
leaving notes in the chart.
calling the physician’s office.
using established physician query protocols.
using established physician query protocols.
The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the non-PAR fee schedule amount. The limiting charge is
15%.
10%.
20%.
50%.
15%
When a provider bills separately for procedures that are a part of the major procedure, this is called
fraud.
unbundling.
discounting.
packaging.
unbundling.
______ requires present on admission (POA) indicator to be assigned to the ___________ diagnosis(es) for all claims for __________________admissions.
All, principal and secondary, inpatient and outpatient
Medicare, principal and secondary, inpatient
All, principal, inpatient
Medicare, principal, outpatient
Medicare, principal and secondary, inpatient and outpatient
Use the following table to answer the question.
Under ASC-PPS, the patient is responsible for paying the coinsurance amount based upon ____ of the national median charge for the services rendered.
15%
80%
20%
50%
20%
If a query is submitted to the provider, and the coder receives no response within 5 days to a week, the coder should:
contact the HIM Director to refer to the Medical Director.
tell the CEO of the hospital.
phone the physician every day until a response is provided.
code whatever you can and move on.
contact the HIM Director to refer to the Medical Director.
Under APCs, payment status indicator “V” means
inpatient procedure.
ancillary services.
clinic or emergency department visit (medical visits).
significant procedure, not discounted when multiple.
clinic or emergency department visit (medical visits).
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. DNFB is an acronym for _____________.
diagnosis not finally balanced
dollars not fully billed
days not fiscally balanced
discharged no final bill
discharged no final bill
Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT
providers must file all Medicare claims.
fees are restricted to charging no more than the “limiting charge” on nonassigned claims.
nonparticipating providers have a higher fee schedule than that for participating providers.
collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim.
nonparticipating providers have a higher fee schedule than that for participating providers.
The prospective payment system (PPS) requiring the use of DRGs for inpatient care was implemented in 1983. This PPS is used to manage the costs for
assisted living facilities.
home health care.
medical homes.
inpatient hospital stays.
inpatient hospital stays.
Use the following case scenario to answer the question.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The non-PAR Medicare fee schedule amount for this service is $190.00.
If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient’s financial liability (out-of-pocket expense) is
$160.00.
$200.00.
$30.00.
$40.00.
$40.00.
CMS identified specific 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
will not receive additional payment for these conditions when they are present on admission.
will receive additional payment for these conditions when they are not present on admission.
will receive additional payment for these conditions whether they are present on admission or not.
will not receive additional payment for these conditions when they are not present on admission.
will not receive additional payment for these conditions when they are not present on admission.
The term “hard coding” refers to
ICD-10-CM/ICD-10-PCS codes that appear in the hospital’s chargemaster and that are automatically included on the patient’s bill.
HCPCS/CPT codes that appear in the hospital’s chargemaster and will be included automatically on the patient’s bill.
ICD-10-CM/ICD-10-PCS codes that are coded by the coders.
HCPCS/CPT codes that are coded by the coders.
HCPCS/CPT codes that appear in the hospital’s chargemaster and will be included automatically on the patient’s bill.
An Advance Beneficiary Notice (ABN) is a document signed by the
physician advisor indicating that the patient’s stay is denied.
patient indicating whether he/she wants to receive services that Medicare probably will not pay for.
utilization review coordinator indicating that the patient stay is not medically necessary.
provider indicating that Medicare will not pay for certain services.
patient indicating whether he/she wants to receive services that Medicare probably will not pay for.
Which of the following statements is FALSE regarding the use of modifiers with the CPT codes?
Some procedures may require more than one modifier.
Not all procedures need a modifier.
All modifiers will alter (increase or decrease) the reimbursement of the procedure.
Modifiers are appended to the end of the CPT code.
All modifiers will alter (increase or decrease) the reimbursement of the procedure
Use the following case scenario to answer the question.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The non-PAR Medicare fee schedule amount for this service is $190.00.
If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is
$218.50.
$200.00.
$250.00.
$190.00.
$200.00.
A patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively, he develops a pulmonary embolism. The present on admission (POA) indicator for the pulmonary embolism is
W = provider is unable to clinically determine if condition was present at the time of admission.
U = documentation is insufficient to determine if condition was present at the time of admission.
N = not present at the time of inpatient admission.
Y = present at the time of inpatient admission.
N = not present at the time of inpatient admission.
The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator for the ulcer is
W = provider is unable to clinically determine if condition was present at the time of admission.
N = not present at the time of inpatient admission.
U = documentation is insufficient to determine if condition was present at the time of admission.
Y = present at the time of inpatient admission.
U = documentation is insufficient to determine if condition was present at the time of admission.
Based on CMS’s DRG system, other systems have been developed for payment purposes. The one that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients, is known as
RDRGs.
APR-DRGs.
AP-DRGs.
IR-DRGs.
APR-DRGs.
Under APCs, payment status indicator “T” means
significant procedure, not discounted when multiple.
significant procedure, multiple procedure reduction applies.
clinic or emergency department visit (medical visits).
ancillary services.
significant procedure, multiple procedure reduction applies.
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 patient is financially liable for the coinsurance amount, which is
80%.
15%.
100%.
20%.
20%.
A Medicare Summary Notice (MSN) is sent to ________ as their EOB.
physicians
skilled nursing facilities
patients (beneficiaries)
hospitals
patients (beneficiaries)
Assume the patient has already met their deductible and that the physician is a Medicare participating (PAR) provider. The physician’s standard fee for the services provided is $120.00. Medicare’s PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?
$120.00
$ 60.00
$ 96.00
$ 48.00
$ 48.00
Under the APC methodology, discounted payments occur when
there are two or more (multiple) procedures that are assigned to status indicator “S.”
there are two or more (multiple) procedures that are assigned to status indicator “T.”
pass-through drugs are assigned to status indicator “K.”
modifier -78 is used to indicatean unplanned return to the operating room by the same physician
there are two or more (multiple) procedures that are assigned to status indicator “T.”
This prospective payment system is for ____________________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).
skilled nursing facilities
long-term acute care hospitals
home health agencies
inpatient rehabilitation facilities
inpatient rehabilitation facilities
Use the following case scenario to answer the question.
A patient with Medicare is seen in the physician’s office.
The total charge for this office visit is $250.00.
The patient has previously paid his deductible under Medicare Part B.
The PAR Medicare fee schedule amount for this service is $200.00.
The non-PAR Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is
$250.00.
$218.50.
$190.00.
$200.00.
$218.50.
Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT
the patient has a total of 60 lifetime reserve days.
lifetime reserve days are usually reserved for use during the patient’s final (terminal) hospital stay.
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.
lifetime reserve days are paid under Medicare Part B.
lifetime reserve days are paid under Medicare Part B.
Under APCs, payment status indicator “S” means
significant procedure, multiple procedure reduction applies.
clinic or emergency department visit (medical visits).
ancillary services.
significant procedure, multiple procedure reduction does not apply.
significant procedure, multiple procedure reduction does not apply.
The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement.
both HCPCS/CPT codes and ICD-10-CM/ICD-10-PCS codes
ICD-10-CM/ICD-10-PCS codes
HCPCS/CPT codes
NPI codes
ICD-10-CM/ICD-10-PCS codes
This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes are listed in the memoranda.
LCD (Local Coverage Determinations)
OSHA (Occupational Safety and Health Administration)
SI/IS (Severity of Illness/Intensity of Service Criteria)
PEPP (Payment Error Prevention Program)
LCD (Local Coverage Determinations)
Health care claims transactions use one of three electronic formats, including which one of those listed below?
Medicare Summary Notice format
CMS-1500 flat-file format
ANSI ASC X12N 837 format
National Claim Format
ANSI ASC X12N 837 format
This accounting method attributes a dollar figure to every input required to provide a service.
cost accounting
reimbursement
contractual allowance
charge accounting
cost accounting
Use the following table to answer the question.
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.
general ledger key
HCPCS code
charge/service code
revenue code
general ledger key
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
Includes a predetermined list of services which are not separately reimbursed
each service is paid based on the actual charges.
paying a fixed amount per member per month.
involves a group of physicians or an individual physician.
each service is paid based on the actual charges.
Under APCs, payment status indicator “X” means
significant procedure, multiple procedure reduction applies.
clinic or emergency department visit (medical visits).
significant procedure, not discounted when multiple.
ancillary services.
ancillary services.
Under an FFS payment methodology, reimbursement would be determined by ___ reported on the claim.
diagnosis codes
POA Indicator
OASIS
procedure codes
procedure codes
Which of the following is a federal program, state administered that provides health care coverage to low-income populations and certain aged and disabled individuals?
Medicaid
Medicare Part B
Medicare Part A
TRICARE
Medicaid
Accounts receivable (A/R) refers to
claims for which money has not yet come in.
denials that have been returned to the hospital.
the amount the hospital was paid.
claims for which money has been received.
claims for which money has not yet come in.
Use the following table to answer the question.
Which type of code or key provides a uniform system for identifying procedures, services, or supplies?
HCPCS/CPT code
general ledger key
revenue code
charge/service code
HCPCS/CPT code
Under APCs, payment status indicator “C” means
inpatient procedures/services.
ancillary services.
significant procedure, multiple procedure reduction applies.
significant procedure, not discounted when multiple.
inpatient procedures/services.
The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement.
ICD-10-CM/ICD-10-PCS codes
HCPCS/CPT codes
revenue codes
both HCPCS/CPT codes and ICD-10-CM/ICD-10-PCS codes
ICD-10-CM/ICD-10-PCS codes
This is the amount collected by the facility for the services it bills.
costs
contractual allowance
charges
reimbursement
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 investigations 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’s website.
the Federal Register
the OIG’s Model Compliance Plan
the OIG’s Work Plan
the OIG’s Evaluation and Management Documentation Guidelines
the OIG’s Work Plan
Use the following table to answer the question.
Which column on this table contains an assigned number to each product or procedure provided in this facility?
revenue code
HCPCS code
general ledger key
charge/service code
charge/service code
In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a(n)
revenue master.
chargemaster.
superbill.
encounter form.
chargemaster.
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.
National Practitioner Data Bank (NPD)
Universal Physician Number (UPN)
National Provider Identifier (NPI)
Master Patient Index (MPI)
National Provider Identifier (NPI)
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 website or on a CD-ROM.
HAVEN (Home Assessment Validation and Entry)
PACE (Patient Assessment and Comprehensive Evaluation)
PEPP (Payment Error Prevention Program)
HHASS (Home Health Agency Software System)
HAVEN (Home Assessment Validation and Entry)
Use the following table to answer the question.
Which column provides a narrative name of the services provided?
item/service description
