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Health Insurance and Reimbursement > Ch 18: Review Test > Flashcards

Ch 18: Review Test Flashcards

Hospital Billing and the UB-04

1
Q

The construction of today’s modern hospital is regulated by ____?

A
  • Federal and state laws
  • State health department policies
  • City ordinances
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2
Q

Today’s hospitals mainly offer what?

A

Private and semiprivate rooms

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3
Q

Hospitals that provide all levels of care are referred to as what?

A

Vertically integrated hospitals

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4
Q

A popular designation given to today’s healthcare patients is what?

A

Customers

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5
Q

A single building or campus, typically having a large number or beds, specialized facilities for various medical care types, and an emergency department, is called a ____

A

General hospital

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6
Q

A medical facility smaller than a hospital is typically referred to as what?

A

Clinic

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7
Q

A healthcare facility that is equipped and staffed to respond immediately to critical situations and provide continuous care to patients with “worst-case” scenarios is a(n) ____?

A

Acute care facility

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8
Q

A facility designed for patients who have had acute events as a result of an illness, injury, or exacerbation of a disease process is a(n) ____?

A

Subacute care facility

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9
Q

The type of facility in which patients have the advantage of constant access to nursing care as they more toward recovery and return to their home is a(n) ____?

A

Subacute care facility

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10
Q

A facility that is licensed or approved under state or local law that is primarily engaged in providing experienced nursing care and related services is a(n) ____?

A

Skilled nursing facility

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11
Q

Temporary relief for an individual providing healthcare to a family member is commonly called what?

A

Respite care

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12
Q

The type of care facility provided for adults who are chronically ill or disabled and are no longer able to manage in independent living situations is referred to as what?

A

Long-term care

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13
Q

What is the acronym for the federal act the ensures public assess to emergency services regardless of ability to pay?

A

EMTLA (emergency medical treatment & labor act)

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14
Q

The voluntary process through which an organization is able to measure the quality of its services and performance against nationally recognized standards is called ____?

A

Accreditation

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15
Q

The independent, nonprofit organization that performs quality-oriented accreditation reviews on HMOs and similar types of managed care plans is ____?

A

NCQA (national committee for quality assurance)

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16
Q

What is the acronym for the organization formed in 1979 to assist ambulatory healthcare organizations in improving the quality of care provided to patients?

A

AAHC (association of academic health centers)

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17
Q

What is the independent, nonprofit organization that promotes continuous improvement in the quality and efficiency of healthcare delivery through the establishment of standards, education, and communication?

A

URAC (Utilization review accreditation commission)

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18
Q

How any organization is run, in its simplest definition, is referred to as ____?

A

Governance

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19
Q

Moral principles that govern the practice of medicine by physicians and other healthcare practitioners are commonly referred to as medical ____?

A

Ethics

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20
Q

Medicare hospital claims are processed by contracted nongovernment organizations or agencies that are commonly referred to as ____?

A
  • Medicare administrative contractors (MACs)
  • Fiscal intermediaries
  • Medicare carriers
21
Q

Medicare Part A pays toward what?

A

Hospital charges

22
Q

Medicare’s acute care payment system is called the ____?

A

Prospective payment system (PPS)

23
Q

What is the abbreviation for an inpatient hospital coding system that groups related diagnoses and their associated medical/surgical treatment?

A

DRGs

24
Q

Many Medicaid programs adjust payments to reflect such things as patient demographics, diagnostic and treatment information, and total charges, which is referred to as ____?

A

A case mix

25
Q

If a military treatment facility is unavailable, TRICARE patients, in many cases, must obtain a ____?

A

Nonavailability statement (NAS)

26
Q

Most third-party payers’ reimbursement rates are subject to change how often?

A

Annually

27
Q

Most hospitals in the United States contract with Blue Cross and Blue Shield and are referred to as ____?

A

Member hospitals

28
Q

The designated spaces on the UB-04 are called what?

A

Form locators

29
Q

The universal claim form for current use in inpatient hospital claims is what?

A

UB-04

30
Q

The process by which a patient can participate in choices about his or her healthcare’s commonly referred to as what?

A

Informed consent

31
Q

An individual who has the legal authority to speak on a patient’s behalf is called what?

A

Surrogate

32
Q

What manual is currently used for inpatient diagnostic coding?

A

ICD-10-CM

33
Q

What manual is now used for inpatient procedural coding?

A

ICD-10-PCS

34
Q

Coders must distinguish key elements or words in the patient’s hospital health record that identify the ____?

A

Principal diagnosis

35
Q

What is the electronic equivalent to the UB-04 paper claim form?

A

837I

36
Q

The overall data stream of the electronic UB-04 file is known as a(n) ____?

A

Transaction set

37
Q

The total number of codes in the ICD-10-PCS system is approximately ____?

A

12,500

38
Q

“That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” defines the ____?

A

Principal diagnosis

39
Q

The payment system implemented in 2000 and used by the Centers for Medicare and Medicaid Services (CMS) to reimburse for hospital outpatient services is called the ____?

A

Hospital outpatient prospective payment system

40
Q

OPPS (or HOPPS) allows for temporary payment of new technologies, drugs, devices, and biologies for which no ambulatory payment classification (APC) payment rate is available, which is called ____?

A

Pass-throughs

41
Q

A computer application interface commonly used in hospitals to send and retrieve data for grouping, editing, and reimbursement outcomes is called the ____?

A

Grouper software system

42
Q

Identify the program implemented by CMS in 1996 to control improper coding that leads to inappropriate increased payment for healthcare services

A

National Correct Coding Initative

43
Q

Impatient acute care hospitals that are paid under the DRG payment system are required to report a specific indicator for every diagnosis on inpatient acute care hospital claims called ____?

A

Present on admission (POA)

44
Q

Identify the congressional act that stipulates that hospitals cannot charge uninsured patients more for the same treatment than what those with health insurance are billed

A

The Affordable Care Act

45
Q

The process of verifying that the diagnosis and procedure codes used on claims comply with all current coding guidelines and rules is called ____?

A

Coding compliance

46
Q

According to the textbook, the implementation date for the ICD-10 coding system is ____?

A

October 1, 2015

47
Q

ICD-10-PCS codes are composed of ____ characters

A

7

48
Q

Regardless of the coding system used, diagnosis codes must be supported by ____?

A

Medical documentation

49
Q

Identify the number of significant procedures other than the principal procedure that may be reported on the UB-04 claim form

A

5

Health Insurance and Reimbursement (38 decks)

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