Chapter 17 Flashcards
There is more chance for advancements working in a hospital facility than in a private physician’s office.
True
because of the diversity in reimbursement methods, it is very important that the insurance billing specialist have basic knowledge of insurance programs.
True
When a manged care patient is admitted for a non-emergency to a hospital without a manged care contract, the managed care program needs to be notified by the hospital withing 48 hours.
False
Emergency department charges are billed along with the impatient stay on the CMS-1500 claim form
False
when admitted as a workers’ compensation case, the patient will not have an insurance card.
True
The physician’s office uses ICD-9-CM Volumes 1,2, and 3 to code diagnoses and procedures.
False
surgical procedures performed in the hospital operating room are billed b the hospital billing department
False
Elective surgeries are deferrable.
True
A patient has a right to request an itemized bill from a hospital stay with out cost to the patient
True
on the UB-92 claim form, the patient’s date of birth should be entered using 6 digits in block 14.
False
on the UB-92 claim form in bock 2 code 20 (expired) is used to indicate the patient’s status
True
information such as “patient is HMO enrollee” (code 04) listed in blocks 24 through 30 of the UB-92 claim form, is called condition code
True
The DRG is assigned using an automated system called the DRG selector.
False
The purpose of the DRG-based system is to hold down rising health care cost
True
The grouper differentiates between chronic and acute conditions
False
Ambulatory payment classification (APCs) are based on diagnoses
False
Confidential information about patients should never be discussed with
co-workers, family, friends
when criteria are used by the review agency for admission screening this is referred to as
AEPs
one criterion that needs to be met to certify severity of illness (SI) in an admission is
Active, uncontrolled bleeding
a patient is considered an inpatient to the hospital on admission
for an overnight stay
when a patient is admitted who has a managed care contract for an emergency to a hospital the managed care program needs to be notified within
48 hours
The rule stating that when a patient receives outpaitent services whithing 72 hours of admission, then all outpatient services are combined with inpatient services and became part of the diagnostic-related group rate for admission is called the
72-hour rule
what organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review?
QIO
Readmission review occurs if the patient is readmitted within
7 days of discharge
A review for additional Medicare reimbursement is called
day outlier review
The significant reason for which a patient is admitted to the hospital is coded using
principal diagnosis
classification of surgical and nonsurgical procedures and miscellaneous therapeutic and diagnostic procedure are found in
ICD-9-CM Volume 3
ICD-9-CM procedures contain
at least two digits and two to four digits
The codebook used to list procedures on outpatient hospital claims is
CPT
the person who interviews the patient and obtains personal and insurance information and the admitting diagnosis is a/a
admitting clerk
Daily progress notes are entered on the patient’s medical record by a/an
nurse
the claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called the
UB-92
the form that accompanies the billing claim form for inpatient hospital services is called a/an
detail statment
the hospital insurance claim form must always be reviewed by the
insurance billing editor
professional services billed by the physician insclude
hospital consultation, hospital visits, emergency department visits
professional services billed by the physician include
hospital consultation, hospital visits, emergency departments visits
if a patient is being admitted to a hospital and refuses all preadmission testing but a bill is sent to the insurance carrier for these services anyway this is called
phantom charges
a tentavice DRG is based on
admission diagnosis, scheduled procedures, age , and secondary diagnosis
