Chapter 17

Question 1

There is more chance for advancements working in a hospital facility than in a private physician’s office.

Answer 1

True

Question 2

because of the diversity in reimbursement methods, it is very important that the insurance billing specialist have basic knowledge of insurance programs.

Answer 2

True

Question 3

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.

Answer 3

False

Question 4

Emergency department charges are billed along with the impatient stay on the CMS-1500 claim form

Answer 4

False

Question 5

when admitted as a workers’ compensation case, the patient will not have an insurance card.

Answer 5

True

Question 6

The physician’s office uses ICD-9-CM Volumes 1,2, and 3 to code diagnoses and procedures.

Answer 6

False

Question 7

surgical procedures performed in the hospital operating room are billed b the hospital billing department

Answer 7

False

Question 8

Elective surgeries are deferrable.

Answer 8

True

Question 9

A patient has a right to request an itemized bill from a hospital stay with out cost to the patient

Answer 9

True

Question 10

on the UB-92 claim form, the patient’s date of birth should be entered using 6 digits in block 14.

Answer 10

False

Question 11

on the UB-92 claim form in bock 2 code 20 (expired) is used to indicate the patient’s status

Answer 11

True

Question 12

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

Answer 12

True

Question 13

The DRG is assigned using an automated system called the DRG selector.

Answer 13

False

Question 14

The purpose of the DRG-based system is to hold down rising health care cost

Answer 14

True

Question 15

The grouper differentiates between chronic and acute conditions

Answer 15

False

Question 16

Ambulatory payment classification (APCs) are based on diagnoses

Answer 16

False

Question 17

Confidential information about patients should never be discussed with

Answer 17

co-workers, family, friends

Question 18

when criteria are used by the review agency for admission screening this is referred to as

Answer 18

AEPs

Question 19

one criterion that needs to be met to certify severity of illness (SI) in an admission is

Answer 19

Active, uncontrolled bleeding

Question 20

a patient is considered an inpatient to the hospital on admission

Answer 20

for an overnight stay

Question 21

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

Answer 21

48 hours

Question 22

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

Answer 22

72-hour rule

Question 23

what organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review?

Answer 23

QIO

Question 24

Readmission review occurs if the patient is readmitted within

Answer 24

7 days of discharge

Question 25

A review for additional Medicare reimbursement is called

Answer 25

day outlier review

Question 26

The significant reason for which a patient is admitted to the hospital is coded using

Answer 26

principal diagnosis

Question 27

classification of surgical and nonsurgical procedures and miscellaneous therapeutic and diagnostic procedure are found in

Answer 27

ICD-9-CM Volume 3

Question 28

ICD-9-CM procedures contain

Answer 28

at least two digits and two to four digits

Question 29

The codebook used to list procedures on outpatient hospital claims is

Answer 29

CPT

Question 30

the person who interviews the patient and obtains personal and insurance information and the admitting diagnosis is a/a

Answer 30

admitting clerk

Question 31

Daily progress notes are entered on the patient's medical record by a/an

Answer 31

nurse

Question 32

the claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called the

Answer 32

UB-92

Question 33

the form that accompanies the billing claim form for inpatient hospital services is called a/an

Answer 33

detail statment

Question 34

the hospital insurance claim form must always be reviewed by the

Answer 34

insurance billing editor

Question 35

professional services billed by the physician insclude

Answer 35

hospital consultation, hospital visits, emergency department visits

Question 36

professional services billed by the physician include

Answer 36

hospital consultation, hospital visits, emergency departments visits

Question 37

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

Answer 37

phantom charges

Question 38

a tentavice DRG is based on

Answer 38

admission diagnosis, scheduled procedures, age , and secondary diagnosis

Question 39

How many major diagnostic categories (MDCs) are there in the DRG-based system

Answer 39

25

Question 40

on the Ub-92 claim form, code 6 ( transfer from another health care facility) in block 20 is used to indicate

Answer 40

source of admission

Question 41

The claim for used for outpatient hospital services is the

Answer 41

UB-92 claim form

Question 42

PAT is an abbreviation for

Answer 42

pre-admission testing

Question 43

The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge plan to determine whether admisison are justified is called the ____________ departmetn

Answer 43

Utilization Review

Question 44

the_____ coding system is used to list procedural codes for medical patients on hospital insurance claims that are not in the CPT book

Answer 44

HCPCS

Question 45

The ______ is the clinical resume for final progress note

Answer 45

Discharge summary

Question 46

The uniform bill claim form is considered a _____ statement

Answer 46

summary

Question 47

Medicare provides stop loss called _____ in its regulations

Answer 47

outliers

Question 48

The abbreviation of the phrase that indicates when claims are submitted electronically is

Answer 48

EDI

Question 49

on the UB-92 claim form the first digit of the three-digit bill code in block 4 indicates the type of _____

Answer 49

facility

Question 50

on the UB-92 claim form the number of inpatient days is indicated in block 7 these are referred to as ____ days

Answer 50

cover

Question 51

on the UB-92 claim form, 1553 listed as the hour admission indicated that the patient was admitted at

Answer 51

3:53pm

Question 52

a three or four digit code corresponding to each narrative description or standard abbreviation that identifies a specific accommodation, ancillary service, or billing calculation related to service billed is called a/a

Answer 52

Revenue

Question 53

the DRG-based system changed hospital reimbursement from a fee-for-service system to a lump sum, fixed-fee payment base on the ___________ rather than on time or services rendered

Answer 53

Diagnostic

Question 54

cases that cannot be assigned an appropriate DRG because if atypical situations are called

Answer 54

cost outliers

Question 55

an unethical practice of upcoding a patients DRG category for a more severe diagnosis to increase reimbursement is called

Answer 55

DRG creep

Question 56

_______ is a preexisting conditon that will because of its effect on the specific principal diagnosis require more intensive therapy or cause an increase in lenght of stay by at lease 1 say in approximately 75% of cases

Answer 56

Comobrbidity

Question 57

ambulatory payment

Answer 57

an outpatient classification scheme developed by health system international based on procedures rather than diagnostic

Question 58

bed leasing

Answer 58

a managed care plan leases beds from facility

Question 59

capitation or percentage of revenue

Answer 59

reimbursement tot he hospital on a per-member per-month basis to cover costs for the member of the plan

Question 60

case rate

Answer 60

an averaging after a flat rate has been given to certain categories of procedurs

Question 61

diagnosis-related groups (DRGs)

Answer 61

a classification system that categorizes inpatient who are medically related with respect diagnosis and treatment and are statistically similar in length of hospital stay

Question 62

differential by day in hospital

Answer 62

the first day of hospital stay is paid at a higher rate

Question 63

differential by service type

Answer 63

the hospital receives a flat per-admission reimbursement for the service to which the patient is admitted

Question 64

fee schedule

Answer 64

a comprehensive listing of charges based on procedures codes that states fee maximum paid by the health plan

Question 65

flat rate

Answer 65

a single charge per hospital admission paid by the managed care plan

Question 66

per diem

Answer 66

a single charge for a day i the hospital regardless of actual charges or costs incurred

Question 67

periodic interim payments (PIPs) and cash advances

Answer 67

methods in which the plans advances cash to cover expected claims to the hospital

Question 68

withold

Answer 68

method by which part of the plan's payment to the hospital bay be withheld or set aside in a bonus pool

Question 69

reinsurance stop loss

Answer 69

a form of reinsurance in which the hospital buys insurance to protect against lost revenue and receives less of a capitation fee, and the amount the hospital does not receive helps pay for the insurance

Question 70

charges

Answer 70

dollar amount owed to a participating provider for health care services rendered to a plan member according to a fee schedule set by the managed care plan

Question 71

discounts in the for of sliding scale

Answer 71

a reduction in charges for total bed days per year with incremental increases in the discount up to a maximum percentage

Question 72

sliding scales for discounts and per diem

Answer 72

an interim per diem is paid for each day in the hospital

Question 73

reimbursement methods

Answer 73

ambulatory payment classification, bed leasing, capitation or percentage of revenue,case rate, contract rate, diagnosis-related groups, differential b day in hospital, differential by service type, fee-for-schedule, fee schedule, flat rate, per diem, percentage of accrued charges, periodic interim payments (PIPs) and cash advances, relative value studies (scale)(RVS), resource-basd relative value scale (RBRVS), usual customary and reasonalbe (UCR), etc

Question 74

Resection

Answer 74

cutting our or off, without replacement, all of body part

Question 75

Reposition

Answer 75

moving to its normal location or other suitable location (all or a portion of a body part)

Question 76

Transfer

Answer 76

Moving, without taking out, all or portion of a body part to another location to take over the function of all or a portion of a body part

Question 77

Drainage

Answer 77

taking or letting out fluids and/or gases from a body part

Question 78

Inspection

Answer 78

Visually and/or manually exploring a body part

Question 79

Dilation

Answer 79

expanding an orifice or lumen of a tabular body part

Question 80

Restriction

Answer 80

Partially closing the orifice or lumen of a tabular body part

Question 81

Replacement

Answer 81

Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

Question 82

Removal

Answer 82

Taking out or off (all or portion of body part)

Question 83

Division

Answer 83

Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part

Question 84

Release

Answer 84

Freeing a body part from an abnormal physical constraint

Question 85

Repair

Answer 85

Restoring, to the extent possible, a body part to its normal anatomic structure and funtion

Question 86

to code drugs what code do we use?

Answer 86

j codes

Question 87

QIO is responsible for

Answer 87

admission review, readmission review, procedure review, day & cost outlier review, DRG validation, and transfer review

Question 88

QIO is designed for

Answer 88

to monitor and improve usage and quality of care for medicare benefices

Question 89

Readmission Review

Answer 89

is when a patient is readmitted 7 days of admission

Question 90

what form is used for inpatient for billing?

Answer 90

UB-04

Question 91

what form is used for outpatient for billing?

Answer 91

CM-1500

Question 92

UHDDS

Answer 92

Uniform Hospital Discharge Data Set

Question 93

significant procedures

Answer 93

is surgical in nature, carries a procedural risk, carries an anesthetic risk, requires specialized training to perform

Question 94

revision

Answer 94

correcting to the extent possible, a portion of a malfunctioning or the position of a displaced device

Question 95

An all-inclusive rate is paid both institutional and professional service

Answer 95

Bundled case rate