Domain 4:Subdomain 1

Question 1

A classification system to group cases into groups expected to use similar amounts of resources. It was developed for Medicare and used as part of the PPS for reimbursement.

Answer 1

DRG: Diagnosis Related Group

Question 2

System that is based on a predetermined, fixed amount.

Answer 2

PPS: Prospective Payment System

Question 3

Case-mix management system that utilizes data from the MDS in long-term care settings/ SNFs.

Answer 3

RUG: Resource Utilization Group

Question 4

A scale of uniformed relative values for all physicians’ services in outpatient settings.

Answer 4

RBRVS: Resource-Based Relative Value Scale

Question 5

RBRVS comprises these three elements. What are they?

Answer 5

Malpractice, Physician work, and Physician practice expense

Question 6

The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ___________ for patients with Medicare.

Answer 6

skilled nursing facilities

Question 7

What are the three major steps in a patient’s hospital stay from an insurance company’s point of view?

Answer 7

Admission, treatment, discharge

Question 8

Measure of the clinical severity or resource equipment

Answer 8

Case-mix index

Question 9

Medicare payment system for hospital services that determines the number of hospital stays and hospital services that are reimbursed.

Answer 9

Inpatient prospective payment system (IPPS)

Question 10

Payment system for Medicare Part B services that facilities provided on an outpatient basis.

Answer 10

Outpatient prospective payment system (OPPS)

Question 11

What are two important guidelines that apply to OPPS billing?

Answer 11

The inpatient only list and the three day payment window rule

Question 12

Paper claim for hospital billing, Monitored by the National uniformed billing committee.

Answer 12

UB 04

Question 13

Medicare-refinement of the diagnosis-related group (DRG) payment system. This allows payment to be closely aligned to resource intensity

Answer 13

Medicare-severity diagnosis-related group (MS-DRG)

Question 14

All of the following items are “packaged” under the Medicare outpatient prospective payment system, except:

a. medical visits
b. medical supplies
c. anesthesia
d. recovery room

Answer 14

a. medical visits

Question 15

Under the RBRVS, each HCPCS/CPT code contains three components. Each having assigned relative value units. What are they?

Answer 15

Malpractice insurance expense, practice expense, and physician work

Question 16

The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called.

Answer 16

APCs

Question 17

A patient was seen by Dr. Hope. The charge for the office visit was $200. The Medicare beneficiary had already met his deductible. The Medicare fee schedule amount is $100. Dr. Hope does not accept assignment. The office manager will apply a practice term which is called “balance billing,”what does this term mean

Answer 17

It means that the patient is financially liable for charges in excess of the Medicare fee schedule, up to a limit

Question 18

Rewarding providers for delivering high-quality, efficient clinical care

Answer 18

Value based purchasing (VBP)

Question 19

All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

Answer 19

Revenue cycle management

Question 20

A network of healthcare providers who provide services to those enrolled in the ________.Reimbursement is based either on a contracted fee based off an identified fee schedule or a defined pre-established discounted amount. Providers may elect to join a PPO as a means to increase patient volume while providing services via a discounted fee schedule.

Answer 20

PPO