Domain 7 Flashcards
All of the following items are “packaged” under the Medicare outpatient prospective payment prospective payment system. EXCEPT for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ A. Medical visits B. Medical supplies C. Recovery room D. Anesthesia
A. Medical visits are not packaged under Medicare OPP
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 nonPAR 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 A. $250.00 B. $190.00 C. 218.50 D. $200.00
D. $200.00
If a physician is a participating physician who accepts assignment, he will receive the lesser of “the total charges” or “the PAR Medicare fee schedule amount.” In this case, the Medicare fee schedule amount is less; therefore, the total received by the physician is $200.00
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ A. Scrubber B. Case mix analyzer C. Encoder D. Grouper
D. Grouper
The software program is called a grouper
This accounting method attributes a dollar figure to every input required to provide a service. A. Reimbursement B. Cost accounting C. Charge accounting D. Contractual allowance
B. Cost accounting
Is a process of collecting, recording, classifying, analyzing, summarizing, allocating and evaluating various alternative courses of action & control of costs. It’s goal is to advise the management on the most appropriate course of action based on the cost efficiency and capability
The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is \_\_\_\_\_\_\_\_\_ A. Appropriateness B. Medical necessity C. Benchmarking D. Evidence-based medicine
B.medical necessity
Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable , necessary, and/or appropriate, based on evidence-based clinical standards of care.
Assume the patient has already met his or her 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? A. 12.00 B. 48.00 C. 96.00 D. 60.00
B. $48.00
If the physician is a participating physician (PAR) who accepts the assignment, he will receive the lesser of the “total charges” or the “PAR amount” (on the Medicare Physician fee schedule). Since the PAR amount is lower, the physician collects 80% of the PAR amount. (60.00) x .80=$48.00, from Medicare. The remaining 20% (60.00 x .20=12.00) of the PAR amount is paid by the patient to the physician. Therefore, the physician will receive $48.00 directly from Medicare.
Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient? A. ASCs B. RBRVS C, MS-DRGs d. APCs
B. RBRVS
Resource Based Relative Value Scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all Health Maintenance Organizations (HMOs)
When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of but not in addition to, a code for a medical visit or emergency department service. A 35001 B. 99358 C. 50300 D. 99291
D.99291
CPT Code 99291 (critical care) when a patient meets the definition of critical care, the hospital must use CPT Code 99291 to bill for outpatient encounters in which critical care services are furnished. This code is used instead of another E&M code
The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS) A. Psychiatric hospital B. Cancer hospital C. Rehabilitation hospital D. Long-term care hospital
B. Cancer hospital
Cancer hospitals can apply for and receive waivers from the centers for Medicare and Medicaid services (CMS) and are therefore excluded from the inpatient prospective payment system (MS-DRGs) rehab hospitals are reimbursed under the Inpatient ‘Rehabilitation prospective payment system (IRF PPS). Long term care hospitals are reimbursed under the Long-Term care Hospital Prospective Payment System (LTCH PPS). Skilled nursing facilities are reimbursed under the Skilled Nursing Facility Prospective payment system (SNF PPS)
CMS adjusts the Medicare Severity DRGs and the reimbursement rates every A. Calendar year beginning January 1 B. Month C. Quarter D. Fiscal year beginning October 1
D.fiscal year beginning October 1
How long does the Health Insurance Portability and Accountability Act (HIPAA) require facilities to retain health insurance claims and accounting records? A. Six years B. Seven years C. Ten years D. Five years
A. Six years
Unless state law specifies a longer period
Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT\_\_\_\_\_\_\_\_\_\_\_\_\_\_ A. Changes in services offered B. Changes in coding rules C. Changes in medical staff composition D. Changes in coding productivity
D. Changes in coding productivity
Coding productivity will not directly affect CMI. Inaccuracy or poor coding quality can affect CMI
If a participating provider’s usual fee for a service is $700.00 and Medicare’s allowed amount is $450.00. What amount is written off by the physician? A. None of it is written off B. 340,00 C, 391.00 D. 250.00
D. 250.00
The participating physician agrees to accept Medicare’s fee as payment in full. The physician would write off the difference between $700.00 and $450.00, which is $250.00
How many major diagnostic categories are there in the MS-DRG system? A. 2000 B. 25 C. 80 D. 100
B. 25
There are 25 major diagnostic categories in the MS-DRG system
The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called\_\_\_\_\_\_\_\_\_ A. CMS-1600 b. CMS-1500 C. CMS-1491 D. UB-04
D. UB-04
The standard claim form is a UB-04
