Missed Practice Questions Flashcards
What organization is responsible for updating procedure classification of ICD-10-PCS?
Centers for Medicare and Medicaid Services (CMS)
In ICD-10-CM, a condition that is produced by another illness or an injury and remains after the acute phase of the illness or injury is called?
Sequela
What does the forth character of an ICD-10-CM diagnosis code capture?
Etiology
If a procedure is performed on a body part that does not have a specific value in ICD-10-PCS, what two resources can be used to identify the correct body part character to assign?
ICD-10-PCS alphabetic index and ICD-10-PCS body part key
What are the purposes and goals of ICD-10-PCS?
Improve accuracy and efficiency of coding; Reduce training efforts; and Improve communication with physicians
The assignment of a diagnosis code is based on what?
The providers statement that the patient has a particular condition
What does Medicare require to identify a wound closed with tissue adhesives?
A Level II HCPCS code
What type of hospital is excluded from Medicare inpatient prospective payment system?
Children’s hospitals
What hospital is not reimbursed according to the Medicare outpatient prospective payment system?
Critical access hospitals
What form would a health record technician use to perform the billing function for a physician’s office?
CMS-1500
When a provider accepts assignment, this means the ….?
Provider agrees to accept as payment in full the allowed charge from the fee schedule
What is the goal of coding compliance?
To reduce liability in regards to fraud and abuse
What are NCCI automated prepayment edits based on?
Coding conventions defined in CPT book; National and local policies and coding edits; and analysis of standard medical and surgical practice
What is the NCCI editing system used in processing OPPS claims called?
Outpatient code editor (OCE)
Denials of outpatient claims are often generated from what edits?
National Correct Coding Initiative (NCCI); Outpatient code editor (OCE); and national and local policies
What are essential data elements for healthcare insurance claims?
Revenue code; Procedure name; and Provider name
CMS has made significant advances to link quality to reimbursement using …… programs, which provide accountability by healthcare providers?
Value-based purchasing (VBP)
What is the pre-MDC assignment based on?
A defined set of ICD-10-PCS procedures
What is the government sponsored program that provides expanded coverage of many healthcare services including HMO plans, PPO plans, special needs plans, and Medical Savings accounts?
Medicare Advantage
What system reimburses hospitals a predetermined amount for each Medicare inpatient admission?
MS-DRG
What did CMS implement in 2004 to provide fair and accurate payments while rewarding efficiency and high-quality care for Medicare’s chronically ill population?
Hierarchical condition categories (CMS-HCCs)
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of review?
Quantitative
What is a defining characteristic of an integrated health record format?
Components are arranged in strict chronological order
What is a goal of a CDI program?
Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures
What doe using uniform terminology improve?
Data reliability
What is a record of all transactions in the computer system that is maintained and reviewed for unauthorized access called?
Audit trail
Who issues compliance program guidance?
OIG (Office of the Inspector General)
The charge description master coordinator’s tasks include planning for a review of payment system rules and ….?
Incorporation of CMS rule changes into the CDM
What was created in 2009 to prevent waste, fraud and abuse, reduce healthcare costs, and improve the quality of care provided to Medicare patient?
The Health Care Fraud Prevention Team (HEAT)
What are the two types of queries used in clinical documentation integrity?
Paper and electronic
What is a misrepresentation that an individual knows to be false and knows could result in an unauthorized benefit to some other person an example of?
Fraud
What is used by some healthcare organizations to extract information for research and reimbursement purposes from an electronic health record?
Computer-assisted coding
What is the legal term used to define the protection of health information in a patient-provider relationship?
Confidentiality
Where are online transactions processed?
Clinical data repositories
What law was issued by the Office of National Coordinator for health information technology to be a resource to the nation as a vision and reference?
Federal Health Information Technology Strategic Plan 2015-2020
What system requires the author to sign into the system using a user ID and password to complete the entries made?
Electronic signature authentication
When a patient is seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the seventh character is based on what?
Whether there is a complication in the healing process (malunion, nonunion, sequelae, etc)
What is each HCPCS code assigned that establishes how a service, procedure, or item is paid in the outpatient prospective payment system (OPPS)?
Payment status indicator (SI)
What is the basic formula for calculating each MS-DRG hospital payment?
Hospital payment= MS-DRG relative weight x hospital base rate
What are the possible add-on payments that a hospital could receive in addition to the basic Medicare DRG payment?
Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases
What is the name of the national program to detect and correct improper payments in the Medicare fee-for-service (FFS) program?
Recovery audit contractors (RACs)
What should a hospital refer to if they need to know how much Medicare paid on a claim so they can bill the secondary insurance?
Remittance advice
A fee schedule is ….?
Developed by third-party payers and includes a list of healthcare services, procedures, and changes associated with each
If a provider believes a service may be denied by Medicare because it could be considered unnecessary, the provider must notify the patient before the treatment begins using what form?
Advance beneficiary notice (ABN)
What is the name of the criteria potential organ donors must meet?
United Network of Organ Sharing (UNOS)
Statements that define the performance expectations and structures or processes that must be in place are called what?
Standards
What organization is not an accrediting body for behavioral healthcare?
American Psychological Association
What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals?
State licensure agencies
What component of the revenue cycle is responsible for determining the appropriate financial class for the patient?
Pre-claims submission
Who are the government inspectors whose mission is to reduce Medicare improper payments through the detection and collection of overpayments, identification of underpayments, and implementation of activities to prevent future improper payments?
Recovery audit contractors (RACs)
Computer assisted coding can help prevent fraudulent coding and ensure complete, consistent coding due to what?
Natural language processing
What is the biggest threat to data security?
People
Each state has …… that may include specific requirements for content, format, retention, and use of patient records.
Licensure regulations
What is the best reference tool to determine how CPT codes should be assigned?
American Medical Association’s CPT Assistant newsletter
The Office of Inspector General’s (OIG) Compliance Program for Hospitals recommends that hospitals appoint a cheif compliance officer and …..?
Establish a compliance committee
What is the best reference tool for ICD-10-CM and ICD-10-PCS coding advice?
AHA’s Coding Clinic for ICD-10-CM/PCS
Two Medicare patients were hospitalized with pneumonia. One patient was hospitalized for three days, the other for 30 days. Both cases result in the same MS-DRG with different lengths of stay. How will the hospital be reimbursed?
The hospital will receive the same reimbursement for the same MS-DRG regardless of the length of stay
What condition fails to meet the CMS classification of a hospital-acquired condition?
Gram-negative pneumonia
What is the maximum number of ambulatory payment classifications (APCs) that may be reported per outpatient encounter?
There is no maximum number. It’s unlimited
The physician has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. What is this called?
Auto-authentication
What type of data is exemplified by the insured party’s member identification number?
Financial data (includes details about patient’s occupation, employer, and insurance coverage)
What is the type of master patient index (MPI) matching algorithm that assigns weights to specific data elements and uses the weights to compare one record to another?
Rules-based
Two patients were assigned the same health record number. What is this an example of?
Overlay
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis?
Quantitative (looks for the presence of documents and signatures)
What federal fraud and abuse law prohibits a physician’s referral of designated health services for Medicare and Medicaid patients if the physician has a financial relationship with the entity?
Stark Law (Physician Self-Referral Law; prohibits physicians from referring patients to a business in which they are a member)
What program has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards?
Quality improvement
Charge description master (CDM) software is primarily designed to continuously apply edits to point out compliance issues, check validity of CPT and revenue codes and …..?
Identify item pricing
Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used?
Front-end
A valid authorization for disclosure of information requires what?
An expiration date or event; Must have enough information to identify the patient
The right of an individual to keep his or her personal information from being disclosed to anyone is a definition of what?
Privacy; the right of an individual to be left alone; includes freedom from observation or intrusion into one’s private affairs and the right to maintain control over certain personal and health information
According to the Joint Commission Accreditation Standards, which document must be placed in the patient’s record before a surgical procedure may be performed?
Report of history and physical examination
External clinical validation audits are typically conducted on Medicare patients’ health records by who?
Recovery audit contractors (RACs)
What are the two types of physician queries?
Open-ended and multiple-choice
The inpatient clinical documentation integrity process can be divided into three main functions; query for documentation clarification, physician education and what?
Record review
