Reimbursement methodologies Flashcards
What part of Medicare covers Hospital Insurance that helps cover inpatient hospital, skilled nursing, home health, and hospice care?
a. Part A
b. Part B
c. Part C
d. Part D
Part A
Correct Answer: A
Medicare Part A Hospital Insurance covers inpatient hospital, skilled nursing, home health, and hospice care (Sayles 2013, 239‒241).
The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for:
a. Part A Medicare claims
b. Part B Medicare claims
c. Medicaid claims
d. Medicare and Medicaid claims
Correct Answer: B
CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims (Sayles 2013, 289).
What kind of care is covered when a patient requires nursing or rehab services occurring within 30 days of a 3-day stay or longer in an acute care hospital setting and is certified as medically necessary?
a. Skilled nursing facility care
b. Home health care
c. Hospice care
d. Acute healthcare
Correct Answer: A
Skilled nursing care (SNF) is covered when a patient requires skilled nursing or rehab services within 30 days of a 3-day or longer acute care hospitalization stay (Sayles 2013, 241).
What is the healthcare expense the patient or insured party is responsible to pay which limited the amount the patient would be responsible for:
a. Out-of-pocket expense
b. Coinsurance
c. Deductible
d. Premium
Correct Answer: A
Out-of-pocket expenses are the healthcare expenses that the insured party is responsible for paying. Insurance companies introduced this high-benefit-level in major medical plans to limit the amount of out-of-pocket expenses to the insured (Sayles 2013, 234).
When the CCI editor flags that a comprehensive code and a component code are billed together for the same beneficiary on the same date of service, Medicare will pay for:
a. The component code but not the comprehensive code
b. The comprehensive but not the component code
c. The comprehensive and the component codes
d. Neither the comprehensive nor the component codes
Correct Answer: B
The component code is integral to the comprehensive code and should not be billed separately (CMS 2015).
What part of Medicare covers physician services, outpatient care and home healthcare?
a. Part A
b. Part B
c. Part C
d. Part D
Correct Answer: B
Medicare Part B insurance covers physician services, outpatient care, and home healthcare (Sayles 2013, 239).
A Medicare Advantage Plan (like an HMO or PPO) is a health coverage option under what part of Medicare?
a. Part A
b. Part B
c. Part C
d. Part E
Correct Answer: C
Medicare Part C combines Medicare Part A and Medicare Part B coverage and is operated by private insurance companies that are approved by and under contract with Medicare to form Medicare Advantage Plans (Sayles 2013, 239).
MS-DRG may be split into a maximum of _______ payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC; or no CC.
a. Two
b. Three
c. Four
d. Five
Correct Answer: B
The Medicare IPPS categorizes diagnosis and procedure codes. The diagnosis codes may qualify for a major complication or comorbidity (MCC), or other complication or comorbidity (CC). A diagnosis code may not qualify for either, allowing diagnosis codes to be grouped into three higher or lower DRG groupings (Schraffenberger 2013, 53, 486; Sayles 2013, 267).
Which statement fails to be true for Medicare coverage?
a. Medicare pays for healthcare services provided to Social Security beneficiaries 65 years old and older
b. Medicare pays for healthcare services provided to Social Security beneficiaries for new moms 65 years and younger and their newborn babies
c. Medicare pays for healthcare services provided to Social Security beneficiaries for people under 65 years old with certain disabilities
d. Medicare pays for healthcare services provided to S
Correct Answer: B
Medicare does not cover moms and newborn babies unless the mother has a disability. Moms and newborn babies can be covered under the Medicaid program if they meet specific income guidelines (Sayles 2013, 239).
