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111 Cards in this Set

  • Front
  • Back
The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called

A. Medicare Severity Diagnosis Related Groups (MS-DRGs).
B. Resource Based Relative Value System (RBRVS).
C. Resource Utilization Groups (RUGs).
D. Ambulatory Patient Classifications (APCs).
C. Resource Utilization Groups (RUGs).
The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from

A. MDS (Minimum Data Set).
B. OASIS (Outcome and Assessment Information Set).
C. UHDDS (Uniform Hospital Discharge Data Set).
D. UACDS (Uniform Ambulatory Core Data Set).
B. OASIS (Outcome and Assessment Information Set).
Under APCs, the payment status indicator “N” means that the payment

A. is for ancillary services.
B. is for a clinic or an emergency visit.
C. is discounted at 50%.
D. is packaged into the payment for other services.
A. is for ancillary services.
All of the following items are “packaged” under the Medicare outpatient prospective payment system, EXCEPT for

A. recovery room.
B. medical supplies.
C. anesthesia.
D. medical visits.
D. medical visits.
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are

A. geographic index, wage index, and cost of living index.
B. fee-for-service, per diem payment, and capitation.
C. conversion factor, CMS weight, and hospital-specific rate.
D. physician work, practice expense, and malpractice insurance expense.
D. physician work, practice expense, and malpractice insurance expense.
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called

A. APGs.
B. RBRVS.
C. APCs.
D. MS-DRGs.
C. APCs.
A patient was seen by Dr. Zachary. The charge for the office visit was $125. The Medicare beneficiary had already met his deductible. The Medicare fee schedule amount is $100. Dr. Zachary does not accept assignment. The office manager will apply a practice termed as “balance billing,” which means that the patient is

A. financially liable for the Medicare fee schedule amount.
B. financially liable for charges in excess of the Medicare fee schedule, up to a limit.
C. not financially liable for any amount.
D. financially liable for only the deductible.
B. financially liable for charges in excess of the Medicare fee schedule, up to a limit.
The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ____________________ for patients with Medicare.

A. freestanding ambulatory surgery centers
B. hospital-based outpatients
C. intermediate care facilities
D. skilled nursing facilities
D. skilled nursing facilities
The _______________ is a statement sent to the provider to explain payments made by third-party payers.

A. remittance advice
B. advance beneficiary notice
C. attestation statement
D. acknowledgment notice
A. remittance advice
How many major diagnostic categories are there in the MS-DRG system?

A. 100
B. 2,000
C. 80
D. 25
D. 25
The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called

A. HIPPA (Health Insurance Portability and Accountability Act).
B. electronic data interchange (EDI).
C. health information exchange (HIE).
D. health data exchange (HDE).
B. electronic data interchange (EDI).
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)

A. encoder.
B. case-mix analyzer.
C. grouper.
D. scrubber.
C. grouper.
The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the

A. UB-04.
B. CMS-1500.
C. CMS-1491.
D. CMS-1600.
A. UB-04.

The UB-04 is used by hospitals. The CMS-1500 is used by physicians and other noninstitutional providers and suppliers. The CMS-1491 is used by ambulance services.
Under ASCs, when multiple procedures are performed during the same surgical session, a payment reduction is applied. The procedure in the highest level group is reimbursed at ____ and all remaining procedures are reimbursed at ___.

A. 50%, 25%
B. 100%, 50%
C. 100%, 25%
D. 100%, 75%
B. 100%, 50%
The _____ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider.

A. Medicare summary notice
B. remittance advice
C. advance beneficiary notice
D. coordination of benefits
A. Medicare summary notice
Currently, which prospective payment system is used to determine the payment to the “physician” for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient?

A. MS-DRGs
B. APGs
C. RBRVS
D. ASCs
C. RBRVS

The prospective payment system used to reimburse the “hospital” for outpatient surgery is APCs. The prospective payment used to reimburse a “free-standing surgery center” for outpatient surgery is ASCs. The prospective payment system used to reimburse the “physician” for outpatient surgery is RBRVS.
Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services?

A. The provider is reimbursed at 15% above the allowed charge.
B. The provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus 10%.
C. The provider cannot bill the patients for the balance between the MPFS amount and the total charges.
D. The provider is a nonparticipating provider.
C. The provider cannot bill the patients for the balance between the MPFS amount and the total charges.

Since the provider accepts assignment, he will accept the Medicare Physician Fee Schedule (MPFS) payment as payment in full.
When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital

A. makes a profit.
B. can bill the patient for the difference.
C. absorbs the loss.
D. can bill Medicare for the difference.
C. absorbs the loss.
Under ASCs, bilateral procedures are reimbursed at ____ of the payment rate for their group.

A. 50%
B. 100%
C. 200%
D. 150%
D. 150%
The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period.

A. six
B. five
C. seven
D. ten
A. six
25. ____ is an act that represents a crime against payers or other health care programs (e.g., Medicare), or attempts or conspiracies to commit those crimes.

A. Fraud
B. Whistle-blowing
C. Abuse
D. Assault
A. Fraud
26. These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid.

A. geographic practice cost indices
B. major diagnostic categories
C. minimum data set
D. payment status indicator
D. payment status indicator
27. 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. evidence-based medicine.
C. benchmarking.
D. medical necessity.
D. medical necessity.
28. This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of their family has a financial interest.

A. the False Claims Act
B. the Civil Monetary Penalties Act
C. the Federal Antikickback Statute
D. the Stark I Law
D. the Stark I Law
29. ____ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.

A. Sentinel events
B. Adverse preventable events
C. Never events
D. Potential compensable events
C. Never events
30. When a provider, in order to increase their reimbursement, reports codes to a payer that are not supported by documentation in the medical record, this is called

A. fraud.
B. abuse.
C. unbundling.
D. hypercoding.
B. abuse.
What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care?

A. home health resource groups
B. inpatient rehabilitation facility
C. long-term care Medicare severity diagnosis-related groups
D. the skilled nursing facility prospective payment system

A. home health resource groups

If the Medicare nonPAR approved payment amount is $128.00 for a proctoscopy, what is the total Medicare approved payment amount for a doctor who does not accept assignment, applying the limiting charge for this procedure?

A. $140.80
B. $143.00
C. $192.00
D. $147.20

D. $147.20




The limiting charge is 15% above Medicare's approved payment amount for doctors who do NOT accept assignment ($128.00 × 1.15 = $147.20).

33. Under the inpatient prospective payment system (IPPS), there is a 3-day payment window (formerly referred to as the 72-hour rule). This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for

A. diagnostic services.
B. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.
C. therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) does not match the code used for preadmission services.
D. both A and B.

D. both A and B.

This initiative was instituted by the government to eliminate fraud and abuse and recover overpayments, and involves the use of ______________. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government.

A. Clinical Data Abstraction Centers (CDAC)
B. Quality Improvement Organizations (QIO)

C. Medicare Code Editors (MCE)
D. Recovery Audit Contractors (RAC)

D. Recovery Audit Contractors (RAC)

When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n)

A. interrupted stay.
B. transfer.
C. per diem.
D. qualified discharge.

A. interrupted stay.

36. In a global payment methodology, which is sometimes applied to radiological and similar types of procedures that involve professional and technical components, all of the following are part of the “technical” components EXCEPT

A. radiological equipment.
B. physician services.
C. radiological supplies.
D. support services.

B. physician services.

Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT

A. changes in medical staff composition.
B. changes in coding rules.
C. changes in services offered.
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.





This prospective payment system replaced the Medicare physician payment system of “customary, prevailing, and reasonable (CPR)” charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service.

A. Medicare Physician Fee Schedule (MPFS)
B. Medicare Severity-Diagnosis Related Groups (MS-DRGs)
C. Global payment
D. Capitation

A. Medicare Physician Fee Schedule (MPFS)




The Medicare Physician Fee Schedule (MPFS) reimburses providers according to predetermined rates assigned to services.







CMS-identified “Hospital-Acquired Conditions” mean that when a particular diagnosis is not “present on admission,” CMS determines it to be

A. medically necessary.
B. reasonably preventable.
C. a valid comorbidity.
D. the principal diagnosis.

B. reasonably preventable.

40. This process involves the gathering of charge documents from all departments within the facility that have provided services to patients. The purpose is to make certain that all charges are coded and entered into the billing system.

A. precertification
B. insurance verification
C. charge capturing
D. revenue cycle

C. charge capturing

The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled “comprehensive codes” and “component codes.” According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service

A. code only the component code.
B. do not code either one.
C. code only the comprehensive code.
D. code both the comprehensive code and the component code.

C. code only the comprehensive code.

42. 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. rehabilitation hospital
B. long-term care hospital
C. psychiatric hospital
D. cancer hospital

D. 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). Rehabilitation 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).

43. These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments.

A. limiting charge
B. indemnity insurance
C. hold harmless
D. pass through

C. hold harmless

44. LCDs and NCDs are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors. LCD and NCD are acronyms that stand for

A. local covered determinations and noncovered determinations.
B. local coverage determinations and national coverage determinations.
C. list of covered decisions and noncovered decisions.
D. local contractor's decisions and national contractor's decisions.

B. local coverage determinations and national coverage determinations.

45. This information is printed on the UB-04 claim form to represent the cost center (e.g., lab, radiology, cardiology, respiratory, etc.) for the department in which the item is provided. It is used for Medicare billing.

A. HCPCS
B. revenue code
C. charge code
D. general ledger key

B. revenue code

46. This information is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can be available for various financial classes.

A. HCPCS code
B. revenue code
C. general ledger key
D. charge code

A. HCPCS code

47. This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. When possible, the narratives from the HCPCS/CPT book should be utilized.

A. general ledger key
B. HCPCS
C. item description/service description
D. revenue code

C. item description/service description

48. This information is the numerical identification of the service or supply. Each item has a unique number with a prefix that indicates the department number (the number assigned to a specific ancillary department) and an item number (the number assigned by the accounting department or the business office) for a specific procedure or service represented on the chargemaster.

A. charge code/service code
B. HCPCS code
C. revenue code
D. general ledger key

A. charge code/service code

49. This information is used to assign each item to a particular section of the general ledger in a particular facility's accounting section. Reports can be generated from this information to include statistics related to volume in terms of numbers, dollars, and payer types.

A. general ledger key
B. charge code
C. revenue code
D. HCPCS code

A. general ledger key

50. Under APCs, the patient is responsible for paying the coinsurance amount based upon ____ of the national median charge for the services rendered.

A. 50%
B. 15%
C. 20%
D. 80%

C. 20%

51. ____ is a program that pays for medical assistance to individuals and families with low incomes and limited financial resources.

A. Medigap
B. Medicare Part A
C. Medicaid
D. Medicare Part B

C. Medicaid

52. The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. DNFB is an acronym for _____________.

A. diagnosis not finally balanced
B. days not fiscally balanced
C. dollars not fully billed
D. discharged not final billed

D. discharged not final billed

53. The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the nonPAR fee schedule amount. The limiting charge is

A. 10%.
B. 15%.
C. 20%.
D. 50%.

B. 15%.

54. 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.


j

54. The patient is financially liable for the coinsurance amount, which is

A. 80%.
B. 100%.
C. 20%.
D. 15%.

C. 20%.

55. If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is

A. $200.00.
B. $250.00.
C. $218.50.
D. $190.00.

A. $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.

56. If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is

A. $250.00.
B. $200.00.
C. $218.50.
D. $190.00.

C. $218.50.




If a physician is a nonparticipating physician who does not accept assignment, he can collect a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount. In this case, the nonPAR Medicare fee schedule amount is $190.00 and 15% over this amount is $28.50; therefore, the total that he can collect is $218.50.

57. If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is

A. $200.00.
C. $160.00.
B. $40.00.
D. $30.00.

B. $40.00.




The PAR Medicare fee schedule amount is $200.00. The patient has already met the deductible. Of the $200.00, the patient is responsible for 20% ($40.00). Medicare will pay 80% ($160.00). Therefore, the total financial liability for the patient is $40.00.

58. If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is

A. $66.50.
B. $38.00.
C. $190.00.
D. $152.00.

A. $66.50.




$190.00 = nonPAR Medicare schedule amount$190.00 × 0.20 = $38.00 = patient liable for 20% coinsurance$190.00 × 0.80 = $152.00 = Medicare pays 80%$190.00 × 0.15 = $28.50 = 15% (limiting charge) over nonPAR Medicare fee schedule amountPhysician can balance bill and collect from the patient the difference between the nonPAR Medicare fee schedule amount and the total charge amount. Therefore, the patient's financial liability is $38.00 + 28.50 = $66.50.

59. A fiscal year is a yearly accounting period. It is the 12-month period on which a budget is planned. The federal fiscal year is

A. October 1st through September 30 of the next year.
B. January 1st through December 31.
C. July 1st through the June 30 of the next year.
D. April 1st through March 31 of the next year.



A. October 1st through September 30 of the next year.

60. There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by

A. e-mailing physicians.
B. using physician query forms.
C. calling the physician's office.
D. leaving notes in the chart.

B. using physician query forms.

61. Under APCs, payment status indicator “C” means

A. ancillary services.
B. clinic or emergency department visit (medical visits).
C. significant procedure, multiple procedure reduction applies.
D. significant procedure, not discounted when multiple.

A. ancillary services.




Under the APC system, there exists a list of status indicators (also called service indicators, payment status indicators, or payment indicators). This indicator is provided for every HCPCS/CPT code and identifies how the service or procedure would be paid (if covered) by Medicare for hospital outpatient visits.

62. Under APCs, payment status indicator “V” means

A. ancillary services.
B. clinic or emergency department visit (medical visits).
C. inpatient procedure.
D. significant procedure, not discounted when multiple.

B. clinic or emergency department visit (medical visits).

63. Under APCs, payment status indicator “S” means

A. ancillary services.
B. clinic or emergency department visit (medical visits).
C. significant procedure, multiple procedure reduction applies.
D. significant procedure, multiple procedure reduction does not apply.

D. significant procedure, multiple procedure reduction does not apply.




Payment Status Indicator (PSI) “S” means that if a patient has more than one CPT code with this PSI, none of the procedures will be discounted or reduced. They will all be paid at 100%.







64. Under APCs, payment status indicator “T” means

A. ancillary services.
B. clinic or emergency department visit (medical visits).
C. significant procedure, multiple procedure reduction applies.
D. significant procedure, not discounted when multiple.

C. significant procedure, multiple procedure reduction applies.




Payment Status Indicator (PSI) “T” means that if a patient has more than one CPT code with this PSI, the procedure with the highest weight will be paid at 100% and all others will be reduced or discounted and paid at 50%.

65. Under APCs, payment status indicator “C” means

A. ancillary services.
B. inpatient procedures/services.
C. significant procedure, multiple procedure reduction applies.
D. significant procedure, not discounted when multiple.

B. inpatient procedures/services.

66. This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms.

A. National Practitioner Databank (NPD)
B. Universal Physician Number (UPN)
C. Master Patient Index (MPI)
D. National Provider Identifier (NPI)

D. National Provider Identifier (NPI)

67. In the managed care industry, there are specific reimbursement concepts, such as “capitation.” All of the following statements are true in regard to the concept of “capitation,” EXCEPT

A. each service is paid based on the actual charges.
B. the volume of services and their expense do not affect reimbursement.
C. capitation means paying a fixed amount per member per month.
D. capitation involves a group of physicians or an individual physician.

A. each service is paid based on the actual charges.

Which of the following statements is FALSE regarding the use of modifiers with the CPT codes?

A. All modifiers will alter (increase or decrease) the reimbursement of the procedure.
B. Some procedures may require more than one modifier.
C. Modifiers are appended to the end of the CPT code.
D. Not all procedures need a modifier.

A. All modifiers will alter (increase or decrease) the reimbursement of the procedure.

69. This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS' Web site.

A. the OIG's Evaluation and Management Documentation Guidelines
B. the OIG's Model Compliance Plan
C. the Federal Register
D. the OIG's Workplan

D. the OIG's Workplan

70. Accounts Receivable (A/R) refers to

A. cases that have not yet been paid.
B. the amount the hospital was paid.
C. cases that have been paid.
D. denials that have been returned to the hospital.

A. cases that have not yet been paid.

71. The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement.

A. HCPCS/CPT codes
B. ICD-9-CM codes
C. both HCPCS/CPT codes and ICD-9-CM codes
D. none of the above

B. ICD-9-CM codes

72. The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement.

A. HCPCS/CPT codes
B. ICD-9-CM codes
C. both HCPCS/CPT codes and ICD-9-CM codes
D. none of the above

B. ICD-9-CM codes

73. An Advance Beneficiary Notice (ABN) is a document signed by the

A. utilization review coordinator indicating that the patient stay is not medically necessary.
B. physician advisor indicating that the patient's stay is denied.
C. patient indicating whether he/she wants to receive services that Medicare probably will not pay for.
D. provider indicating that Medicare will not pay for certain services

C. patient indicating whether he/she wants to receive services that Medicare probably will not pay for.

74. CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital

A. will receive additional payment for these conditions when they are not present on admission.
B. will not receive additional payment for these conditions when they are not present on admission.
C. will receive additional payment for these conditions whether they are present on admission or not.
D. will not receive additional payment for these conditions when they are present on admission.

B. will not receive additional payment for these conditions when they are not present on admission.

75. Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT

A. providers must file all Medicare claims.
B. nonparticipating providers have a higher fee schedule than that for participating providers.
C. fees are restricted to charging no more than the “limiting charge” on nonassigned claims.
D. collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim.

B. nonparticipating providers have a higher fee schedule than that for participating providers.




Under Medicare Part B, Congress has mandated special incentives to increase the number of health care providers signing PAR (participating) agreements with Medicare. One of those incentives includes a 5% higher fee schedule for PAR providers than for nonPAR (nonparticipating) providers.

76. Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT

A. the patient has a total of 60 lifetime reserve days.
B. lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay.
C. lifetime reserve days are paid under Medicare Part B.
D. lifetime reserve days are not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges.

C. lifetime reserve days are paid under Medicare Part B.




Lifetime reserve days are applicable for hospital inpatient stays that are payable under Medicare Part A.

77. When a provider bills separately for procedures that are a part of the major procedure, this is called

A. fraud.
B. packaging.
C. unbundling.
D. discounting.

C. unbundling.

78. Once all data are posted to a patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have internal auditing systems. The auditing systems run each claim through a set of edits specifically designed for the various third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction. These “internal” auditing systems are called

A. scrubbers.
B. pricers.
C. groupers.
D. encoders.

A. scrubbers.

79. To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the

A. conversion factor.
B. case-mix index.
C. geographic practice cost index.
D. relative weight for the MS-DRG.

D. relative weight for the MS-DRG.

80. Under the APC methodology, discounted payments occur when

A. there are two or more (multiple) procedures that are assigned to status indicator “T.”
B. there are two or more (multiple) procedures that are assigned to status indicator “S.”
C. modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.
D. both A and C.

A. there are two or more (multiple) procedures that are assigned to status indicator “T.”




C. modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.

81.This prospective payment system is for ____________________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).

A. skilled nursing facilities
B. inpatient rehabilitation facilities
C. home health agencies
D. long-term acute care hospitals

B. inpatient rehabilitation facilities

82. Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS Web site or on a CD-ROM.

A. PACE (Patient Assessment and Comprehensive Evaluation)
B. HAVEN (Home Assessment Validation and Entry)
C. HHASS (Home Health Agency Software System)
D. PEPP (Payment Error Prevention Program)

B. HAVEN (Home Assessment Validation and Entry)

83. This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda.

A. LCD (Local Coverage Determinations)
B. SI/IS (Severity of llness/Intensity of Service Criteria)
C. OSHA (Occupational Safety and Health Administration)
D. PEPP (Payment Error Prevention Program)

A. LCD (Local Coverage Determinations)

84. The term “hard coding” refers to

A. HCPCS/CPT codes that are coded by the coders.
B. HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.
C. ICD-9-CM codes that are coded by the coders.
D. ICD-9-CM codes that appear in the hospital's chargemaster and that are automatically included on the patient's bill.

B. HPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.

85. This is the amount collected by the facility for the services it bills.

A. costs
B. charges
C. reimbursement
D. contractual allowance

C. reimbursement

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. $120.00
B. $ 60.00
C. $ 48.00
D. $ 96.00

C. $ 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.

87. This accounting method attributes a dollar figure to every input required to provide a service.

A. cost accounting
B. charge accounting
C. reimbursement
D. contractual allowance

A. cost accounting

88. This is the amount the facility actually bills for the services it provides.

A. costs
B. charges
C. reimbursement
D. contractual allowance

B. charges

89. This is the difference between what is charged and what is paid.

A. costs
B. charges
C. reimbursement
D. contractual allowance

D. contractual allowance

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. CPT Code 99291 (critical care)
B. CPT Code 99358 (prolonged evaluation and management service)
C. CPT Code 35001 (direct repair of aneurysm)
D. CPT Code 50300 (donor nephrectomy)

A. CPT Code 99291 (critical care)

91. To monitor timely claims processing in a hospital, a summary report of “patient receivables” is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the

A. remittance advice.
B. periodic interim payments.
C. Discharged, Not Final Billed
D. chargemaster.

CDNFB stands for “Discharged, Not Final Billed”

Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's nonPAR fee is $57.00. How much reimbursement will the physician receive from Medicare?

A. $120.00
B. $60.00
C. $57.00
D. $45.60

D. $45.60




Since the physician is a nonparticipating physician, he will receive the nonPAR fee.The Medicare nonPAR fee is $57.00.Medicare will pay 80% of the nonPAR fee ($57.00 × 0.80 = $45.60).The patient will pay 20% of the nonPAR fee ($57.00 × 0.20 = $11.40).Since the physician is accepting assignment on this claim, he cannot charge the patient any more than the 20% copayment. Therefore, the physician will receive $45.60 directly from Medicare.





93. CMS assigns one _______________ to each APC and each ______________ code.

A. payment status indicator, HCPCS
B. CPT code, HCPCS
C. MS-DRG, CPT
D. payment status indicator, ICD-9-CM

A. payment status indicator, HCPCS

94. All of the following statements are true of MS-DRGs, EXCEPT




A. a patient claim may have multiple MS-DRGs.


B. the MS-DRG payment received by the hospital may be lower than the actual cost of providing the services.


C. special circumstances can result in an outlier payment to the hospital.


D. there are several types of hospitals that are excluded from the Medicare inpatient PPS.

A. a patient claim may have multiple MS-DRGs.




Only one MS-DRG is assigned per inpatient hospitalization.

95. This program, formerly called CHAMPUS (Civilian Health and Medical Program—Uniformed Services), is a health care program for active members of the military and other qualified family members.

A. TRICARE
B. CHAMPVA
C. Indian Health Service
D. workers' compensation

A. TRICARE

96. When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a

A. Fraud Prevention Memorandum of Understanding.
B. Noncompliance Agreement.
C. Corporate Integrity Agreement.
D. Recovery Audit Contract.

C. Corporate Integrity Agreement.

97. Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment, which statement is true?

A. Each facility is accountable for developing and implementing its own methodology.
B. The level of service codes reported by the facility must match those reported by the physician.
C. Each facility must use the same methodology used by physician coders based on the history, examination, and medical decision-making components.
D. Each facility must use acuity sheets with acuity levels and assign points for each service performed.

A. Each facility is accountable for developing and implementing its own methodology.

98. CMS adjusts the Medicare Severity DRGs and the reimbursement rates every

A. calendar year beginning January 1.
B. quarter.
C. month.
D. fiscal year beginning October 1.

D. fiscal year beginning October 1.

99. In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

A. geographic practice cost indices.
B. national conversion factor.
C. usual and customary fees for the service.
D. cost of living index for the particular region.

A. geographic practice cost indices.




After the three relative value units are each multiplied by the geographic practice cost indices, then this total is multiplied by the national conversion factor.

100. 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. $250.00
C. $340.00
D. $391.00

B. $250.00




The participating physician agrees to accept Medicare's fee as payment in full; therefore, the physician would write off the difference between $700.00 and $450.00, which is 250.00

101. Health plans that use ____________ reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time.

A. episode-of-care (EOC)
B. capitation
C. fee-for-service
D. bundled

A. episode-of-care (EOC)

102. _______________________ offers voluntary, supplemental medical insurance to help pay for physician's services, outpatient hospital services, medical services, and medical-surgical supplies not covered by the hospitalization plan.

A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D

B. Medicare Part B

103. Commercial insurance plans usually reimburse health care providers under some type of _________ payment system, whereas the federal Medicare program uses some type of __________ payment system.

A. prospective, retrospective
B. retrospective, concurrent
C. retrospective, prospective
D. prospective, concurrent

C. retrospective, prospective

When the third-party payer refuses to grant payment to the provider, this is called a

A. denied claim.
B. clean claim.
C. rejected claim.
D. unprocessed claim.

A. denied claim.

105. Some services are performed by a nonphysician practitioner (such as a Physician Assistant). These services are an integral yet incidental component of a physician's treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called

A. “Technical component” billing.
B. “Assignment” billing.
C. “Incident to” billing.
D. “Assistant” billing.

C. “Incident to” billing.

When payments can be made to the provider by EFT, this means that the reimbursement is

A. sent to the provider by check.
B. sent to the patient, who then pays the provider.
C. combined with all other payments from the third party payer.
D. directly deposited into the provider's bank account.

A. sent to the provider by check.

107, The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.

A. surgical procedures
B. clinical lab services
C. clinic/emergency visits
D. radiology/radiation therapy



B. clinical lab services

108. A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by

A. ambulatory surgery centers (ASC).
B. home health agencies (HHA).
C. inpatient rehabilitation facilities (IRF).
D. B and C.

D. B and C.

The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that were not present on hospital admission but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as

A. a sentinel event.
B. a payment status indicator.
C. a hospital acquired condition.
D. present on admission.

D. present on admission.

110. A patient is admitted for a diagnostic workup for cachexia. The final diagnosis is malignant neoplasm of lung with metastasis. The present on admission (POA) indicator is

A. Y = Present at the time of inpatient admission.
B. N = Not present at the time of inpatient admission.
C. U = Documentation is insufficient to determine if condition was present at the time of admission.
D. W = Provider is unable to clinically determine if condition was present at the time of admission

A. Y = Present at the time of inpatient admission




The malignant neoplasm was clearly present on admission, although it was not diagnosed until after the admission occurred.

111. A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator is

A. Y = Present at the time of inpatient admission.
B. N = Not present at the time of inpatient admission.
C. U = Documentation is insufficient to determine if condition was present at the time of admission.
D. W = Provider is unable to clinically determine if condition was present at the time of admission.

A. Y = Present at the time of inpatient admission.




The atrial fibrillation developed prior to a written order for inpatient admission; therefore, it was present at the time of inpatient admission.

112. A patient is admitted to the hospital for a coronary artery bypass surgery. Postoperatively, he develops a pulmonary embolism. The present on admission (POA) indicator is

A. Y = Present at the time of inpatient admission.
B. N = Not present at the time of inpatient admission.
C. U = Documentation is insufficient to determine if condition was present at the time of admission.
D. W = Provider is unable to clinically determine if condition was present at the time of admission.

B. N = Not present at the time of inpatient admission.




The pulmonary embolism is an acute condition that was not present on admission because it developed after the patient was admitted and after the patient had surgery.

The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator is

A. Y = Present at the time of inpatient admission.
B. N = Not present at the time of inpatient admission.
C. U = Documentation is insufficient to determine if condition was present at the time of admission.
D. W = Provider is unable to clinically determine if condition was present at the time of admission.

C. U = Documentation is insufficient to determine if condition was present at the time of admission.




Query the physician as to whether the decubitus ulcer was present on admission or developed after admission.

The present on admission (POA) indicator is required to be assigned to the ___________ diagnosis(es) for _________________ claims on _________________ admissions.

A. principal and secondary, Medicare, inpatient
B. principal, all, inpatient
C. principal and secondary, all, inpatient and outpatient
D. principal, Medicare, inpatient and outpatient

A. principal and secondary, Medicare, inpatient