Deck 9: Healthcare Coding and Reimbursement

Question 1

Which of the following is a fixed minimum that the patient must pay before a plan begins paying?

A) Deductible
B) Reimbursement
C) Premium
D) Disbursement
E) Copay

Answer 1

Deductible

Question 2

HCPCS II codes were created for billing:

A) surgical procedures.
B) outpatient services.
C) inpatient treatments.
D) supplies, injectable medications, and blood products.
E) emergency services.

Answer 2

supplies, injectable medications, and blood products.

Question 3

Which of the following is NOT a type of HMO?

A) Staff model
B) Gatekeeper model
C) Independent practice association model
D) Group practice model
E) Integrated delivery network model

Answer 3

Gatekeeper model

Question 4

Health plans are also called:

A) guarantors.
B) fiscal intermediaries.
C) contractors.
D) heath payers.
E) All of the above

Question 5

A fixed amount a health plan may require a patient to pay at each visit is called a:

A) deductible.
B) copay.
C) reimbursement.
D) premium.
E) payment.

Question 6

Which of the following are standardized codes for reporting medical services, procedures, and treatments performed for patients by the medical staff?

A) ICD-9-CM
B) CPT-4
C) HCPCS II
D) ABC
E) MS-DRG

Question 7

Which of the following is a bill for healthcare services or supplies?

A) Explanation of benefits
B) Adjudication
C) Service plan
D) Remittance advice
E) Claim

Question 8

An ICD-9-CM V code is used to code a(n):

A) non-illness condition.
B) accident.
C) medication error.
D) disease.
E) procedure.

Question 9

________ agree not to collect more for a service than the amount allowed by the contract.

A) Insurers
B) Third party payers
C) Participating providers
D) Patients
E) Employers

Question 10

All of the following statements are true of ICD-10-CM EXCEPT:

A) HHS has proposed that the ICD-10 code sets be used for billing 01/01/10.
B) it is used broadly in Europe and Canada.
C) transition to ICD-10 will require significant time and effort.
D) it is used in the United States for reporting the cause of death on death certificates.
E) clinical modifications in ICD-10 will include only volumes 1 and 2.

Question 11

________ is the processing of a claim by the health plan.

A) Adjudication
B) Explanation of benefits
C) Administration of benefits
D) Remittance advice
E) Billing service

Question 12

The person responsible for the patient's portion of the bill is the:

A) third party.
B) insurer.
C) guarantor.
D) health payer.
E) enrollee.

Question 13

Companies that contract with CMS programs to process claims and disburse payments are called:

A) fiscal intermediaries.
B) health payers.
C) third parties.
D) guarantors.
E) contractors.

Question 14

A unique ID number assigned by a health plan to each policy is a:

A) member number.
B) policy number.
C) insurance ID.
D) All of the above
E) None of the above

Question 15

An explanation of benefits (EOB) is also referred to as a(n):

A) service plan.
B) bill.
C) remittance advice.
D) adjudication.
E) claim.

Question 16

Which of the following refers to a person who is entitled to received benefits from a plan?

A) Beneficiary
B) Third party
C) Provider
D) All of the above
E) None of the above

Question 17

When a patient is covered by more than one insurance plan, the ________ plan adjudicates the claim first, followed by the ________ plan.

A) first; second
B) primary; secondary
C) principle; standard
D) major; minor
E) prime; subprime

Question 18

Third party payers usually pay the full amount of the fees for service.

Question 19

The amount the provider receives from the insurance plan is the:

A) remittance.
B) reimbursement.
C) disbursement.
D) Both A and B
E) Both b and c

Question 20

The primary person on the health insurance card is referred to as the:

A) subscriber.
B) enrollee.
C) beneficiary.
D) member.
E) All of the above

Question 21

________ were created to measure the value of one procedure compared to other procedures.

A) Fee schedules
B) Reimbursement methodologies
C) Procedure codes
D) Charge masters
E) Relative value units

Question 22

Which of the following is a dollar amount determined by a hospital's operating costs and whether it is located in an urban area with a population of more than 1 million?

A) Relative weight
B) IPPS rate
C) Reimbursement rate
D) Population rate
E) RUG-III

Question 23

Both RBRVS units and DRG relative weights change by geographic location.

Question 24

A numerical value assigned to each DRG code is called the:

A) comorbidity.
B) relative value.
C) relative weight.
D) reimbursement rate.
E) medical severity index.

Question 25

Which of the following refers to health insurance policies sold by private insurance companies to fill "gaps" in Medicare plan coverage?

A) Medicare Part C
B) Medigap
C) Medicaid
D) PPOs
E) All of the above

Question 26

Hospital billing includes which of the following codes?

A) ICD-9-CM codes
B) HCPCS codes
C) Principle diagnosis codes
D) Associate revenue codes
E) All of the above

Question 27

The 14,000 ICD-9-CM codes are categorized by the DRG system into ________ major diagnostic categories (MDCs).

A) 10
B) 25
C) 50
D) 75
E) 100

Question 28

Providers are not required to tell a Medicare patient in advance if he or she will have to pay for a test or service because it is not covered by Medicare.

Question 29

The payment to which a hospital is entitled is calculated by multiplying which of the following?

A) The hospital's IPPS rate by the RW of the DRG code
B) The hospital's IPPS rate by the DRG code
C) The hospital's IPPS rate by the MS-DRG weight
D) The hospital's IPPS rate by the RBRVS unit
E) None of the above

Question 30

Medicare is a health insurance program for:

A) people under the age of 65 who have disabilities.
B) people of any age with kidney failure requiring dialysis or transplant.
C) people 65 and older.
D) All of the above
E) None of the above

Question 31

A Resource-Based Relative Value Scale for each code is determined using:

A) practice expense.
B) physician work.
C) malpractice expense.
D) All of the above
E) None of the above

Question 32

Hospitals bill insurance companies by using a form called the:

A) RBRVS.
B) CMS-1500 claim form.
C) UB-04 claim form.
D) All of the above
E) None of the above

Question 33

The reason (after study) that the patient was admitted to the hospital is called the:

A) principle diagnosis.
B) discharge diagnosis.
C) final diagnosis.
D) Both A and B
E) Both B and C

Question 34

Inpatient acute care hospitals are reimbursed a single total payment for each patient discharge based on a(n) ________ code, which assumes that patients with the same sort of diagnoses require about the same length of stay and use approximately the same amount of resources.

A) ICD-9-CM
B) HCPCS
C) CPT-4
D) DRG
E) ABC

Question 35

All of the following statements about PPOs are true, EXCEPT:

A) patients have the option of seeing other providers, but must pay a higher coinsurance.
B) patients are encouraged to use the PPO physicians.
C) the PPO tries to encourage members to make choices that save the plan money.
D) copays encourage patients to use PPO doctors because patients pay only a small fee regardless of the complexity of the visit.
E) a PPO provides fewer choices for the patient.

Question 36

A capitation model succeeds when the group of HMO patients is large enough that the costs of treating members who need services and those who never see the doctor average out.

Question 37

The Medicare payment schedule for all procedure codes is updated every ________ by the CMS.

A) year
B) 2 years
C) 4 years
D) 6 years
E) 10 years

Question 38

Which of the following is NOT one of the MS-DRG levels of severity?

A) Non CC
B) CC
C) MCC
D) Multiple CC
E) All of the above are levels of severity.

Question 39

________ provides hospitals and healthcare services to military veterans.

A) The Federal Employee Compensation Act
B) Workers' compensation
C) Medicaid
D) Civilian Health and Medical Program-Veterans Affairs
E) The Veteran's Administration

Question 40

Plans that pay for healthcare services and are funded by federal or state governments are called:

A) entitlements.
B) health maintenance organizations.
C) insurance companies.
D) healthcare communities.
E) None of the above

Question 41

The skilled nursing facility (SNF) prospective payment system reimbursement rate is based on:

A) DRGs.
B) APCs.
C) RUG-III.
D) HCPCS.
E) RAIs.

Question 42

A compliance plan should include which of the following?

A) Education and training sessions
B) Ongoing internal audits
C) Effective communication
D) Code of ethics
E) All of the above

Question 43

When the cost of treating a patient exceeds the payment for the MS-DRG by a certain amount, Medicare will increase the payment.

Question 44

When a patient is admitted to a skilled nursing facility, the first assessment must be recorded:

A) on the day of admission.
B) within 48 hours of admission.
C) within 8 days of admission.
D) within 10 days of admission.
E) within 30 days of admission.

Question 45

All of the following are categories of hospital acquired conditions (HACs), EXCEPT:

A) myocardial infarction.
B) blood incompatibility.
C) catheter-associated urinary tract infection.
D) falls and trauma.
E) air embolism.

Question 46

A physician must renew an order for home health care every:

A) 5 days.
B) 10 days.
C) 14 days.
D) 30 days.
E) 60 days.

Question 47

Medicare payments to inpatient psychiatric facilities are based on a ________ rate.

A) diagnosis
B) standard
C) per diem
D) group
E) basic

Question 48

All of the following are an unethical and/or illegal practice EXCEPT:

A) upcoding.
B) unbundling.
C) billing for services provided.
D) billing for levels of service not supported by documentation.
E) medically unnecessary procedures performed to increase reimbursement.

Question 49

Outpatient Prospective Payment System is used for:

A) partial hospitalization services by community mental health centers.
B) hospital outpatient services.
C) administration of certain vaccines, splints, casts, and antigens by home health agencies.
D) certain Medicare B services provided to hospitalized patients who do not have Medicare A.
E) All of the above

Question 50

The patient classification system groupings for long term care facilities are called:

A) LTC-DRGs.
B) APCs.
C) RUG-III.
D) OPPS.
E) HHRGs.