Question 1

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?

Accepted Answer

The limiting charge for nonPAR providers is 115% of the nonPAR approved payment amount. Therefore, for this proctoscopy, the limiting charge would be $147.20 (128.00 x 1.15). So the total Medicare approved payment amount for a doctor who does not accept assignment and applies the limiting charge would be $147.20.

Question 2

The case-mix index (CMI) for the top 10 MS-DRGs above is

Accepted Answer

To calculate the CMI, we need to divide the total weight of MS-DRGs by the total number of discharges. Summing up the weights of the top 10 MS-DRGs, we get 13,839.67. The total number of discharges for these MS-DRGs is 10,836. Therefore, the CMI can be calculated as 13,839.67/10,836 = 1.278. Therefore, the correct answer is B.

Question 3

This means 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.

Accepted Answer

Medical necessity refers to the standard that a service or procedure is deemed as reasonable and necessary for the diagnosis or treatment of an illness or injury, in line with generally accepted standards of care. This criterion is crucial in determining whether a treatment or service will be covered by insurance providers.

Question 4

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.

Accepted Answer

Payment status indicators are assigned to each 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. These indicators determine whether the service is separately paid, packaged, subject to multiple procedure discounting, or subject to a status indicator specific payment policy.

Question 5

The first step is

Accepted Answer

The answer of The first step is
...

Question 6

The third step is

Accepted Answer

The answer of The third step is
...

Question 7

Based on this patient volume, the MS-DRG which brings in the highest total profit to the hospital is

Accepted Answer

The question does not provide specific data on patient volume, reimbursement rates, or costs associated with each MS-DRG, which are necessary to determine total profit.

Question 8

The second step is

Accepted Answer

The answer of The second step is
...

Question 9

All of the following elements are found in the charge description master, EXCEPT for

Accepted Answer

The charge description master contains the charge, HCPCS/CPT code, and narrative description for each medical service or item. It does not include the ICD-9-CM code, which is used for diagnosis coding rather than procedural coding.

Question 10

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

Accepted Answer

Changes in coding productivity do not directly affect the case mix index (CMI), which is a measure of the relative costliness of the patients treated. CMI is influenced by factors like medical staff composition, coding rules, and services offered, which can change the types of cases and their complexity, but not by how quickly coding is done.

Question 11

A discharge in which the patient was discharged from the inpatient rehabilitation facility and returned within 3 calendar days is called a(n)

Accepted Answer

An interrupted stay is when a patient is discharged from an inpatient rehabilitation facility and then returns within 3 calendar days. This is different from a transfer, which is when a patient is moved from one healthcare facility to another. Per diem refers to daily rates for healthcare services, and qualified discharge is not a term related to this situation.

Question 12

The fourth step is

Accepted Answer

The fourth step involves differentiating cases based on the presence or absence of complications/comorbidities (CCs) or major complications comorbidities (MCCs). This helps in assigning an appropriate Medicare Severity Diagnosis Related Group (MS-DRG) to the case, which is used for payment and reimbursement purposes.

Question 13

Under the inpatient prospective payment system (IPPS), there is a three-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

Accepted Answer

The three-day payment window rule under IPPS covers both diagnostic services and therapeutic services if the inpatient principal diagnosis code matches the code used for pre-admission services.

Question 14

Under the outpatient prospective payment system (OPPS), status indicator "______" is a payment indicator that refers to "significant procedures for which the multiple procedure reduction applies." This means that the reported CPT and/or HCPCS Level II code will be paid a discounted APC reimbursement rate when reported with other procedures on the same claim.

Accepted Answer

The answer of Under the outpatient prospective payment system (OPPS),...

Question 15

Based on this patient volume, the MS-DRG which brings in the highest total reimbursement to the hospital is

Accepted Answer

MS-DRG 470 typically involves major joint replacement or reattachment of lower extremity without major complications or comorbidities, which often has a higher reimbursement rate due to the cost and complexity of the procedures involved.

Question 16

Under ASCs, bilateral procedures are reimbursed at _______ of the payment rate for their group

Accepted Answer

Under ASCs, bilateral procedures are reimbursed at 150% of the payment rate for their group. This means that a procedure that would normally be paid $1,000 would be reimbursed at $1,500 if performed on both sides.

Question 17

Which of the listed MS-DRGs has the highest CMS relative weight?

Accepted Answer

The answer of Which of the listed MS-DRGs has the...

Question 18

According to the Federal Register, the definition of a "new" patient when assigning a CPT Evaluation and Management (medical visit) code to a Medicare hospital outpatient under the prospective payment system is a patient that has

Accepted Answer

The answer of According to the Federal Register, the definition...

Question 19

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

Accepted Answer

The technical component of radiological procedures includes all necessary components for the actual execution of the procedure, including radiological equipment, radiological supplies, and support services. However, physician services are part of the professional component, which is billed separately. Therefore, B is the correct answer as it is the only choice that is not part of the technical component.

Question 20

Home health agencies are reimbursed on a prospective payment system (PPS) for Medicare patients. This PPS is called

Accepted Answer

Home health agencies are reimbursed on a prospective payment system (PPS) for Medicare patients. This PPS is called home health resource groups (HHRGs). The HHRG system assigns patients to one of 432 case-mix groups based on clinical and functional factors, and agencies are paid a predetermined rate for each group. Therefore, A) is the correct choice. B) case-mix groups (CMGs) are used for determining reimbursement for inpatient rehabilitation facilities, C) diagnosis-related groups (DRGs) are used for determining reimbursement for hospitals, and D) resource utilization groups (RUGs) are used for determining reimbursement for skilled nursing facilities.

Exam 1: Registered Health Information Administrator