Question 1

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

Accepted Answer

The term used for internal auditing systems specifically designed for identifying errors in claims is "scrubbers." Outliers are data points that fall outside the normal range of values, groupers are software used to create disease classification based on certain criteria, and encoders are software used to assign codes to medical terms.

Question 2

Under Medicare Part B, Medicare participating providers

Accepted Answer

Medicare participating providers who accept assignment agree to accept the allowed charge from the nonPAR fee schedule as payment in full, and are not allowed to bill the beneficiary for any excess charges. They may only collect the standard deductible and coinsurance amounts from the beneficiary.

Question 3

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.

Accepted Answer

CPT code 99291 (critical care) is used when a patient's condition is critical and requires continuous monitoring and interventions by a physician or other qualified healthcare provider. This code can be used instead of a code for a medical visit or emergency department service when appropriate. Codes 99358, 35001, and 50300 are not appropriate replacements for a medical visit or emergency department service.

Question 4

Under the APC methodology, discounted payments occur when

Accepted Answer

Under the APC methodology, discounted payments occur when there are two or more (multiple) procedures that are assigned to status indicator "T" or when modifier -73 is used to indicate a procedure is terminated after the patient is prepared, but before anesthesia is started.

Question 5

If the physician's standard fee for a service is $210.00 and the Medicare PAR fee is $115.00, what is the limiting charge for a nonparticipating (nonPAR) provider?

Accepted Answer

The answer of If the physician's standard fee for a...

Question 6

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

Accepted Answer

The reimbursement for a particular MS-DRG is calculated by multiplying the hospital's base payment rate by the relative weight for that MS-DRG. The relative weight is a measure of the relative resources required to treat patients in that particular MS-DRG compared to the average case in all MS-DRGs. The conversion factor, case-mix index, and geographic price index are all factors that may influence the base payment rate or adjust it for geographic location or patient complexity, but they do not directly determine the reimbursement to the hospital for a particular MS-DRG.

Question 7

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.

Accepted Answer

The software system utilized by HHAs is called HAVEN (Home Assessment Validation and Entry), which was developed by CMS and is available for free on the CMS website or on a CD-ROM. The other options (PACE, HHASS, and PEPP) are not specifically related to data entry software for home health agencies.

Question 8

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

Accepted Answer

A patient claim can only be assigned one MS-DRG, which determines the payment for the hospital stay.

Question 9

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 provider is $120.00. Medicare's PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?

Accepted Answer

Medicare reimburses 80% of the PAR fee, which is $60.00. Therefore, the physician will receive 80% of $60.00, which is $48.00.

Question 10

The occurrence of an OCE (outpatient code editor) edit can result in one of __________ different dispositions, which help to ensure that the fiscal intermediaries in all parts of the country are following similar claims processing procedures. An example of one of these dispositions is "claim rejection."

Accepted Answer

There are six different dispositions for an OCE edit, which include actions like claim rejection, line item denial, and line item rejection, among others.

Question 11

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

Accepted Answer

The contractual allowance is the difference between what a health care provider charges for a service and what an insurance company actually pays for that service, which is agreed upon in advance through a contractual agreement.

Question 12

The term "hard coding" refers to

Accepted Answer

Hard coding refers to codes that are programmed into a system and do not require manual input or coding. In healthcare, hard coding often refers to codes that are included in a hospital's chargemaster and will be automatically included on a patient's bill. Therefore, option B is correct. A, C, and D refer to coding by a coder and do not involve hard coding.

Question 13

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.

Accepted Answer

Aged receivables refer to outstanding balances on patient accounts that have not been paid for a significant amount of time. The DNFB (discharged, no final bill) report identifies patients who have been discharged but do not have a final bill, which can contribute to aged receivables. Therefore, monitoring the DNFB report can help identify and address potential issues with timely claims processing, which can ultimately impact a hospital's cash flow. Remittance advice refers to a document sent by an insurance company to a healthcare provider that explains how a patient's claim was processed and paid. Periodic interim payments refer to payments made by an insurance company to a healthcare provider before a final determination of coverage is made. A chargemaster is a comprehensive list of prices for all items, goods, and services provided by a hospital. While the chargemaster can impact a hospital's revenue cycle, it is not directly related to monitoring timely claims processing.

Question 14

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 receives from Medicare?

Accepted Answer

When a nonparticipating provider accepts assignment, they are reimbursed 95% of the Medicare-approved amount (nonPAR fee). Therefore, the physician will receive 95% of $57.00, which is $54.15. However, the correct answer choice provided is $45.60, which is incorrect based on the calculation.

Question 15

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

Accepted Answer

Cost accounting involves assigning a dollar value to each input required for providing a service or producing a product. This allows businesses to determine the cost of their services and products, which is essential for pricing decisions and profit analysis. Charge accounting, reimbursement, and contractual allowance are all terms that relate to accounting in the healthcare industry and do not necessarily involve assigning dollar values to inputs.

Question 16

This prospective payment system is for ______________ and utilizes a patient assessment instrument (PAI) to classify patients into case-mix groups (CMGs).

Accepted Answer

The prospective payment system that utilizes a patient assessment instrument (PAI) to classify patients into case-mix groups (CMGs) is used for inpatient rehabilitation facilities. Skilled nursing facilities use the Resource Utilization Groups (RUGs) system, home health agencies use the Patient-Driven Groupings Model (PDGM), and long-term acute care hospitals use the Long-Term Care Hospital Prospective Payment System (LTCH PPS).

Question 17

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

Accepted Answer

Reimbursement is the amount collected by the facility for the services it bills, as it represents the payment received from insurers or patients.

Question 18

This information is published by the Medicare contractors to describe when and under what circumstances Medicare will cover a services. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda.

Accepted Answer

LCD (Local Coverage Determinations) are published by Medicare contractors to describe the circumstances under which Medicare will cover a service, and typically include lists of ICD-9-CM and CPT/HCPCS codes that are covered or not covered. CCI (Correct Coding Initiatives) are edits used by Medicare to prevent improper coding practices, OSHA (Occupational Safety and Health Administration) is a federal agency that sets and enforces safety standards in the workplace, and PEPP (Payment Error Prevention Program) is a program used by Medicare to prevent payment errors.

Question 19

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

Accepted Answer

Charge accounting refers to the amount that the facility bills for the services it provides, which is different from the actual cost of providing those services. Reimbursement refers to the amount that the facility receives in payment for those services, which may be less than the amount charged. Contractual allowance is the difference between the amount charged and the amount actually received, which is often negotiated with insurance companies or other payers.

Question 20

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.

Accepted Answer

TRICARE is the former CHAMPUS program, and it provides health care for active duty military members and their families, as well as certain retired military members and their dependents. CHAMPVA (Choice B) is a different program that provides health care for eligible dependent survivors of veterans who have died as a result of their service or who have permanent disabilities related to their service. The Indian Health Service (Choice C) is a federal health program for Native Americans and Alaska Natives, and workers' compensation (Choice D) is a program that provides benefits to workers who are injured or become ill as a result of their job.

Exam 1: Registered Health Information Administrator