Deck 11: Hospital Medical Billing

Question 1

The method of reimbursement that pays hospitals a fixed rate per day for all services provided is:

A) capitation.
B) fee for service.
C) per diem.
D) prospective payment system.

Answer 1

per diem.

Question 2

Software that is used to calculate the DRG payment group is called a(n):

A) claims processing system.
B) grouper.
C) accounts receivable system.
D) database.

Answer 2

grouper.

Question 3

Most major diagnostic categories (MDCs) are based on:

A) a particular organ system.
B) number of diagnoses.
C) age of the patient.
D) health status of the patient.

Answer 3

a particular organ system.

Question 4

The physician who is primarily responsible for a patient's care while in the hospital is referred to as the:

A) admitting physician.
B) attending physician.
C) rendering physician.
D) primary care physician.

Question 5

A facility's case mix is based on all of the following EXCEPT:

A) discharge status.
B) severity of illness.
C) treatment difficulty.
D) resource intensity.

Question 6

A patient control number (PCN) is a unique identifier assigned to each hospital patient at the time of:

A) admission.
B) diagnosis.
C) surgery.
D) discharge.

Question 7

The method of reimbursement that establishes the rate of payment to a hospital before services are rendered is:

A) capitation.
B) fee for service.
C) per diem.
D) prospective payment system.

Question 8

A case that cannot be assigned an appropriate DRG because of an atypical situation is called a(n):

A) misdiagnosis.
B) cost differential.
C) cost outlier.
D) unsubstantiated claim.

Question 9

The process of collecting a patient's personal information and entering it into the hospital's database is referred to as:

A) verification.
B) registration.
C) certification.
D) authorization

Question 10

Services covered under the APC system include all of the following EXCEPT:

A) outpatient surgical procedures.
B) inpatient surgical procedures.
C) emergency department visits.
D) diagnostic services.

Question 11

The majority of hospital reimbursement comes from:

A) bank loans.
B) insurance companies.
C) patients.
D) private donations.

Question 12

DRG classification takes into account all of the following criteria EXCEPT:

A) age and sex of the patient.
B) social status and family support.
C) comorbidity and complications.
D) principal and secondary diagnoses.

Question 13

OPPS stands for:

A) Outpatient Payment for Preventive Services.
B) Outpatient Prospective Payment System.
C) Optimal Payment for Procedures and Services.
D) Other Payments for Procedures and Services.

Question 14

The Diagnosis Related Group (DRG) system is a type of:

A) utilization review system.
B) capitation system.
C) prospective payment system.
D) retrospective payment system.

Question 15

Reimbursement methods for inpatient and outpatient hospital services include all of the following EXCEPT:

A) capitation.
B) fee for service.
C) per diem.
D) prospective payment system.

Question 16

The Ambulatory Payment Classification (APC) system bases payments on:

A) usual fees.
B) procedures.
C) diagnoses.
D) number of days.

Question 17

The list of APC rates is maintained by:

A) the American Medical Association (AMA).
B) the Blue Cross/Blue Shield Association.
C) the Centers for Medicare and Medicaid Services (CMS).
D) contracted health plans.

Question 18

A charge description master includes all of the following information EXCEPT:

A) procedure code.
B) procedure or service description.
C) charge.
D) physician identification number.

Question 19

To prevent a cash flow problem, hospital records should be completed and signed no later than:

A) 1-2 days following discharge.
B) 7 days following admittance.
C) 14 days following discharge.
D) 30 days following admittance.

Question 20

The UB-04 claim form allows for a maximum of:

A) four diagnoses.
B) six diagnoses.
C) eight diagnoses.
D) 10 diagnoses.

Question 21

If a patient is homeless at the time of admission, which condition code would be entered?

A) 17
B) 21
C) 37
D) 40

Question 22

To signify that a patient was discharged from the hospital at midnight, which code would be entered in form locator 16 on the UB-04?

A) 00
B) 12
C) 24
D) 99

Question 23

In form locator 17 on the UB-04 claim form, the codes for "Left against medical advice or discontinued care," "Expired (or did not recover)," and "Admitted as an inpatient to this hospital" represent:

A) admission source codes.
B) discharge status codes.
C) admission type codes.
D) condition codes.

Question 24

What color of ink is the UB-04 form printed in to allow for processing with optical scanning equipment?

A) blue
B) black
C) red
D) purple

Question 25

When using a FOUR-digit Medicare "type of bill" code in form locator 4, the type of facility is represented by the:

A) first digit.
B) second digit.
C) third digit.
D) fourth digit.

Question 26

Codes that identify special circumstances, events, or room accommodations that may affect the payer's processing of the bill are called:

A) condition codes.
B) occurrence codes.
C) value codes.
D) revenue codes.

Question 27

A pre-existing condition that, because of its effect on the principal diagnosis, results in more intensive therapy or a longer stay is a(n):

A) chronic condition.
B) complication.
C) comorbidity.
D) exacerbation.

Question 28

On the UB-04, codes that give the number of services and benefit days for Medicare patients are the:

A) CPT codes.
B) ICD-10-CM codes.
C) revenue codes.
D) value codes.

Question 29

When using a FOUR-digit Medicare "type of bill" code in form locator 4, the frequency is represented by the:

A) first digit.
B) second digit.
C) third digit.
D) fourth digit.

Question 30

In form locator 15 on the UB-04 claim form, the codes for Physician Referral, HMO Referral, and Transfer from a skilled nursing facility (SNF) represent:

A) admission source codes.
B) discharge status codes.
C) admission type codes.
D) condition codes.

Question 31

On the UB-04, codes that identify the department that supplied the services are the:

A) CPT codes.
B) ICD-10-CM codes.
C) revenue codes.
D) value codes.

Question 32

Occurrence codes are used to:

A) determine liability.
B) coordinate benefits.
C) administer subrogation clauses.
D) all of the above.

Question 33

On form locator 10 of the UB-04 form, the patient birth date is:

A) optional.
B) required.
C) not applicable.
D) not required.

Question 34

When using a FOUR-digit Medicare "type of bill" code in form locator 4, the bill classification (type of care) is represented by the:

A) first digit.
B) second digit.
C) third digit.
D) fourth digit.

Question 35

For a patient whose condition permits adequate time to schedule the service, the admission type code would be reported as:

A) emergency.
B) urgent.
C) elective.
D) trauma.

Question 36

TRICARE and other private insurance companies that use DRGs use DRG numbers:

A) 200-400.
B) 300-500.
C) 500-800.
D) 600-900.

Question 37

When referring to DRGs, the abbreviation CC is used to indicate:

A) chief complaint.
B) closed case.
C) chronic condition.
D) complications or comorbidities.

Question 38

If the time that a patient was admitted to the hospital is unknown, which code would be entered in form locator 13?

A) It would be left blank.
B) It would be noted as "unknown."
C) Code 00
D) Code 99

Question 39

Which of the following codes would be entered to report that the patient is female in form locator 11 on the UB-04?

A) 1
B) 2
C) M
D) F

Question 40

For a patient whose condition requires immediate attention for the treatment of a physical or mental disorder, the admission type code would be reported as:

A) emergency.
B) urgent.
C) elective.
D) trauma.

Question 41

The four sections of the UB-04 claim form include information on:

A) patient, billing, payer, and diagnosis.
B) patient, physician, procedures, and diagnosis.
C) patient, prognosis, diagnosis, and facility.
D) patient, billing, payer, and physician.

Question 42

A department in a hospital that provides outpatient surgery services is known as the:

A) ambulatory surgical center.
B) ambulatory surgical unit.
C) hospital surgical center.
D) outpatient surgical facility.

Question 43

Ambulatory payment classifications are applied to outpatient services that include:

A) implants.
B) chemotherapy.
C) preventive screenings.
D) all of the above.

Question 44

An emergency room physician who admits a patient to the hospital and has no further involvement in the patient's care is referred to as the attending physician.

Question 45

The type of facility that would use the UB-04 claim form includes all of the following EXCEPT:

A) rehabilitation centers.
B) physicians' offices.
C) outpatient surgical centers.
D) skilled nursing facilities.

Question 46

The current federal reimbursement plan for outliers is to pay the full DRG rate plus an additional payment for services provided.

Question 47

A master patient index is the main database of all of the hospital's patients.

Question 48

Situations that require immediate attention to avoid the loss of life or limb are:

A) critical.
B) emergencies.
C) urgent.
D) terminal.

Question 49

The prospective payment system (PPS) is NOT widely used as a reimbursement method for inpatient care.

Question 50

The type of care that provides palliative services for terminally ill patients is known as:

A) hospice care.
B) home healthcare.
C) critical care.
D) terminal care.

Question 51

A case that cannot be assigned an appropriate DRG because of an atypical situation is called a cost outlier.

Question 52

The UB-04 claim form is considered a summary document and is supported by an itemized or detailed bill.

Question 53

A code that describes an accident or mishap responsible for the patient's admission to the hospital is known as a(n):

A) condition code.
B) occurrence code.
C) value code.
D) revenue code.

Question 54

The four main sections of the UB-04 claim form include all of the following EXCEPT:

A) patient information.
B) billing information.
C) physician information.
D) diagnosis information.

Question 55

The DRG system categorizes patients (cases) who are medically related with respect to diagnosis, treatment, and length of stay.

Question 56

Hospice care, billed using a UB-04 claim form, can be delivered as:

A) inpatient only.
B) outpatient only.
C) either inpatient or outpatient.
D) ambulatory care.

Question 57

The number of form locators on the UB-04 claim form is:

A) 33.
B) 62.
C) 81.
D) 94.

Question 58

Comorbidity may affect payment if the condition causes an increase in hospital length of stay by at least 2 days in approximately 50% of cases.

Question 59

The majority of hospital reimbursement comes from patients.

Question 60

Per diem is a type of reimbursement that pays a fixed rate per day for all services provided by a hospital.

Question 61

The admission and discharge hour codes on the UB-04 form are based on military time.

Question 62

In determining payment for hospital services, diagnoses and treatments are categorized into groups called ________ Groups.

Question 63

The hospital database that contains information on all admitted patients is the ________ index.

Question 64

The provider who supplies the reported service or performs the reported procedure is known as the ________ physician.

Question 65

Inpatient care refers to a hospital confinement of more than 24 hours.

Question 66

The UB-04 claim form is required by all private payers and is accepted by the Centers for Medicare and Medicaid Services (CMS).

Question 67

In urgent care situations, there is no risk of the patient losing life or limb.

Question 68

A patient whose condition permits adequate time to schedule the service is reported as an urgent admission.

Question 69

The number assigned to a patient upon admission to the hospital is the ________ number.

Question 70

The computerized comprehensive list of codes for all services and items provided to hospital patients is known as the ________.

Question 71

It is the responsibility of the ________ physician to determine the principal diagnosis for his or her patient.

Question 72

A case that cannot be assigned an appropriate DRG because of an atypical situation is referred to as a(n) ________.

Question 73

A condition code would be used to describe a situation in which neither the patient nor the spouse is employed.

Question 74

An ambulatory surgical center must be affiliated with a hospital in order to operate.

Question 75

If the patient requires an operation, the physician who conducts the operation is referred to as the ________.

Question 76

Revenue codes on the UB-04 claim form identify services and benefit days for Medicare patients.

Question 77

For Medicare services, the type of bill code in form locator 4 must include four digits.

Question 78

________ or admission is the process of collecting a patient's personal information, including insurance information, and entering it into the hospital's health information system (HIS).

Question 79

The type of care provided in a hospital that does NOT require the patient to stay overnight is known as outpatient or ________ care.

Question 80

If a patient were admitted to the hospital because of an auto accident, an occurrence code would be used to describe the accident.