Deck 17: Hospital Billing

Question 1

The rule stating that when a patient receives outpatient services within 72 hours of admission, then all outpatient services are combined with inpatient services and become part of the diagnostic-related group rate for admission, is called the

A) preop rule.
B) preadmission rule.
C) Medicare 72-hour rule.
D) PAT.

Answer 1

Medicare 72-hour rule.

Question 2

Which organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review?

A) QIO
B) APC
C) PPS
D) MRO

Answer 2

QIO

Question 3

The person who interviews the patient and obtains personal and insurance information and the admitting diagnosis is a/an

A) admitting clerk.
B) ward clerk.
C) insurance billing clerk.
D) nurse.

Answer 3

admitting clerk.

Question 4

When a patient who has a managed care contract is admitted to a hospital for an emergency, the managed care program needs to be notified within

A) 24 hours.
B) 48 hours.
C) 72 hours.
D) 1 week.

Question 5

The claim form used for outpatient hospital procedure billing is the

A) CMS-1500 claim form.
B) CMS 1450 (UB-04) claim form.
C) HOP claim form.
D) standard outpatient claim form (SOCF).

Question 6

Confidential information about patients should never be discussed with

A) news media.
B) family.
C) friends.
D) any of the above.

Question 7

The hospital insurance claim form must always be reviewed by the

A) admitting clerk.
B) ward clerk.
C) patient accounts representative.
D) nurse.

Question 8

When criteria are used by the hospital's review agency for admission screening, this is referred to as

A) DRGs.
B) AEPs.
C) APCs.
D) PIPs.

Question 9

Daily progress notes are entered on the patient's medical record by a/an

A) admitting clerk.
B) ward clerk.
C) insurance billing clerk.
D) nurse.

Question 10

A review for additional Medicare reimbursement is called

A) DRG validation.
B) day outlier review.
C) cost outlier review.
D) procedure review.

Question 11

On the CMS 1450 (UB-04) claim form, code 6 (transfer from another health care facility) in Field 15 is used to indicate

A) type of admission.
B) source of admission.
C) occurrence span.
D) treatment authorization.

Question 12

ICD-10-PCS codes are used to identify

A) outpatient surgery.
B) inpatient surgery.
C) outpatient diagnosis.
D) inpatient diagnosis.

Question 13

The significant reason for patient admission to the hospital is coded as the

A) primary diagnosis.
B) secondary diagnosis.
C) main diagnosis.
D) principal diagnosis.

Question 14

One AEP criterion that needs to be met for intensity of service (IS) in an admission is

A) sudden onset of unconsciousness.
B) administration and monitoring of intravenous medications.
C) pulse rate less than 50 or greater than 140.
D) sudden onset of loss of sight or hearing.

Question 15

Medicare's Inpatient Prospective Payment System has approximately _________ MS-DRGs.

A) 250
B) 300
C) 500
D) 745

Question 16

ICD-10-PCS codes contain

A) at least two digits.
B) three to five characters.
C) seven characters.
D) five digits.

Question 17

If a patient is being admitted to a hospital and refuses all preadmission testing, but a bill is sent to the insurance carrier for these services anyway, this is called

A) duplicate billing.
B) double billing.
C) phantom charges.
D) posting errors.

Question 18

A patient is considered an inpatient to the hospital on admission

A) to the emergency department.
B) for an overnight stay.
C) for an outpatient surgical procedure.
D) both b and c

Question 19

The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called the

A) UB-82.
B) CMS 1450 (UB-04).
C) CMS-1500.
D) standard hospital billing form.

Question 20

One AEP criterion that needs to be met to certify severity of illness (SI) in an admission is

A) use of chemotherapeutic agents that require continuous observations.
B) administration of intramuscular antibiotics at least every 8 hours.
C) active, uncontrolled bleeding.
D) vital sign monitoring at least every 2 hours.

Question 21

All of the following are considered computer security safeguards EXCEPT:

A) use of passwords and encryption.
B) downloading of unauthorized data from a website.
C) logging off workstations when leaving a workstation or desk.
D) policies and procedures for fax machine use.

Question 22

A four-digit code corresponding to each narrative description or standard abbreviation that identifies a specific accommodation, ancillary service, or billing calculation related to services billed is called a/an _____________________ code.

Question 23

The Administrative Simplification provisions of the Health Information Portability and Accountability Act of 1996 prohibit the submission of most _____________________.

Question 24

The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge plan to determine whether admissions are justified is called the ____________________ department.

Question 25

______________________ is a preexisting condition that will, because of its effect on the specific principal diagnosis, require more intensive therapy or cause an increase in length of stay by at least 1 day in approximately 75% of cases.

Question 26

The MS-DRG-based system is a complex _________________-tiered system.

Question 27

An unethical practice of upcoding a patient's DRG category for a more severe diagnosis to increase reimbursement is called _____________________.

Question 28

______________________ are DRG cases that cannot be assigned properly because of an atypical situation.

Question 29

The Uniform Bill claim form is considered a ____________________ statement.

Question 30

On the CMS 1450 (UB-04) claim form, the second digit of the four-digit bill code in Field 4 indicates the type of ____________________.

Question 31

The __________________________________________________ is used to list procedural codes for Medicare patients on hospital insurance claims that are not in the CPT book.

Question 32

Preauthorization is needed for patients who are

A) covered by an HMO.
B) covered by a PPO.
C) covered by a managed care organization.
D) none of the above.

Question 33

What is QIO an abbreviation for?

Question 34

PAT is an abbreviation for ____________________.

Question 35

In an effort to reduce the processing time for each health insurance claim submitted and to reduce costs related to health care delivery, Medicare uses a ______________ prospective payment system on which hospital fee reimbursements are based.

Question 36

____________________ are used for CPT and HCPCS codes to modify or provide more detailed information on the procedure and/or medical supply.

Question 37

Medicare provides stop-loss called _____________________ in its regulations.

Question 38

On the CMS 1450 (UB-04) claim form, 1553 listed as the hour of admission indicates that the patient was admitted at ____________________.

Question 39

The ____________________ is the clinical résumé for final progress notes.

Question 40

What is the document that needs to be completed and signed by the physician after a patient leaves the hospital, before the hospital can receive reimbursement?

Question 41

Match the type of reimbursement method with the correct description below.

Dollar amount owed to a participating provider for health care services rendered to a plan member according to a fee schedule set by the managed care plan.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 42

Surgical procedures performed in the hospital operating room are billed by the hospital billing department.

Question 43

Match the type of reimbursement method with the correct description below.

An averaging after a flat rate has been given to certain categories of procedures.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 44

What does the abbreviation CC indicate when used with DRGs?

Question 45

Match the type of reimbursement method with the correct description below.

Term for a managed care plan that leases beds from a facility.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 46

Match the type of reimbursement method with the correct description below.

A classification system that categorizes inpatients who are medically related with respect to diagnosis and treatment and are statistically similar in length of hospital stay.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 47

Match the type of reimbursement method with the correct description below.

A single charge for a day in the hospital regardless of actual charges or costs incurred.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 48

Match the type of reimbursement method with the correct description below.

Term for the first day of a hospital stay being paid at a higher rate.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 49

Match the type of reimbursement method with the correct description below.

Methods in which the plan advances cash to cover expected claims to the hospital.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 50

Match the type of reimbursement method with the correct description below.

A form of reinsurance in which the hospital buys insurance to protect against lost revenue and receives less of a capitation fee, and the amount the hospital does not receive helps pay for the insurance.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 51

Match the type of reimbursement method with the correct description below.

A comprehensive listing of charges based on procedure codes that states fee maximums paid by the health plan.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 52

Match the type of reimbursement method with the correct description below.

Type of arrangement in which the hospital receives a flat per-admission reimbursement for the service to which the patient is admitted.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 53

Match the type of reimbursement method with the correct description below.

A single charge per hospital admission paid by the managed care plan.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 54

Match the type of reimbursement method with the correct description below.

Reimbursement to the hospital on a per-member, per-month basis to cover costs for the member of the plan.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 55

Match the type of reimbursement method with the correct description below.

Method by which part of the plan's payment to the hospital may be withheld or set aside in a bonus pool.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 56

Emergency department charges are billed along with the inpatient stay on the CMS-1500 claim form.

Question 57

Match the type of reimbursement method with the correct description below.

An interim per diem is paid for each day in the hospital.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 58

Match the type of reimbursement method with the correct description below.

An outpatient classification system developed by Health Systems International is ambulatory payment classifications (APCs).

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 59

When admitted as a workers' compensation case, the patient will not have an insurance card.

Question 60

Match the type of reimbursement method with the correct description below.

A reduction in charges for total bed days per year with incremental increases in the discount up to a maximum percentage.

A)Ambulatory payment
B)Bed leasing
C)Capitation or percentage of revenue
D)Case rate
E)Diagnosis-related groups (DRGs)
F)Differential by day in hospital
G)Differential by service type
H)Fee schedule
I)Flat rate
J)Per diem
K)Periodic interim payments (PIPs) and cash advances
L)Withhold
M)Reinsurance stop-loss
N)Charges
O)Discounts in the form of sliding scale
P)Sliding scales for discounts and per diems

Question 61

MS-DRGs are weighted to reflect the average costs for inpatient care.

Question 62

Ambulatory payment classifications (APCs) are based on the principal diagnosis.

Question 63

The MS-DRG system is designed to increase reimbursement for sicker patients.

Question 64

A patient has a right to request an itemized bill from a hospital stay with no cost to the patient.

Question 65

The MS-DRG is assigned using an automated system called the DRG selector.

Question 66

On the CMS 1450 (UB-04) claim form, the patient's date of birth should be entered using six digits in block 14.

Question 67

Elective surgeries are deferrable.

Question 68

The patient care representative should obtain a copy of the front and back of the patient's health identification card, but a copy of the driver's license is optional.

Question 69

A patient who is covered under an HMO plan must have authorization prior to admission unless the patient is admitted for an emergency.

Question 70

Insurances from different states have the same standards for reimbursement.

Question 71

Information such as "condition is employment related" (code 02), listed in Fields 18 through 28 of the CMS 1450 (UB-04) claim form, is called a condition code.

Question 72

On the CMS 1450 (UB-04) claim form in Field 17, code 20 (patient expired) is used to indicate the patient's discharge status.