Deck 26: Reimbursement Methodologies

Question 1

A listing of the services,procedures,drugs,and supplies that can be applied to a patient's hospital bill is called a ____.

A)chargemaster
B)charge description number
C)department number
D)revenue code

Answer 1

A

Question 2

A condition that arises during a patient's hospitalization and may lead to increased resource use is a ____.

A)comorbidity
B)complication
C)provisional diagnosis
D)morbidity

Answer 2

B

Question 3

____ is the manipulation of codes to receive maximum reimbursement without the supporting documentation in the medical record or with disregard for the coding conventions,guidelines,and UHDDS definitions.

A)Comorbidity
B)Complication
C)Maximization
D)Optimization

Answer 3

C

Question 4

A four-digit code that is used on the UB-04 to indicate a particular type of service is called a ____.

A)chargemaster
B)charge description number
C)department number
D)revenue code

Question 5

____ is the process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled based on the documentation in the health record.

A)Comorbidity
B)Complication
C)Maximization
D)Optimization

Question 6

Which of the following is a factor in determining how sick the patient is and is an interrelated part of case-mix?

A)Severity of illness
B)Prognosis
C)Need for intervention
D)All of the above
E)None of the above

Question 7

The old payment method or ____ was based on charges or a percentage of charges that did not promote best practices and quality care because the hospital was paid based on charges;the higher the charges were,the higher was the payment.

A)retrospective payment system
B)prospective payment system
C)preferred provider organization
D)Tax Equity and Fiscal Responsibility Act

Question 8

Medicare was established in what year?

A)1995
B)1935
C)1965
D)1945

Question 9

A preexisting condition that is present on admission and may lead to increased resource use is a ____.

A)comorbidity
B)complication
C)provisional diagnosis
D)morbidity

Question 10

All of the following are TRUE of the individual hospital payment rate EXCEPT _____.

A)a regional- or national-adjusted standardized amount that considers type of hospital affects payment
B)the individual hospital payment rate never changes
C)whether the hospital is designated as a large urban or a rural hospital is a factor in payment
D)the wage index for the geographic area where the hospital is located is a factor in payment

Question 11

Which of these are factors that can determine MS-DRG assignment?

A)Patient's sex
B)Presence or absence of MCC/CC
C)Patient's discharge status
D)All of the above

Question 12

Which one of these is NOT a commonly missed CC (complication/comorbidity) for MS-DRGs?

A)Atrial flutter
B)Hypokalemia
C)Hyponatremia
D)Malnutrition

Question 13

Specialized software (called "groupers") is used to assign the appropriate MS-DRG.Groupers are often part of encoder or coding software that is used to assign the diagnosis and procedure codes.

A)Both statements are true
B)Both statements are false
C)The first statement is true;the second statement is false
D)The first statement is false;the second statement is true

Question 14

Medicare is a health coverage program for all of the following EXCEPT those ____.

A)65 or older
B)younger than 65 with certain disabilities
C)62 or older
D)of all ages with end-stage renal disease

Question 15

Which of the following is a characteristic of MS-DRGs?

A)Each MS-DRG has a relative weight
B)All hospitals have the same payment rate
C)MS-DRGs are updated every 2 years
D)All of the above are correct

Question 16

A number that designates a particular service or procedure and is used to generate a charge on a patient bill is called a ____.

A)chargemaster
B)charge description number
C)department number
D)revenue code

Question 17

Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service are known as ____.

A)good documentation
B)charge description master
C)medical necessity
D)department number

Question 18

SOW stands for ____.

A)surgery of whitlows
B)scars of weight
C)scope of work
D)scope of weight

Question 19

The condition that,after study,is established as chiefly responsible for occasioning the admission of the patient to the hospital is a ____.

A)primary diagnosis
B)complication
C)provisional diagnosis
D)principal diagnosis

Question 20

The Quality Improvement Organizations function under ___-year contracts called SOW.

A)1
B)3
C)6
D)9

Question 21

What is Uniform Bill-04 (UB-04)?

Question 22

Clinical documentation specialists would perform a concurrent review of a patient's health record for any missing or incomplete nursing documentation.

Question 23

Medicare is responsible for more than ___% of patients.

Question 24

A(n) ____________________ is a preexisting condition (present on admission) of hospitalization.

Question 25

Match the following terms to the correct definitions.
a.Complication
b.Comorbidity
c.Quality Improvement Organization (QIO)
d.PEPPER-Program for Evaluating Payment Patterns Electronic Report
e.Postacute Transfer Policy
The United States Congress required CMS through the Balanced Budget Act of 1997 to begin applying a slightly different payment methodology when transferring patients from the acute care to the postacute care setting

Question 26

Medicare has medical necessity guidelines that outline the criteria for what services are to be determined to be reasonable and necessary.

Question 27

Quality improvement organizations (QIO) work with consumers,____________________,and ____________________ to make sure that patients are getting the "right care at the right time."

Question 28

One of the goals of a clinical documentation improvement program is to improve a facility's case mix.

Question 29

A patient with COPD is admitted to the hospital.Two days after admission,the COPD becomes exacerbated.The exacerbation of COPD should be designated as present on admission.

Question 30

The ____________________ Act was responsible for the establishment of the Medicare program.

Question 31

DRGs were developed at Yale University in the late 1960s to ____________________ and ____________________.

Question 32

Match the following terms to the correct definitions.
a.Complication
b.Comorbidity
c.Quality Improvement Organization (QIO)
d.PEPPER-Program for Evaluating Payment Patterns Electronic Report
e.Postacute Transfer Policy
This refers to a condition that arises during a patient's hospitalization

Question 33

Match the following terms to the correct definitions.
a.Complication
b.Comorbidity
c.Quality Improvement Organization (QIO)
d.PEPPER-Program for Evaluating Payment Patterns Electronic Report
e.Postacute Transfer Policy
This refers to a preexisting condition (i.e.,it is present on admission)

Question 34

When errors in coding occur,the hospital may resubmit the billing data with revised codes on the claim or UB-04.

Question 35

A patient is admitted with a cough and hemoptysis and is diagnosed with lung cancer.The patient's lung cancer is present on admission.

Question 36

Match the following terms to the correct definitions.
a.Complication
b.Comorbidity
c.Quality Improvement Organization (QIO)
d.PEPPER-Program for Evaluating Payment Patterns Electronic Report
e.Postacute Transfer Policy
This program is an electronic report that is sent to a hospital;it contains hospital-specific information for 13 target areas

Question 37

The ____________________ is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 38

Match the following terms to the correct definitions.
a.Complication
b.Comorbidity
c.Quality Improvement Organization (QIO)
d.PEPPER-Program for Evaluating Payment Patterns Electronic Report
e.Postacute Transfer Policy
It works with consumers and healthcare providers and hospitals to make sure that patients are getting the "right care at the right time"

Question 39

The ____________________ indicator is to differentiate between conditions that develop during a particular admission and conditions that are present at the time of admission.

Question 40

Quality improvement organizations are NEVER required to conduct individual case reviews;it is ALWAYS a combined case review.

Question 41

RAC stands for __________.

Question 42

MS-DRG stands for __________.

Question 43

How do you calculate case-mix index?