Question 1

Under Medicare's PPS,long-term care hospitals (LTCHs)generally treat patients who require hospital-level care for an average length of stay greater than _____ days.
A) 10
B) 15
C) 25
D) 60

Accepted Answer

Under Medicare's Prospective Payment System (PPS), long-term care hospitals (LTCHs) are defined as facilities that treat patients requiring hospital-level care for an average length of stay greater than 25 days.

Question 2

Services provided under the hospital outpatient prospective payment system (OPPS)are classified and paid according to:
A) DRGs.
B) ALOS.
C) APCs.
D) PPS.

Accepted Answer

Services provided under the hospital outpatient prospective payment system (OPPS) are classified and paid according to Ambulatory Payment Classification (APC) groups. Each APC group includes a set of related procedures that are expected to require similar hospital resources. Payment rates are assigned to each APC group based on the average cost of providing those services.

Question 3

The amount of payment in the Prospective Payment System (PPS),based on the classification system of that service,is determined by the assigned:
A) capitation amount.
B) diagnosis-related group (DRG).
C) usual, customary, and reasonable (UCR) fee.
D) either b or c

Accepted Answer

The amount of payment in the Prospective Payment System (PPS) is determined by the assigned diagnosis-related group (DRG). The DRG classification system groups patients based on their similar clinical characteristics and expected resource use. The PPS then determines the payment amount based on the DRG assigned to the patient's particular service. Capitation and usual, customary, and reasonable (UCR) fees are not used in the PPS system.

Question 4

When an insurance carrier makes a payment to the patient/insured (or the provider)for a covered expense,it is referred to as:
A) coverage.
B) copayment.
C) deductible(s).
D) reimbursement.

Accepted Answer

When an insurance carrier makes a payment to the patient/insured (or the provider) for a covered expense, it is referred to as reimbursement.

Question 5

The presence of one or more disorders/diseases in addition to the primary disorder/disease is called a:
A) comorbidity.
B) complication.
C) dual diagnosis.
D) medical history.

Accepted Answer

Comorbidity refers to the presence of one or more additional disorders or diseases alongside the primary disorder/disease. Complication refers to a new problem that arises as a result of the primary disorder or its treatment. Dual diagnosis usually refers to the presence of a mental health disorder along with a substance abuse disorder. Medical history refers to a record of a patient's past and present medical conditions and treatments.

Question 6

The typical length of stay for a patient classified to a long-term care (LTC)DRG is referred to as the:
A) APC.
B) GPCI.
C) ALOS.
D) ADL.

Accepted Answer

ALOS stands for Average Length of Stay, and it represents the typical length of stay for a patient in a particular DRG (such as long-term care). Therefore, the correct answer is C. APC (A) refers to Ambulatory Payment Classifications, which are used for outpatient services. GPCI (B) stands for Geographic Practice Cost Index, which is used to adjust Medicare payment rates based on the cost of living in different areas. ADL (D) stands for Activities of Daily Living, which are used to assess a patient's functional status and determine their level of care needed.

Question 7

The federal payment rate adjustment for LTCH stays that are significantly shorter than the average length of stay for a long-term care DRG is referred to as:
A) GPCI.
B) ALOS.
C) LTC adjuster.
D) a short-stay outlier.

Accepted Answer

The federal payment rate adjustment for LTCH stays that are significantly shorter than the average length of stay for a long-term care DRG is referred to as a short-stay outlier. Options A, B, and C are all unrelated to short-stay outliers.

Question 8

Medicare and Medicaid's patient classification system,consisting of distinct groupings that provide a means for relating the type of patients a hospital treats with the costs incurred for treating them is called:
A) PPS.
B) DRG.
C) RVS.
D) APC.

Accepted Answer

Medicare and Medicaid's patient classification system is called the Diagnosis Related Group (DRG) system. It consists of distinct groupings that provide a means for relating the type of patients a hospital treats with the costs incurred for treating them. The DRG system categorizes patients based on their diagnoses and procedures and assigns a payment to each DRG based on the average cost of treating patients within that group. This system is used to determine reimbursement rates for hospitals and other healthcare facilities that treat Medicare and Medicaid patients.

Question 9

When determining the applicable DRG classification,the key piece of information is the patient's:
A) chief complaint.
B) primary diagnosis.
C) principal diagnosis.
D) underlying symptoms.

Accepted Answer

The principal diagnosis is the condition that is ultimately responsible for the patient's admission to the hospital, and it is the key factor in determining the appropriate DRG classification.

Question 10

A computer software program that takes the coded information and identifies the patient's DRG category is called a:
A) descrambler.
B) DRG grouper.
C) DRG identifier.
D) digitalized coder.

Accepted Answer

A DRG grouper is a computer software program designed to identify the patient's DRG category based on the coded information provided. The other options (descrambler, DRG identifier, digitalized coder) do not accurately describe the function of a DRG grouper.

Question 11

The basic idea of resource utilization groups (RUGs)is to calculate payments to:
A) outpatient clinics.
B) acute care hospitals.
C) skilled nursing facilities.
D) long-term care facilities.

Accepted Answer

Resource Utilization Groups (RUGs) are used to calculate payment rates for skilled nursing facilities that provide long-term care services. This payment system assesses the amount and level of resources used by a resident to determine payment.

Question 12

A method of payment for healthcare services whereby the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided is called:
A) UCR.
B) PPG.
C) capitation.
D) fee-for-service.

Accepted Answer

Capitation is a payment method in which the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided. This helps to incentivize preventive care and efficient use of resources, as the provider does not receive more money for offering more services or procedures.

Question 13

A system of payment for healthcare services whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient or by the patient's insurance carrier is called:
A) capitation.
B) fee-for-service.
C) discounted fee-for-service.
D) prospective payment system (PPS).

Accepted Answer

Fee-for-service is a payment model in which healthcare providers receive a specific fee for each service they provide. This fee is usually negotiated in advance between the provider and the patient's insurance carrier. Under this system, patients are free to choose their healthcare providers and the services they receive, and providers are compensated for each service rendered. This is the most common payment model used in healthcare today.

Question 14

Which of the following is not one of the three components that make up the total relative value unit (RVU)?
A) Physician work
B) Patient diagnosis
C) Practice expense
D) Malpractice risk

Accepted Answer

The three components that make up the total RVU are physician work, practice expense, and malpractice risk. Patient diagnosis is not a component of the RVU.

Question 15

The Prospective Payment System (PPS)is Medicare's system for reimbursing which of the following?
A) Part A inpatient hospital costs
B) Part B physician and outpatient charges
C) Both Part and Part B costs
D) Only emergency room fees

Accepted Answer

The Prospective Payment System (PPS) only applies to Medicare Part A inpatient hospital costs. It determines a fixed amount of payment for each specific diagnosis-related group (DRG) regardless of the actual cost of the services provided. This encourages hospitals to provide efficient and cost-effective care while controlling healthcare spending.

Question 16

A type of reimbursement used by CMS that bases Medicare payments on a predetermined,fixed amount (e.g.,DRGs for inpatient hospital services)is called:
A) capitation.
B) fee-for-service.
C) discounted fee-for-service.
D) prospective payment system.

Accepted Answer

The prospective payment system (PPS) uses a predetermined, fixed amount to determine Medicare payments for services such as inpatient hospital care, home health services, and skilled nursing facilities. This system aims to control healthcare costs by incentivizing healthcare providers to deliver efficient and effective care. Capitation refers to a payment model where healthcare providers receive a fixed amount per patient, regardless of the number or type of services provided. Fee-for-service and discounted fee-for-service both refer to payment models where providers are reimbursed for each service provided, rather than a fixed amount per patient or diagnosis.

Question 17

The relative value of each service on Medicare's RVRVS fee schedule is multiplied by the ______________,an annually adjusted conversion factor for each Medicare locality.
A) GPCI
B) ALOS
C) ANSII
D) RBRVS

Accepted Answer

The GPCI (Geographic Practice Cost Index) is a factor used in the RVRVS fee schedule to adjust for differences in practice costs among different Medicare localities. The GPCI is multiplied by the relative value of each service to determine the payment amount. The conversion factor, which is also adjusted annually, is then applied to this amount to arrive at the final payment. The ALOS and ANSII are not part of the RVRVS fee schedule. The RBRVS (Resource-Based Relative Value Scale) is used to determine the relative values of services on the RVRVS fee schedule but is not multiplied by the GPCI.

Question 18

CPT Level I and HCFA Common Procedure Coding System (HCPCS)Level II codes determine the assignment of the individual ___________ payment rate.
A) APC
B) ASCII
C) ICD
D) HCPCS

Accepted Answer

CPT Level I and HCPCS Level II codes are used to group procedures into Ambulatory Payment Classifications (APCs) which determine the payment rate for a specific service. Therefore, the correct answer is A) APC.

Question 19

The current Medicare RBRVS physician fee schedule is calculated using the ____________ of the service provided (identified by a CPT code)and based on the resources the service consumes.
A) UCR rate
B) per diem rate
C) relative value
D) resource-based value

Accepted Answer

The RBRVS physician fee schedule is calculated using the relative value of the service provided, identified by a CPT code, and based on the resources the service consumes. The relative value is calculated using three components: physician work, practice expense, and malpractice insurance. This system was implemented to more accurately and fairly reimburse physicians for their services. The UCR rate and per diem rate are not used in the calculation of the RBRVS physician fee schedule.

Question 20

Several variations of payment systems from the initial PPS currently being used by Medicare and other third-party payers in the United States have been developed by the:
A) Affordable Care Act.
B) Department of Health/Human Services.
C) Social Security Amendments of 1983.
D) Centers for Medicare/Medicaid Services.

Accepted Answer

The Centers for Medicare/Medicaid Services (CMS) have developed several alternative payment models (APMs) as part of their efforts to transition from traditional fee-for-service payment systems to value-based care models. These APMs include accountable care organizations (ACOs), bundled payments, and patient-centered medical homes (PCMHs), among others. The Affordable Care Act and Social Security Amendments of 1983 have influenced healthcare payment policies in the United States, but they are not responsible for the development of the specific payment systems mentioned in the question. The Department of Health/Human Services also plays a role in healthcare payment policies as the parent agency of CMS, but CMS is the primary driver of payment system innovation.

Quiz 17: Reimbursement Procedures: Getting Paid

Under Medicare's PPS,long-term care hospitals (LTCHs) generally treat patients who require hospital-level care for an average length of stay greater than _____ days.

Services provided under the hospital outpatient prospective payment system (OPPS) are classified and paid according to:

The amount of payment in the Prospective Payment System (PPS) ,based on the classification system of that service,is determined by the assigned:

When an insurance carrier makes a payment to the patient/insured (or the provider) for a covered expense,it is referred to as:

The presence of one or more disorders/diseases in addition to the primary disorder/disease is called a:

The typical length of stay for a patient classified to a long-term care (LTC) DRG is referred to as the:

The federal payment rate adjustment for LTCH stays that are significantly shorter than the average length of stay for a long-term care DRG is referred to as:

Medicare and Medicaid's patient classification system,consisting of distinct groupings that provide a means for relating the type of patients a hospital treats with the costs incurred for treating them is called:

When determining the applicable DRG classification,the key piece of information is the patient's:

A computer software program that takes the coded information and identifies the patient's DRG category is called a:

The basic idea of resource utilization groups (RUGs) is to calculate payments to:

A method of payment for healthcare services whereby the provider is paid a fixed amount for each patient regardless of the actual number or nature of services provided is called:

A system of payment for healthcare services whereby the provider charges a specific fee for each service rendered and is paid that fee by the patient or by the patient's insurance carrier is called:

Which of the following is not one of the three components that make up the total relative value unit (RVU) ?

The Prospective Payment System (PPS) is Medicare's system for reimbursing which of the following?

A type of reimbursement used by CMS that bases Medicare payments on a predetermined,fixed amount (e.g.,DRGs for inpatient hospital services) is called:

The relative value of each service on Medicare's RVRVS fee schedule is multiplied by the ______________,an annually adjusted conversion factor for each Medicare locality.

CPT Level I and HCFA Common Procedure Coding System (HCPCS) Level II codes determine the assignment of the individual ___________ payment rate.

The current Medicare RBRVS physician fee schedule is calculated using the ____________ of the service provided (identified by a CPT code) and based on the resources the service consumes.

Several variations of payment systems from the initial PPS currently being used by Medicare and other third-party payers in the United States have been developed by the: