Deck 10: Introduction to Coding and Reimbursement

Question 1

A medical nomenclature organizes diseases and procedures into numeric and alphabetic characters.

Answer 1

False

Question 2

The intent of standard coding guidelines is to simplify claims submission for health care providers.

Answer 2

True

Question 3

CPT is the abbreviation for current procedure terms.

Answer 3

False

Question 4

Revenue codes classify hospital categories of service by revenue cost center.

Question 5

Diagnosis-related group (DRG) grouper software is used to assign ICD-10-CM codes to inpatient cases.

Question 6

Medicare legislation prohibits physicians from referring patients to an entity with which the physician or family member(s) have a financial relationship.

Question 7

HCPCS Level II codes are in the public domain, and they are not copyrighted.

Question 8

ICD-10-CM is published by the American Medical Association (AMA) and provides numerical codes for procedures.

Question 9

A clearinghouse is an entity that processes health information received from another entity.

Question 10

Codes are reported to third-party payers for reimbursement and to external agencies for data collection; they are also used internally for education and research.

Question 11

Workers' compensation is a federally mandated insurance program that reimburses health care costs and lost wages for employees injured on the job.

Question 12

Upcoding is the assignment of a DRG that does not match documentation and is for the purpose of increasing outpatient reimbursement.

Question 13

Paying for surgery performed on the wrong body part is not consistent with the goals of Medicare payment reforms.

Question 14

The national limitation amount serves as a ceiling on the amount that third-party payers can pay for clinical laboratory tests.

Question 15

A subscriber is a health plan enrollee.

Question 16

Medicaid is a joint federal and state program that provides health care coverage to individuals age 65 and older.

Question 17

Commercial health insurance payers include private and employer-based health insurance plans.

Question 18

Critical pathways usually focus on one discipline and provide guidelines for standards of care.

Question 19

Chargemasters should undergo annual reviews.

Question 20

The standard classification for mental disorders is Current Procedural Terminology (CPT).

Question 21

The standard institutional claim submitted by hospitals and skilled nursing facilities to payers to obtain reimbursement for health care services is called

A) CMS-1450.
B) CMS-1500.
C) HCFA-1992.
D) HCFA-1500.

Question 22

Which is a standard classification of mental disorders published by the American Psychiatric Association (APA)?

A) CPT
B) DSM
C) ICIDH
D) NDC

Question 23

Which of the following is not an example of a never event?

A) Foreign body left in a patient after surgery
B) Mismatched blood transfusion
C) Severe pressure ulcer present on admission to the hospital
D) Medication error

Question 24

In 1948, Happy Hospital was able to secure federal grant funds to update its surgical units. This funding was established by

A) FECA.
B) Hill-Burton Act.
C) Medicare.
D) Taft-Hartley Act.

Question 25

Sue has just accepted a position at the National Library of Medicine to retrieve and process electronic biomedical information for health care universities. Her supervisor informs her that she will be receiving coding training for

A) CPT.
B) CMIT.
C) DSM-III.
D) UMLS.

Question 26

Each year the business office, ancillary departments, and health information management (HIM) department update the charges and codes for all procedures, services, and supplies. This information is entered into the computer system to create a

A) chargemaster.
B) encounter form.
C) financial record.
D) superbill.

Question 27

Sally works in a pathology laboratory, gathering information for staff pathologists. Which nomenclature does she use in her job?

A) SNO
B) SNDO
C) SNOMED
D) SNOP

Question 28

Hospital reimbursement based on a retrospective payment system that issues payment based on daily charges is called

A) fee-for-service.
B) RPS.
C) per diem.
D) an 80/20 plan.

Question 29

A durable medical equipment company would classify medical equipment using

A) CPT codes.
B) CDT codes.
C) HCPCS Level II codes.
D) NDC codes.

Question 30

Sally is a coder for a dentist and needs to purchase updated coding books. She should purchase

A) CDT.
B) CPT.
C) HCPCS Level II.
D) CDT and ICD-10-CM.

Question 31

Sue has just taken a new job at the Pentagon. Part of her benefits include health insurance coverage through

A) CHAMPVA.
B) FEP.
C) MHS.
D) PACE.

Question 32

National Drug Codes are managed by the

A) American Medical Association.
B) American Pharmacy Association.
C) Centers for Medicare and Medicaid Services.
D) Food and Drug Administration.

Question 33

Which of the following is not an example of a hospital-acquired condition?

A) Fall from hospital bed
B) Staph infection after surgery
C) Catheter-associated urinary tract infection (UTI)
D) Heart attack 24 hours after admission

Question 34

University medical students are reviewing research to determine the death rates of hospital patients admitted for pneumonia. Which system would be helpful in their study?

A) APACHE
B) DRG
C) MMPS
D) RUG

Question 35

Which organization publishes CPT?

A) AHIMA
B) AAPC
C) AMA
D) CMS

Question 36

Barb is completing a report for the hospital governing board. The board wants to review the types and categories of patients treated. Barb should use which data to prepare the report?

A) Case mix
B) Coding
C) Inpatient census
D) Severity of illness scores

Question 37

:Interdisciplinary guidelines developed by hospitals to facilitate the management and delivery of quality clinical care are called

A) clinical pathways.
B) critical pathways.
C) MQ pathways.
D) quality pathways.

Question 38

Which characteristic of electronic data interchange (EDI) below is incorrect?

A) It determines claim status within 14 hours.
B) Payment of electronic claims is faster.
C) Lower administrative costs result.
D) Online receipt is generated.

Question 39

The inpatient prospective payment system (IPPS) 72-hour rule requires that outpatient preadmission services provided by a hospital up to three days prior to a patient's inpatient admission be covered by the DRG payment for

A) diagnostic services.
B) diagnostic and pharmacy services.
C) diagnostic and therapeutic services with the same principal diagnosis code.
D) therapeutic services.

Question 40

Polly's job responsibilities include collecting outcome and assessment information set (OASIS) data and entering the data set into Home Assessment Validation Entry (HAVEN) data-entry software. She most likely works at a

A) hospital.
B) home health agency.
C) nursing facility.
D) rehabilitation center.

Question 41

Pharmacies use ______________________________ to report pharmacy transactions.

Question 42

A retrospective payment system or _________________________ plan bills payers after health care services are provided to the patient.

Question 43

Payers that process both Medicare Part A and Part B claims are known as ______________.

Question 44

Preestablished reimbursement rates for health care services are part of a(n) ____________________.

Question 45

The End-Stage Renal Disease Composite Payment Rate System was established by the _____.

A) Balanced Budget Act of 1997
B) Deficit Reduction Act of 1984
C) Medicare Prescription Drug, Improvement and Modernization Act of 2003
D) Omnibus Budget Reconciliation Act of 1980

Question 46

The Correct Coding Initiative was implemented to reduce ____________________ expenditures by detecting inappropriate coding on claims.

Question 47

Hospitals use a ____________________ to record encounter data about ambulatory care.

Question 48

Private health insurance consists of a(n) _________________________, which covers individuals for certain health care expenses.

Question 49

HCPCS Level II or _________________________ codes classify medical equipment, injectable drugs, and other services not classified in CPT.

Question 50

Dr. James Read developed ____________________ to record clinical summaries in general practice.

Question 51

In the early 1900s, most patients paid for health care services by ____________________ or bartering.

Question 52

A third-party payer is an organization that processes claims for ____________________ covered by a health care plan.

Question 53

In 2008, Medicare implemented ambulatory payment classifications (APCs) and relative payment weights to reimburse ________ for surgical procedures performed.

A) ambulatory surgery centers
B) clinics
C) inpatient facilities
D) emergency departments

Question 54

The goal of the Recovery Audit Contractor program is to

A) audit health care records for incomplete documentation.
B) identify improper payments made on claims of health care services provided to Medicare beneficiaries.
C) recover payments made to health care facilities, regardless of the payer.
D) reimburse beneficiaries for payments made to them in error.

Question 55

The purpose of the ___________________________________ is to aid in the development of systems to help retrieve and integrate electronic biomedical information from a variety of sources.

Question 56

A health care enrollee is known as a(n) ____________________.

Question 57

The Medicare Severity DRG was implemented by CMS in _____.

A) 1983
B) 1997
C) 2003
D) 2007

Question 58

ICD-10-CM and ICD-10-PCS codes are assigned to ____________________ diagnoses and procedures and entered into automated abstracting software.

Question 59

Third-party payers often adopt payment systems and fee schedules after ____________________ has implemented them.

Question 60

The Military Health System (MHS) provides health care services and support to __________________________________________________.

Question 61

Describe when a veteran's dependents may receive benefits from the CHAMPVA program.

Question 62

The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) required adoption of two types of code sets for encoding data elements. Describe the large code sets.

Question 63

List the code sets proposed by HIPAA.

Question 64

Define severity of illness, and summarize the basis of severity of illness scores.

Question 65

Summarize the services that are reimbursed by the Medicare Resource Based Relative Value System (RBRVS), now called the Physician Fee Schedule (PFS).

Question 66

Summarize disability insurance, stating the percentage of income covered and the waiting period.

Question 67

Explain why case-mix analysis should be performed by health care facilities.

Question 68

Errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients are referred to as _____________.

Question 69

State the name of the organization that developed the Systematized Nomenclature of Pathology (SNOP) and the purpose of the nomenclature.

Question 70

Define and state the purpose of an APC. Describe how the APC payment rate is applied to payment.

Question 71

Describe the activities that are coded by SNOMED.