Question 1

In 2000 a specific payment system was implemented for use by CMS for hospital outpatient services reimbursement called the:

Accepted Answer

The hospital outpatient prospective payment system (HOPPS) was implemented in 2000 by CMS as a payment system for hospital outpatient services reimbursement. This system uses a national payment rate for each service or group of services provided to Medicare beneficiaries in hospital outpatient departments. The ambulatory payment classification system is a classification system that assigns each outpatient visit to a payment group based on the resources needed to provide the service. The registered health payment system and vertically integrated payment system are not payment systems used by CMS for hospital outpatient services reimbursement.

Question 2

Regional companies that oversee the administration and processing of Medicare policies and process Part A claims for institutional services are called:

Accepted Answer

Medicare carriers are regional companies that oversee the administration and processing of Medicare policies and process Part A claims for institutional services.

Question 3

How many significant procedures other than the principal procedure may be reported on the UB-04 claim form?

Accepted Answer

The answer of How many significant procedures other than the...

Question 4

When coding inpatient diagnoses,the correct manual(s)to use is/are the:

Accepted Answer

When coding inpatient diagnoses, the correct manual(s) to use is ICD-9-CM. CPT-4 and HCPCS codes are used for outpatient procedures and services.

Question 5

United States hospitals that contract with Blue Cross and Blue Shield organizations are referred to as:

Accepted Answer

Hospitals that contract with Blue Cross and Blue Shield organizations are referred to as member hospitals.

Question 6

Medicare's payment system in which hospitals are paid a set fee for treating patients in a specific category,regardless of the actual cost of care for the individual,is:

Accepted Answer

DRG (Diagnosis Related Group) is Medicare's payment system in which hospitals are paid a set fee for treating patients in a specific category, regardless of the actual cost of care for the individual. This system aims to control healthcare costs by incentivizing hospitals to provide efficient and cost-effective care.

Question 7

To facilitate the process of capturing costs for performing procedures and services,every hospital has what is known as a/an:

Accepted Answer

A charge master is a comprehensive list of all the services, procedures, and supplies provided by a hospital with the associated charges, which is used to capture costs for performing procedures and services.

Question 8

When a patient actively participates in choices about his or her healthcare,this is commonly referred to as:

Accepted Answer

Informed consent refers to the process in which a patient is given all of the relevant information about a medical procedure or treatment, including potential risks and benefits, and is ultimately given the choice to accept or decline the treatment. This process emphasizes the importance of patient autonomy and participation in their own healthcare decisions.

Question 9

Temporary payments for specified new technologies,drugs,devices,and biologics for which costs were not available when calculating APC payment rates are called:

Accepted Answer

Temporary payments for specified new technologies, drugs, devices, and biologics for which costs were not available when calculating APC payment rates are called pass-through payments. These payments are made outside of the standard APC payment rates and are intended to provide extra reimbursement for new technologies that may have higher costs. This allows providers to use these new technologies without taking a financial hit.

Question 10

Medicare Part A helps pay for:

Accepted Answer

Medicare Part A only helps pay for hospital charges, not physician charges or long-term healthcare.

Question 11

Key elements or words in the patient's hospital health record that identify the medical condition that was ultimately determined,after study,to have caused a patient's admission to the hospital is called the _____ diagnosis.

Accepted Answer

The term "principal diagnosis" is commonly used in healthcare to refer to the medical condition that is ultimately determined to have caused a patient's admission to the hospital. This diagnosis is also sometimes referred to as the "primary diagnosis" or "leading diagnosis." However, "principal diagnosis" is the most commonly used term and is recognized by the Centers for Medicare and Medicaid Services (CMS) as the official term to describe the condition that is most responsible for a patient's hospitalization.

Question 12

The process by which a fully informed patient can participate in choices about his or her healthcare is called:

Accepted Answer

Informed consent refers to the process where a healthcare provider explains the risks and benefits of a medical intervention, and the fully informed patient can make a choice about their healthcare based on that information. Recapitulation refers to the repetition of an earlier developmental stage, preauthorization refers to obtaining permission from a payer before a medical procedure, and certification refers to the process of meeting certain standards or qualifications.

Question 13

Many health insurance companies change both their premiums and reimbursement rates:

Accepted Answer

Health insurance companies typically change their premiums and reimbursement rates on an annual basis, usually at the start of the calendar year or at the anniversary date of a particular policy.

Question 14

The designated spaces on the UB-04 are commonly called:

Accepted Answer

The designated spaces on the UB-04 are officially called form locators, as they refer to the specific numbered fields on the form.

Question 15

The name for Medicare's acute care payment system is:

Accepted Answer

Medicare's acute care payment system is called the prospective payment system (PPS). This system pays hospitals a predetermined amount for each case according to the patient's diagnosis, regardless of the actual cost of treatment. The goal of the PPS is to control healthcare costs by incentivizing hospitals to provide efficient care and prevent unnecessary readmissions. The cost share system is a term used to describe the proportion of healthcare costs that patients are responsible for paying out of pocket. The per diem system pays hospitals a fixed amount per day of hospitalization, and DEERS (Defense Enrollment Eligibility Reporting System) is a database used by the military to track eligibility for healthcare benefits.

Question 16

All rules about how much Medicare Part A pays depend on how many days of inpatient care the beneficiary has during what is called a/an:

Accepted Answer

Medicare Part A payments depend on the benefit period, which is a period of time that starts on the first day the beneficiary receives inpatient hospital or skilled nursing care and ends when the beneficiary has not received any inpatient care for 60 consecutive days. The benefit period can include multiple hospitalizations within the same time frame. Therefore, the correct answer is B) benefit period.

Question 17

TRICARE patients,in certain cases,must attain a _____ if a military treatment facility is not available.

Accepted Answer

TRICARE patients must obtain a nonavailability statement in certain cases where a military treatment facility is not available. This statement confirms that no military treatment facility is available to provide the required care, and allows the patient to seek treatment from a civilian provider.

Question 18

Groups of practicing healthcare professionals who oversee the quality of care provided to Medicare beneficiaries are called:

Accepted Answer

Quality Improvement Organizations (QIOs) are groups of practicing healthcare professionals who monitor and improve the quality of care provided to Medicare beneficiaries. They work with healthcare providers to implement evidence-based practices, reduce healthcare disparities, and improve patient outcomes. Fiscal intermediaries primarily process Medicare claims, utilization review commissions review medical necessity and appropriateness of care, and quality review groups may review the quality of care provided but do not have the same level of authority and responsibility as QIOs.

Question 19

When another individual has the authority to speak on a patient's behalf,that individual is often called a:

Accepted Answer

When another individual is authorized to speak on a patient's behalf, they are referred to as a surrogate. A surrogate is often appointed when a patient is incapacitated or unable to make their own healthcare decisions.

Question 20

A Medicaid payment adjustment that reflects patient demographics,diagnostic and treatment information,and total charges is referred to as:

Accepted Answer

A case mix is a Medicaid payment adjustment that reflects patient demographics, diagnostic and treatment information, and total charges. A per diem structure refers to a daily rate of payment, a swing bed configuration refers to the use of hospital beds for different levels of care, and cost sharing refers to sharing healthcare costs between the patient and the insurance provider.

Quiz 18: Hospital Billing and the UB-04