Question 1

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

Accepted Answer

A chargemaster is a comprehensive listing of all services, procedures, drugs, and supplies that a hospital can charge a patient or their insurance provider for. Each item in the chargemaster is associated with a unique charge code, which allows the hospital to generate accurate bills and track revenue. The chargemaster helps ensure that all charges are fairly and consistently applied to all patients, and that the hospital is appropriately reimbursed for the care that is provided.

Question 2

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

Accepted Answer

A complication is an unexpected condition that arises during a patient's hospitalization and often requires additional resources to manage. Comorbidity refers to the presence of multiple medical conditions in a patient, and morbidity refers to the burden of illness. A provisional diagnosis is a tentative diagnosis that is subject to confirmation through further testing or evaluation.

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.

Accepted Answer

Maximization involves manipulating codes to receive maximum reimbursement without the supporting documentation in the medical record or with disregard for the coding conventions, guidelines, and UHDDS definitions. Comorbidity and complication are medical terms related to the presence of additional diseases or conditions in the patient's medical record. Optimization is a general term that may refer to different practices and strategies aimed at improving the efficiency and effectiveness of various processes, including coding-related tasks.

Question 4

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

Accepted Answer

Revenue codes are four-digit codes used on the UB-04 to indicate a particular type of service.

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.

Accepted Answer

Optimization is the process of maximizing the reimbursement or the highest possible payment based on the documentation in the health record. This includes accurate and complete documentation of patient care, diagnosis codes, and procedures performed. It also involves performing audits and appeals to ensure that the facility is receiving the proper reimbursement for the services provided.

Question 6

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

Accepted Answer

All of the above factors (severity of illness, prognosis, and need for intervention) are interrelated parts of case-mix and play a role in determining how sick the patient is. Severity of illness refers to the extent of physiological derangement or organ system failure, while prognosis refers to the expected outcome and likelihood of recovery. Need for intervention encompasses the necessary medical treatments and interventions required to manage the patient's condition. All three factors are important in assessing the acuity and complexity of the patient's illness, which can impact resource utilization and healthcare costs.

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.

Accepted Answer

The retrospective payment system was based on charges, which incentivized hospitals to increase their charges in order to get higher payments. This led to a lack of focus on quality care and best practices. In contrast, the prospective payment system (choice B) pays hospitals a fixed amount for each episode of care or diagnosis, which encourages them to be more efficient and to provide high-quality care. Preferred provider organizations (choice C) are a type of insurance plan that contracts with medical providers to offer discounts to their members. The Tax Equity and Fiscal Responsibility Act (choice D) is a piece of legislation from the 1980s that made significant changes to healthcare financing and reimbursement, but it is not directly related to payment methods.

Question 8

Medicare was established in what year?

Accepted Answer

Medicare was established in 1965 under President Lyndon B. Johnson as a federal health insurance program for individuals 65 and older, as well as those with certain disabilities.

Question 9

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

Accepted Answer

Comorbidity refers to the presence of additional preexisting conditions that can complicate a patient's treatment and may require increased use of resources. This is different from a complication, which is a new condition that arises during the course of treatment. Provisional diagnosis refers to a tentative diagnosis that is subject to change, and morbidity refers to the incidence of disease in a population.

Question 10

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

Accepted Answer

The individual hospital payment rate can change annually based on various factors such as inflation, changes in reimbursement policies, and updates to the wage index. Therefore, option B is false. The other options are true about the individual hospital payment rate.

Question 11

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

Accepted Answer

All of the factors listed can determine MS-DRG assignment.

Question 12

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

Accepted Answer

The answer of Which one of these is NOT a...

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.

Accepted Answer

The first statement is true as specialized software called "groupers" is indeed used to assign the appropriate MS-DRG. The second statement is also true as groupers are often part of encoder or coding software used to assign diagnosis and procedure codes.

Question 14

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

Accepted Answer

Medicare does not cover individuals who are 62 years old, but instead starts coverage at age 65.

Question 15

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

Accepted Answer

MS-DRGs do have relative weights, but not all hospitals have the same payment rate. MS-DRGs are also updated annually, not every 2 years.

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 ____.

Accepted Answer

A charge description number (CDN) is used to designate a specific service or procedure for billing purposes on a patient bill.

Question 17

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

Accepted Answer

Criteria or guidelines determining what is reasonable and necessary for a particular medical service are typically referred to as medical necessity criteria. Good documentation and charge description masters (CDMs) are related but different elements of healthcare billing and coding practices. Department numbers are used to indicate specific service areas within a hospital or healthcare organization.

Question 18

SOW stands for ____.

Accepted Answer

SOW commonly stands for "scope of work," which refers to a document that outlines the tasks, timelines, and deliverables for a specific project or job. Options A and B are not common meanings of SOW, and option D doesn't make sense in this context.

Question 19

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

Accepted Answer

The principal diagnosis is the condition that is primarily responsible for the patient's admission to the hospital. It is the most significant diagnosis that is identified through the medical examination and tests. This diagnosis is reported as the first-listed diagnosis in the patient's medical record and is used for billing purposes.

Option A is incorrect because primary diagnosis means the same as the principal diagnosis. Option B is incorrect because a complication is a secondary condition that may arise during the course of treatment for the principal diagnosis. Option C is incorrect because a provisional diagnosis is a tentative diagnosis made by a physician before further testing or examination.

Question 20

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

Accepted Answer

Quality Improvement Organizations operate under 3-year contracts known as Statements of Work (SOW).

Quiz 26: Reimbursement Methodologies