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Stack #1289377
| Question | Answer |
|---|---|
| there is more chance for advancement working in a hospital facility than a private physican office | true |
| because of the diversity in reimbursement methods, it is very important the insurance billing specialist have basic knowledge of insurance programs | true |
| when a managed care patient is admitted for a nonemergency to a hosptial without a managed care contract, the managed care program needs to be notified by the hospital within 48 hours. | false` |
| emergency department charges are billed along with the inpatient stay on the cms-1500 claim form | false |
| the physicians office uses icd-9 volumes 1,2,3 to code diagnoses and procedures | false |
| elective surgeries are deferrable | true |
| surgical procedures pwerformed in the hospital operating room are billed by the hospital billing department | true |
| a patient has a right to request an itemized bill from a hospital stay with no cost to the patient | true |
| on the UB-04 claim form, the patient's date of birth should be entered using 6 digits in block 14 | false` |
| on the UB-04 claim form in field 17, code 20 is used to indicate the patient's discharge status | true |
| information such as condition is employment related listed in fields 18 through 28 of the UB-04 claim form, is called a codition code | true |
| the grouper differentiates between chronic and acute conditions | false |
| ambulatory payment classifcations (APCs) are based on diagnoses | false It is on procedures |
| confidentail information about patients should never be discussed with | co-workers, family and friends |
| when criteria are used by the review agency for admission screening, this is referred to as | AEPS |
| One criterion that needs to be met to certify severity of illness (SI) in an admission is | active, uncontrolled bleeding |
| one criterion that needs to be met for intensity of service (IS) in an admission is | administration and monitoring of intravenous medications |
| a patient is considered an inpatient to the hospitap on admission | for an overnight stay |
| when a patient who has a managed care contract is admitted to a hospital for an emergency, the managed care program needs to be notified within | 48 hours |
| the rule stating that when a patient receives outpatient services within 72 hours of admission, then all outpatient services are combined with inpatient services and become part of the diagnosstic-related group rate for admission, is called the | 72 hour rule |
| and cost outlier review DRG validation and transfer review | QIO |
| readmission review occurs if the patient is readmitted within | 7 days of discharge |
| a review for addiotnal medicare reimbursement is called | day outlier review |
| the significant reason for which a patient is admitted to the hospital is coded using the | principal diagnosis |
| classifications of surgical and nonsurgical procedures and miscellaneous therapeutic and diagnostic procedures are found in | ICD-9-CM Volume 3 |
| ICD-9-CM procedure codes contain | 2 codes and 2 to four digits |
| the codebook used ti list procedures on outpatient hospital claims is | CPT |
| the person who interviews the patient and obtains personal and isurance information and the admittin diagnosis is a | admitting clerk |
| the claim form transmitted to the insurance carrier for reimbursement for imaptient hospital services is called the | Ub-04 |
| the form that accompanies the billing claim form inpatient hospital services is called a | detail statement |
| the hospital insurance claim form must always be reviewed by the | insurance billing editor |
| Professional services billed by the physician include | hospital consultations, hospital visits. and emergency department visits |
| If a patient is being admitted to a hospital and refuses all preadmission testing but a bill is snet to the insurance carrier for these services anyway, this is called | phantom charges |
| a tentative DRG is Based on | admission diagnosis, scheduduled procedures, age, and secondary diagnosis |
| How many major diagnostic categories (MDCs) are ther in the DRG-based system | 25 |
| On the UB-04 claim form, colde 6 (transfer from another health care facility) in Field 15 is used to inicate | source of admission |
| the claim form used for outpatient hospital services is the | UB-04 claim form |
| PAT | preadimission testing |
| The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge paln to determine whather admissions are justified is called the | Utilization Review Departmant |
| What is the coding system to list procedural codes for medicare patients that are not in the CPT book | HCPCS |
| The clinical resume for the final progress note is the | discharge summary |
| The Uniform Bill claim for is considered a | summary stament |
| Medicare provides stop loss called | outliers |
| ECI is | claims submitted electronically |
| on the UB-04b claim form, the second digit of the four digit code in field 4 indcates the type of | Facility |
| A four digit code corresponding to each narrative description or standard abbreviation that indentifies a specific accomodation, ancillary service, or billing calcuation related to services billed is an | revenue code |
| The DRG based system is based on | diagnoses |
| Cases that cannot be assigned an appropriate DRG because of atypical situations are called | cost outlier |
| an unethical practice of upcoding a patient's DRG category for a more severe diagnosis to increase reimbursement is called | creep |
| Comorbitity is a | preexisting condition that will, becuase of its effect, require more intensive therapy and cause an increase of stay in the hospital |
| QIO | Quality Improvement Organization |
| What is the document that needs to be completed and signed by the doctor after patient leaves the hospital before the hospital gets paid | discharge summury |
| What are the 7 variables that are responsible for DRG classifcations | Principal diagnosis age sex procedure comorbity discharge status |
| What does the abbreviation CC indicate when used with DRGs | comorbid condition and complication |
| under the MS-DRG reimbursement protocaol for Medicare, the 3 levels of Severity are | MCC CC NO CC |
| What is a MS grouper | Medicare severity using a computer software called a grouper that figures out and assigns payments |
| What is a Medicare Code Editor | Protects and reports errors. Does not correct errors for you |
| What is a charge master | Computer program that includes procedure codes, descriptions services, fees revenue codes |
| an averageing after a flat rate has been given to certain categories of procedures | case rate |
| a single charge for a day in the hospital regardless of actual charges or costs incurred | Per diem |
| An outpatient classification scheme developed by health systems intrenational based on procdures rather than on diagnoses | ambulatory payment |
| Method by which part of the plan's payment may be withheld or set aside in a bonus pool | withhold |
| dollar amount owed to a participating provider for health servies rendered to a plan member according to a fee schedule set by the managed care plan | charges |
| Term for a managed care plan that leases beds from a facility | bed leasing |
| A reduction in charges in which the hospitalo receives a flat per-admission reimbursement for the service to which the patient is admitted | differential by service type |
| A calssification system that categorizes inpatients who are medically related with respect to diagnosis and treatment and are statistically simliar in length of hosptial stay | Diagnosis related groups (DRGs) |
| An interim per diem is paid for each day in hospital | Sliding scales for discount and per diems |
| a form of reinsurance in which the hospital buys insurance to protect against lost revenue and receives less of a capitiation gee, and the amount the hospital does not receive helps pay for the insurance | Reinsurance stop loss |
| reimbursement to the hospital on a per-member, per-month basis to cover costs for the member of the plan | Capitation or percentage of revenue |
| Methods in which the plan advances cash to cover expected claims to the hospital | Periodic interim payments (PIPs) and cash advances |
| a comprehensive listing of charges based on procedure codes that states fee maximums paid by the health plan | Fee schedule |
| term for the first day of a hospital stay being paid at a higher rate | differential by day in hospital |
| a single charge per hospital admission paid by the managed care plan | flat rate |
| What do you do with insurance checks | patient financial record, post it |
| what is a tracer or inquiry | where is the money |
| what are some technical errors that can cause a claim to be rejected | misspelled name, wrong dr., wrong address |
| `what happens to claims with invalided codes | They are rejected |
| What do you do if a insurance company denies a procedure as medically unnecessary | appeal it |
| what are the levels for medicare redetermination | 5 |
| How long does a patient have to wait for legal action | 60 days |
| what is an overpayment | insurance sends too much money, DO NOT SEND REFUND |
| what is a batch bundle | claims together- Batch Bundle- Codes |
| what is the turn around time for eci | 7 to 10 business days |
| what is accounts receivable so important to the office | where the money comes in |
| who assigns the NPI number | center for medicare and medicaiad |
| what is encrytion | anx 112 |
| what is cash flow | comes in a any given time |
| what % should be paid on accounts | 15 to 18 % |
| where would a fee reduction be listed | medical record |
| what is capitation and what is fee for service | HMO only |
| what does PCP mean | Primary care Doctor |
| transaction Scribber Report | Where are the areas |
| Edit Checks | what scrubbers do |
| CC | commbilites complication |
| what does assignment mean | predetermined amount the dr accepts |
| what are v codes | they are history codes 1. encounter when patient is out sick 2. Therapeutic procedure 3. outcome of delivery |
| what does medicare part a pay and part b | A hospital b out -patient |
| what is a MAC | contractor |
| what is contained in the physicians payment reform act and what are the 3 goals | 1. decrease medical payment 2. assure quality health care 3. redistributes dr payment equally |
| what is PQRS in detail | category 2 CPT book |
| What is meant by linking | connecting CPT to ICM-9 |
| what is and ABN and which insurance company uses it | medicare, Beneficiary |
| What is a charge summary report | daily report |
| what is a predetermination, reauthorization precertification | predetermination- a financial inquiry before medical treatment to determine cost of the procedure. Precertification- to see if procedure is covered by insurance. Preautorization- some insurance companies require approval before granting payment. |
| what is meant by scrubber summary report | scrubbing is the process in which computer software checks for errors before a claim is submitted. |
| What is a RA | remittance advice |
| what is a PSO | provider-sponsored organization |
| what is a PPO | preferred provider organization |
| What is a PHP | prepaid health plan |
| what is a PCM | primary care manager |
| what is a ur | ultilization review |
| what is a PPS | medicare propective payment system |
Created by:
hudsondrummerman