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Kduvall
Health Insurance Chapter 9
| Question | Answer |
|---|---|
| What is a state licensed, Medicare certified supplier of surgical healthcare services that must accept assignment on claims? | ambulatory surgical center (ASC) |
| In IPPS, this is an indicator to differentiate between conditions present upon admission and those that develop during the hospital stay | present on admission (POA) |
| Medicare reimburses laboratory services based on what? | submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest |
| How does Medicare reimburse DMEPOS? | 80% of the actual charge amount or the fee schedule amount, whichever is lowest |
| In the Home Health PPS, patient assessments are completed using what? | outcomes and assessments information set (oasis) |
| In the IPPS what rule requires outpaient preadmission services provided by a hospital up to 3 days prior to the patient's admission to be covered by IPPS payment: | IPPS 72-hour rule, or IPPS 3-day window rule |
| Medicare reimbursement for physician's services is based on Relative Value Units assigned to each service/procedure consisting of what? | physician work expense, practice expense, & malpractice expense |
| This a condition that arises during the hospitalization that can change the patient's outcome or may require additional treatment | complication |
| This is a pre-existing condition treated during the hospitalization, but may not be what required the hospitalization | co-morbidity |
| Medicare non-par physicians are held to a limiting charge amount. This is what percentage of the non-par medicare physician's fee schedule amount? | 115% |
| NPPS can bill services provided to Medicare beneficiaries as what? It means that their services are billed underr a supervising physician | incident to |
| Home Health Services are reimbursed based on each______episode of care | 60-day |
| DRG's are organized into what? | major diagnostic categories |
| IPPS adjustment available for hospitals that treat a high-percentage of low-income patients | disproportionate share hospital |
| IPPS adjustment for hospitals that treat unusually costly cases | outliers |
| IPPS adjustment for approved teaching hospitals | indirect medical education |
| What classification system is used for the Inpatient PPS? | MS-DRG |
| What does MS-DRG's stand for? | medical severity diagnosis-related groups |
| What classification system is used for the Physician Fee Schedule payment system? | Resource Based Relative ValueSystem (RBRVS) |
| What classification system is used for the Outpatient PPS? | Ambulatory Payment Classifications (APC's) |
| What classification system is used for the Skilled Nursing PPS? | Resource Utilization Groups (RUGs) |
| What classification system is used for the Home Health PPS? | Home Health Resource Groups (HHRGs) |
| What is a measure of the types of patients treated, and reflects a patient utilization of varying levels of healthcare resources for a facility? | case mix |
| This determines the appropriate group (e.g. MS, DRG, HHRG and so on) to classify a patient after data about the patient is input | grouper software |
| Predetermined reimbursement methodology: | payment system |
| Extent of physiological decompensation or organ system loss of function: | severity of illness |
| Hospitals use this to describe their patient encounter form: | chargemaster |
| Date elements collected by long-term care facilities: | minimum data set (MDS) |
| What do institutional and other selected providers submit their claim data on to payers for reimbursement of patient services? | UB-04 |
| What does the acronym NPP stand for? | nonphysician practitioner |
| Name three nonphysician practitioners: | nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA) |
| Which PPS provides a lump-sum payment that depends on the patient's principal diagnosis, comorbidities, complications, and principal and secondary procedures? | IPPS |
| Which is the abbreviation for the numeric codes reported on the CMS-1500 claim that indicate where services were provided to beneficiaries? | POS (place of service) |
| Resource utilization groups (RUGs) is a ____ reimbursement methodology used by skilled nursing facilities | cost-based |
| Which legislated implementation of the long-term (acute) care hospital inpatient prospective payment system? | BBRA |
| The resource-based relative value scale (RBRVS) system is more commonly called the: | medicare physician fee schedule |
| The process by which health care facilities and payers determine anticipated care needs by reviewing tyupes and/or categories of patients treated by a facility is called_____ analysis | case mix |
| Diagnosis-related groups are organized into mutually exclusive categories called______, which are loosely based on body systems | major diagnostic categories |
| Physician work, practice expense, and malpractice expense are components in computing _______ for the resource-based relative value scale system | relative value units |
| Four-digit______ codes are preprinted on a facility's chargemaster to indicate the location or type of service provided to an institutional patient | revenue |
| Which is responsible for developing data elements reported on the UB-40? | NUBC (national uniform billing committee) |
| Which reimbursement system established rates in advance of services and is based on reported charges from which a per diem rate is determined? | prospective cost-based |
| A patient registered as an outpatient at a hospital presents with three encounters,what will the ambulatory patient classification reimbursement be based on? | assignment of multiple APCs that reflect all services provided, with discounting |
| Which type of hospital is excluded from the inpatient prospectice payment system? | cancer, or childrens hospitals |
| Which is the unit of payment for the inpatient prospective payment system? | hospital admission |
| Which is a relative value unit in the medicare physician fee schedule payment system? | practice expense |
| The intent of establishing a limiting charge for nonPARs is to: | offer financial protection for medicare enrollees |
| Which is classified as a nonphysician practitioner? | physician assistant, nurse practitioners, clinical nurse specialists |
| Which publication communicates new or changed policies and procedures that are being incorporated into a specific CMS manual? | program transmittal |
| When an office-based service is performed in a health care facility, payment is affected by the use of: | a site of service differential |
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