Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
RHIA Chap 4
PRG2017/ Medical Billing and Reimbursement Systems
| Question | Answer |
|---|---|
| The case mix management system that utilized info from the Minimum Data Set (MDS) in long term care setting is called | Resource Utilization Groups (RUGs) |
| The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from | OASIS |
| Under APC's, the payment status indicator "N" means that the payment | is packaged into the payment for other services |
| All of the following items are "packaged" under the Medicare ASC payments, EXCEPT for | brachytherapy |
| Under the RBRVS, each HCPCS?CPT code contains three components, each having assigned relative value units. These three components are | physician work, practice expense, and malpractice insurance expense |
| The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is | APC's |
| The prospective payment system is based on resource utilization groups (RUGs) is used for reimbursement to ____ for patients with Medicare | skilled nursing facilities |
| The ____ is a statement sent to the provider to explain payments made by third party payers | remittance advice |
| HIPAA administrative simplification provisions require all of the following code sets to be used EXCEPT | DSM |
| The computer to computer transfer of data between providers and third party payers in a data format agreed upon by both parties is called . | electronic data exchange (EDI) |
| A computer software program that assigns appropriate MS DRGs according to the information provided for each episode of care is called a... | grouper |
| The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the... | UB04 |
| Under ASC PPS, when multiple procedures are performed during the same surgical session, a payment reduction is applied. The procedure in the highest level group is reimbursed at ___ and all remaining procedures are reimbursed at ___ | 100% / 50% |
| The ___ refers to a statement sent to the patient to show how much the provider billed. how much Medicare reimbursed the provider, and what the patient must pay the provider | Medicare Summary Notice |
| Currently, which prospective payment system is used to determine the payment to the MD for physician services covered under Medicare Part B, such as outpatient surgery | ASC PPS |
| Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services? | The provider cannot bill the patients for the balance between the MPFS amount and the total charges |
| When the MS DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital... | absorbs the loss |
| Under ASC PPS, bilateral procedures are reimburse at ___ of the payment rate for their group | 150% |
| HIPAA requires the retention of health insurance claims and accounting records for a minimum of __ years, unless state law specifies a longer period | six years |
| ___ is knowingly making false statement or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist | Fraud |
| These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid | payment status indicator |
| The term used to indicate that the service of procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is... | medical neccessity |
| This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of his family has a financial interest | Stark Law |
| ____ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. | Sentinel Events |
| When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medical program, this is called. | Abuse |
| What prospective payment system reimburses the provider according to prospectively determined rate for a 60 day episode of care? | home health resource groups |
| If the Medicare non PAR approved payment amount for $128 for a proctoscopy, what is the total Medical approved payment for a doctor who does not accept assignment, applying the limiting charge for this procedure? | $147.20 (the limiting charge is 15% above Medicare's approved payment amount for MD who do not accept assignment, so $128 x 15% = 19.20 then 128+1920) |
Created by:
kodom001