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Confidential information about patients should never be discussed with
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when Criterion are used by the review agency for admission screening, this is referred to as
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Confidential information about patients should never be discussed with Coworkers, family, or friends
when Criterion are used by the review agency for admission screening, this is referred to as AEPs
One criteria 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 an monitoring of intravenous medications
a patient is considered an inpatient to the hospital on admission for an overnight stay
when a patient is admitted who has a managed care contract for an emergency to a hospital, the managed care program needs to be notified within 48 hours
the rule stating that when a patient recieves outpatient services within 72 hours of admission, then all outpatient services are combined with inpatient services and become part of the diagnostic- related group rate for admission, is called the 72 hour rule
what organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review PRO
Readmission review occurs if the patient is readmitted within 7 days of discharge
a review for additional Medicare reimbursement is called day outlier review
The significant reason for which a patient is admitted to the hospital is coded using the principle diagnosis
Classification 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 at least two digits, and two to four digits
The code book used to list procedures on outpatient hospital claims is CPT
the person who interviews the patient and obtains personal and insurance information and the admitting diagnosis is a admitting clerk
daily progress notes are entered on the patient's medical record by a nurse
the claim form sent to the insurance carrier for reimbursement for inpatient hospital services is called the UB-92
the form that accompanies the billing claim form for inpatient hospital services is called a detailed 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 sent to the insurance carrier for these services anyways, this is called double billing
a tentative DRG is based on admission diagnosis, scheduled procedures, age, an secondary diagnosis
how many major diagnostic categories (MDCs) are there in the DRG- based system 25
On the UB-92 claim form, code 6 (transfer from another health care facility) in block 20 is used to indicate source of admission
The claim form used for outpatient hospital services is the UB-92 claim form
PAT is an abbreviation for Preadmission testing
The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge plan to determine whether admissions are justified is called the ____ department utilization review
The coding system is used to list procedural codes for Medicare patients on hospital insurance claims that are not in the CPT book Healthcare Common Procedures
The _____ is the clinical resume for final progress note discharge summary
The Uniform bill claim form is considered a _____ statement summary
Medicare provides stop loss called _____ in its regulations outliers
The abbreviation of the phrase that indicates when claims are submitted electronically is EDI electronic data interchange
On the UB-92 claim form, the first digit of the three-digit bill code in block 4 indicates the type of _____ facility
On the UB-92 claim form, 15:53 listed as the hour of admission indicates that the patient was admitted at 3:53 Pm
On the UB-92 claim form, the number of inpatient days is indicated in block 7; these are referred to as _____ days covered
A three- or four-digit code corresponding to each narrative description or standard abbreviation that identifies a specific accomodation, ancillary service, or billing calculation related to services billed is called a ____ code revenue
The DRG- based system changed hospital reimbursement from a fee- for service system to a lump-sum, fixed fee payment based on the ______ rather than on time or services rendered Diagnosis
Cases that cannot be assigned an appropriate DRG because of a typical situations are called cost outliers
An unethical practice of upcoding a patient's DRG category for a more severe diagnosis to increase reimbursement is called DRG creep
____ is a preexisting condition that will, because of its effect on the specific principle diagnosis, require more intensive therapy or cause an increase in length of stay by at least 1 day in approximately 75% of cases Comorbidity
What is the Outpatient Prospective Payment System pricing unit that is comparable to DRGs for inpatient services ambulatory payment classification (APC)
what are the three types of CCI edits Column1/Column 2 code pair edits mutually exclusive edits medically unlikely edits
what is the difference between fraud and abuse fraud is an intentional act of deception to take advantage of another person. Abuse is an action of misusing government allocated money; it is not necessarily intentional
what is a compliance plan a process for finding, correcting, and preventing illegal practices
MDC is an abbreviation for major diagnostic categories
A software program used to assign DRGs MS grouper
Conditions that develop as problems related to surgery or other treatments complications
Average of the DRG weights for all discharged patients during a certain time period is a hospital's case mix index (CMI)
MCE is the abbreviation for Medicare Code Editor
Medicare's national policy on correct CPT coding Correct Coding Initiative (CCI)
Identification of services that could not have reasonably been done during a single patient encounter CCI mutually exclusive edits
Programs that align financial incentives with the delivery of high-quality care pay for performance programs
T/F: when a managed care patient is admitted for a nonemergency to a hospital without a managed care contract, the managed care program needs to be notified by the hospital within 48 hours False: Next Busines day
T/F: Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity False: Clearinghouse, providers and Third party payers are "Covered Entities"
Insurance companies are related according to the number of complaints received about them True: Remember, the state Insurance Commissioner tracts this data and is published in the public domain.
When a physician offers a discount, it must apply to the total bill, not just the portion that is paid by the patient True
A personal check is a guarantee of payment False
Standard policy should be to reduce fees of any patient who dies after receiving medical care False: Perception on part of the family is that an element of guilt is implied
In the UCR system of payment, "Usual" is the fee that the physician usually charges for a given serive to a private patient True
Ambulatory Payment Classifications are based on diagnosis False. Based on Procedures
A patient always has the right to obatin a copy of his or her confidential health information False
A collection rate of 80-85% should be a goal for the practise administrator in charge of collections in the physicians office False
The exchange of data in a standardized format through computer connections is known as electronic data interchange True
Statements should not be sent to the patient who has filed for bankruptcy True
The purpose of the DRG based system is to hold down rising health care costs True
Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a workers com case True
The cash flow factr is used to translate the abstract units (RVUs) in the scale to dollar fees for each service or procedure False. It is the converstion factor
Confidential data should be stored only in the computer's hard drive false
Appeal decision on Medicare unassigned insurance claims are sent to the patient True
If the provider is notified by a commercial carrier that an overpayment has been made, investigate the refund request True
When a physician continues to treat an established patient with an overdue account, patients who fall into this delinquent status should be referred elsewhere False
The physician's office uses ICD-9-CM Volumes 1,2, and 3 to code diagnoses and procedures False. Volume 1 and 2 only in the private office
M/C: Confidential information includes: A.) everthing heard about a patient, B.) Everything that is read about a patient, C.) Everything tha tis seen regarding the patient, D.) All the above D.) all the above
M/C: The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called? UB-04
M/C: A group of insurance claims sent at the same time from one facility is known as a Batch
The most important function of a practise management system is Accounts receivable
M/C: A clearing house performs: A.) Transmits claims to the insurance payer, B.) Performs software edits, C.) Separates claims by carrier, D.) All the above D.) all the above
When a medical practise has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as Carrier- direct
The significant reason for which a patient is admitted to the hospital is coded using the Principle diagnosis
The form that accompanies the billing claim for inpatient hospital services is called Detailed or itemized statement
Nonprivilged information about a patient consists of the patient's City of residence. Remember, the only thing that is privilged is "health information" that can be connected to an individual.
The focus on the health care practise setting and reducing administration costs and burdens are hte goals of which HIPAA title HIPAA Title 2 Administrative Simplification
What is the correct response when a relative calls asking about a patient Have the physican return the phone call
The rule stating that when a patient recieves outpatient services within 72 hours of admission, then all outpatient services are combined with inpatient services and become part of the diagnostic related group for the admission, is called the 72 hour rule
Professional services billed by the physician include hospital consultation, hospital visits, emergency department visits
Pending or resubmitted insurance claims may be tracked through a tickler file
the document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as a EOB (Explanation of benefits)
An example of a technical error on an insurance claim is Duplicate dates of service; transposed numbers, missing "place of service" codes.
The correct method to send documents for a Meedicare reconsideration (Level 2) is by what method certified mail with return receipt request
The average amount of accounts receivable should be 1.5 to 2.0 times the charges for 1 month of services
What is the name of the act designed to address the collection practices of third party debt collectors and attorneys who regularly collect debts from others fair debt collection practices act (FDCPA)
RVU is Relative Value unit
PAT is PreAdmission Testing
CCI is Correct Coding Initiative
DRG is Diagnosis related group
APC is Ambulatory payment classification
RBRVS is Resource based relative value scale (system)
GAF is Geographc Adjustment Factor
UCR is Usual, ustomary and reasonable
HL7 is Health Level 7
EIN is Employer's Identification Number
Assigning a code to represent data is known as Encryption
When keying data, it is wise to ___ frequently to save informaton Back-up
If the medical practice receieves payment from an insurance company that is more than the contracted rate, it is called a ______ Overpayment
If inadequate payment was recieved from an insurance company for a complicated procedure, the insurance billing specialist should file a _ on behalf of the physician Appeal
The relationship of the amount of money owed to a physican and the amount of money collected on the physicians accounts receivable is called the collection ratio
How the physicians office handles the retention, removal, and disposal of paper records is a _____ safeguard Physical
The hospital department that conducts an admission and concurrent review on all cases and prepares a discharge plan to determine whether admissions are justified is the ___ department Utilization review
A 3 to 4 digit code representing a specific accomodation ancillary service or billing calculations related to a service is a Revenue code
DRGs are based on what two elements Diagnosis and treatment
The rangeof usual fees charged by providers of similar training and experience in a geographic area is called Customary (UCR)
Stealing money that has been entrusted to ones care is known as embezzelment
Billing for services for supplies not provided is fraud
A billing practice such as exccessive referrals to other providers for unnecessary services is considered abuse
the procedure of systematically arranging the accounts receivable by age from the date of service is called Age analysis
The statement "This bill is now 30 days past due. Please remit payment." This is known as what kind of message? Dun
A formal regulation of law setting time limits on legal actions is known as what Statue of limitations
in dealing with an estate claim, a call to the _____ can be made periodically to check on the status of the estate executor
A ____ is a claim on the property of anoher as seurity for a debt Lien
Employees should be required to attend a complaiance training session at least annually
the maximum time during which a legale collection suit may be rendered against a debtor is referred to as a Statue of limitation
what are the three names for the form used by inpatient billing services UB-04; CMS-1450; 837i
Explain the following formula. Not only what the abbreviations stand for, but also their meaning: RVU X GAF X CF = MEDICARE REIMBURSEMENT The sum of the three individuals RVUs (Relative Value Units) times the Geographic Adjustment Factor times the Conversion Factor= Reimbursement
What are 5 of the 8 disciplinary standards for employee misconduct verbal warning; written warning; written reprimand; suspenstion or probation; demotion; termination; restitution of damages; referral for procecution
what does the abbreviation HIPAA stand for health insurance portability and accountability act.
Kaiser Permanente's Medical plan is a closed panel program, which means: A.) limits the patients choice of a PCP, B.) Limits the patient choise of a hospital for ER care, C.) Services are provided on a FFS basis, D.) Only Certain illnesses are covered A.) limits the patient choice of a personal physician (PCP)
When a HMO is paid a fixed amount for each patient served, this is known as A.)customary charge, B.) FFS, C.) Usual charge, D.) Capitation D.) Capitation
Created by: Lea99
 

 



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