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Stacks 3 and 4
AAHAM CRCS STACK 3 and 4
| Question | Answer |
|---|---|
| What are the primary functions and responsibilities of Patient Access? | Scheduling Pre admission/pre registration Pre-cert/pre-auth Reg/admission Ins Verification Financial Counseling Collection Compliance |
| What are the collection control points for a Facility? | Pre-admission Admission In-house At discharge After Discharge |
| What are the collection control points for a provider practice? | Preservice Time of service In-house At checkout Post svc |
| What does MOON stand for and describe | MC OP Observation Notice: because hospital IP is part A and observation is part B, the Notice Act requires MOON to be given to pt hospitalized more than 24 hours if they are in observation status. |
| When is the MOON expected to be given and to whom does it apply? | MC OP Obervation Notice No more than 36 hours after observation begins, verbally and in writing. MC pts and patients in psychiatric and critical access hospitals. |
| What are the rules for the Important Message from Medicare? | Hospitals are required to give this to all MC and MC Advantage beneficiaries who are hospital inpatients: w/i 2 days of admission AND w/i 2 days of discharge |
| What are the functions of Case Management (F)? | - prevent un-necc svcs/trmt -evaluate safety/ability to live at home -Obtain approp medical care -secure supplies & equip -obtain home care nursing svcs -obtain assis with errands -coordinate f/u -discharge planning -assist w/ appeals for denials |
| What does HINN stand for and describe | Hospital issued notice of non-coverage - like an ABN for hospital inpatients svcs NOT requiring an ABN/HINN: -svcs listed in MC Manual -screenings: mammo, prostate, routine phys, routine foot care, cosmetic surgery, dental, self administered drugs |
| What are the rules for ABN retention? | Per CMS, required to retain ABN 5 years from discharge/completion of care (unless the state requires longer) whether the pt accepted/refused care. |
| What are the ABN triggering events? | Initiation: Start of trmt, signed prior to svcs Reduction: frequency/duration of care is decreased - only if pt wants to continue frequency knowing it won't be covered. Termination: If beneficiary elects to continue trmt that MC deems no longer nec. |
| What is an ABN and what must it list? | Advance Beneficiary Notice of Noncoverage must be signed preservice if provider thinks MC might not deem it medically necessary. Must have description of svc, estimated cost and reason it's expected to be non-covered. |
| What is the purpose of compliance rules in patient access area? | Prevent, ID and remedy instances of fraud, abuse or other unacceptable conduct. Issuing important docs: MOON, Guarantor forms, ABN, HINN, Important Message from MC. |
| Explain Inpatient and Observation levels of care: | -Inpatient (admitted to a bed, expecting hospital care required. also called acute care. Highest level of care. -Observation - still occupy a bed, but considered OP, monitoring an acute condition that is expected to either get worse or remedy. |
| Explain ER/ED and recurring/series levels of care: | Emergency room - considered OP Recurring/Series - OP coming regularly like PT or chemo |
| Explain what LTC (level of care) stands for and describe: | Long term care: Chronically ill or disabled, in nursing facility or rest home. |
| Describe office and Outpatient levels of care: | Office: Practioner's place of business. OP: Urgent care offices, IV therapy, pain management, wound care, Substance abuse rehab. |
| What does SNF (level of care) stand for and describe: | Skilled Nursing Facility Must be inpatient in hospital 3 days (not including day of discharge) |
| Explain Hospice, Respite and home health levels of care: | Hospice: no life saving measures, keep pt comfortable and without pain. Respite: to give a break to non-paid care providers Home Health - Part time in home nursing care |
| Consent forms: general vs special | Gen: Routine Labs, Diagnostic imaging, Medical trmt Special: HIV + testing, surgery, anesthesia, non-surgical procedure with higher risk, radiation therapy, electroshock/psychiatric treatment, experimental proc., drug/alcohol disorders, blood transfusion |
| list and describe the Types of Consent: | Actual/expressed - written or oral Informed consent: required unless and exception is present (incompacity to understand) Implied in fact: consent by silence, no objection Implied by law: Pt is unconscious and cannot give consent Parental/other |
| What does AOB stand for and describe | Assignment of Benefits: Agreement signed by policyholder (or pt in their absence) to an ins co to pay directly to the provider. If they refuse to sign, insurance co will send $ to them and pt will be responsible. |
| What are the terms for emancipation? | The child has: -fathered or given birth to a child -no longer requires parental guidance/financial support -has reached the age of majority |
| Conditions preventing consent | -Intoxication -unconsciousness -declared mentally incompetent by courts |
| What are the rules for handwritten records? | - Must be clear and concise, legible and well organized - can never alter, erase, delete, remove or destroy a record -if correction is needed, authorized personel can draw a single line strike-thru and initial. NO white out. |
| Who is authorized to make entries in a patient's medical record? | - treating or attending physician - physician extender (PA, NP, etc) - RN - A student from an accredited health profession program |
| When and how can a medical record be released? | - w/ pt written consent -subpoena from a court and proper notice to the patient or patient's legal rep. -may be delivered by fax from 1 facility to another w/ auth. - specific auths are required for dx like hiv, psych, alcohol and drug. |
| What are the rules for accepting verbal order form a referring physician? | Can be accepted by: Physician/physician extender (PA, NP, etc) or RN MUST CONTAIN: -date and time of order Name of ordering physician name of pt and their status exact order, verbatim full name and title of staff member documenting |
| What does NCD stand for and describe: | National Coverage Determination: med review policies issued by CMS that ID specific DME, svcs, procedures or tech that MC can cover. |
| What does LCD stand for and describe: | Local Coverage Determination: policies made by MACs that specify criteria for svcs and show under what clinical circumstances an item/svc is considered to be reasonable, necessary and appropriate. |
| What is a Definitive Diagnosis? | A dx in which a LCD or NCD discusses and lists specific dx codes, ICD (international classification of diseases), procedure codes and sometimes signs & symptoms to support the need for the item/svc. |
| What is a Non-Definitive LCD or NCD? | Provides potential cov scenarios, not specific dx, signs, symptoms or ICD-10 codes. usually says something like "this policy is not exclusive" will require med recs for determination. |
| What does MSP stand for and list when this happens: | MC 2ndary Payer: - 65+ & works -if employer has 20+ employees - 65+ w/ spouse cov -employer has more than 100 employees - has ESRD (for 30 mos, ends 12 mos after dialysys ends. 36 mos after xplant, upon death. WC, auto, The black lung benefits act. |
| What is the IEQ? What is the CWF? | Initial Enrollment Questionnaire (for opt initial enrollment in MC) Common Working File - CMS file w/ pt elegibility & utilization data such as: -PART A & B ENTITLEMENT & DED INFO -DOB/DOD -Benefit periods -MSP info |
| What is the MSPQ and what is it's purpose? | Medicare Secondary Payer Questionaire, form to determine if MC is primary or secondary. asks about employment, accidents, etc. Provider must obtain every 90 days for recurring OP accounts. Must be retained by provider for 10 yrs. |
| What does a provider have to do to terminate a patient relationship? | Provide a 30 day notice in writing with return receipt requested. |
| What does ALOS stand for and how to determine: | Average length of stay: Total number of patient days DIVIDED BY number of discharges. |
| What is the midnight census and how to determine: | refers to the number of pts in a hospital at a particular point in time, most commonly used: Previous midnight census MINUS discharges PLUS admissions PLUS OR MINUS status changes = midnight census |
| What does ADC mean and how to determine: | Average daily census - average number of inpatients each day for a specific period of time: Total number of patient days DIVIDED BY number of days in the period = ADC |
| How do you determine percentage of occupancy? | Census for determined period of time DIVIDED BY # of licensed beds available = Percentage of Occupancy |
| How to calculate average number of patients seen per day (P)? | Total number of patient encounters DIVIDED BY number of days in period = avg number of pts seen / day |
Created by:
Amy17349
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