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Health Insurance Chapter 9
|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
|This is a pre-existing condition treated during the hospitalization, but may not be what required the hospitalization
|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?
|NPPS can bill services provided to Medicare beneficiaries as what? It means that their services are billed underr a supervising physician
|Home Health Services are reimbursed based on each______episode of care
|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
|IPPS adjustment for approved teaching hospitals
|indirect medical education
|What classification system is used for the Inpatient PPS?
|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?
|This determines the appropriate group (e.g. MS, DRG, HHRG and so on) to classify a patient after data about the patient is input
|Predetermined reimbursement methodology:
|Extent of physiological decompensation or organ system loss of function:
|severity of illness
|Hospitals use this to describe their patient encounter form:
|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?
|What does the acronym NPP stand for?
|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?
|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
|Which legislated implementation of the long-term (acute) care hospital inpatient prospective payment system?
|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
|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
|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?
|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?
|Which is a relative value unit in the medicare physician fee schedule payment system?
|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?
|When an office-based service is performed in a health care facility, payment is affected by the use of:
|a site of service differential