Health Insurance Chapter 9
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| What is a state licensed, Medicare certified supplier of surgical healthcare services that must accept assignment on claims? | ambulatory surgical center (ASC)
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| 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)
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| Medicare reimburses laboratory services based on what? | submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest
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| How does Medicare reimburse DMEPOS? | 80% of the actual charge amount or the fee schedule amount, whichever is lowest
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| In the Home Health PPS, patient assessments are completed using what? | outcomes and assessments information set (oasis)
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| 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
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| 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
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| This a condition that arises during the hospitalization that can change the patient's outcome or may require additional treatment | complication
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| This is a pre-existing condition treated during the hospitalization, but may not be what required the hospitalization | co-morbidity
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| 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%
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| NPPS can bill services provided to Medicare beneficiaries as what? It means that their services are billed underr a supervising physician | incident to
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| Home Health Services are reimbursed based on each______episode of care | 60-day
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| DRG's are organized into what? | major diagnostic categories
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| IPPS adjustment available for hospitals that treat a high-percentage of low-income patients | disproportionate share hospital
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| IPPS adjustment for hospitals that treat unusually costly cases | outliers
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| IPPS adjustment for approved teaching hospitals | indirect medical education
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| What classification system is used for the Inpatient PPS? | MS-DRG
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| What does MS-DRG's stand for? | medical severity diagnosis-related groups
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| What classification system is used for the Physician Fee Schedule payment system? | Resource Based Relative ValueSystem (RBRVS)
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| What classification system is used for the Outpatient PPS? | Ambulatory Payment Classifications (APC's)
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| What classification system is used for the Skilled Nursing PPS? | Resource Utilization Groups (RUGs)
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| What classification system is used for the Home Health PPS? | Home Health Resource Groups (HHRGs)
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| 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
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| 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
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| Predetermined reimbursement methodology: | payment system
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| Extent of physiological decompensation or organ system loss of function: | severity of illness
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| Hospitals use this to describe their patient encounter form: | chargemaster
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| Date elements collected by long-term care facilities: | minimum data set (MDS)
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| What do institutional and other selected providers submit their claim data on to payers for reimbursement of patient services? | UB-04
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| What does the acronym NPP stand for? | nonphysician practitioner
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| Name three nonphysician practitioners: | nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA)
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| Which PPS provides a lump-sum payment that depends on the patient's principal diagnosis, comorbidities, complications, and principal and secondary procedures? | IPPS
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| 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)
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| Resource utilization groups (RUGs) is a ____ reimbursement methodology used by skilled nursing facilities | cost-based
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| Which legislated implementation of the long-term (acute) care hospital inpatient prospective payment system? | BBRA
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| The resource-based relative value scale (RBRVS) system is more commonly called the: | medicare physician fee schedule
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| 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
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| Diagnosis-related groups are organized into mutually exclusive categories called______, which are loosely based on body systems | major diagnostic categories
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| Physician work, practice expense, and malpractice expense are components in computing _______ for the resource-based relative value scale system | relative value units
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| Four-digit______ codes are preprinted on a facility's chargemaster to indicate the location or type of service provided to an institutional patient | revenue
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| Which is responsible for developing data elements reported on the UB-40? | NUBC (national uniform billing committee)
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| 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
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| 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
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| Which type of hospital is excluded from the inpatient prospectice payment system? | cancer, or childrens hospitals
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| Which is the unit of payment for the inpatient prospective payment system? | hospital admission
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| Which is a relative value unit in the medicare physician fee schedule payment system? | practice expense
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| The intent of establishing a limiting charge for nonPARs is to: | offer financial protection for medicare enrollees
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| Which is classified as a nonphysician practitioner? | physician assistant, nurse practitioners, clinical nurse specialists
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| Which publication communicates new or changed policies and procedures that are being incorporated into a specific CMS manual? | program transmittal
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| 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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