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Answer

Confidential information about patients should never be discussed with

Coworkers, family, or friends

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when Criterion are used by the review agency for admission screening, this is referred to as

AEPs

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One criteria that needs to be met to certify severity of illness (SI) in an admission is

active, uncontrolled bleeding

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One criterion that needs to be met for intensity of service (IS) in an admission is

administration an monitoring of intravenous medications

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a patient is considered an inpatient to the hospital on admission

for an overnight stay

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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

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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

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what organization is responsible for admission review, readmission review, procedure review, day and cost outlier review, DRG validation, and transfer review

PRO

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Readmission review occurs if the patient is readmitted within

7 days of discharge

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a review for additional Medicare reimbursement is called

day outlier review

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The significant reason for which a patient is admitted to the hospital is coded using the

principle diagnosis

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Classification of surgical and nonsurgical procedures and miscellaneous therapeutic and diagnostic procedures are found in

ICD-9-CM Volume 3

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ICD-9-CM procedure codes contain

at least two digits, and two to four digits

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The code book used to list procedures on outpatient hospital claims is

CPT

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the person who interviews the patient and obtains personal and insurance information and the admitting diagnosis is a

admitting clerk

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daily progress notes are entered on the patient's medical record by a

nurse

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the claim form sent to the insurance carrier for reimbursement for inpatient hospital services is called the

UB-92

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the form that accompanies the billing claim form for inpatient hospital services is called a

detailed statement

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the hospital insurance claim form must always be reviewed by the

insurance billing editor

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professional services billed by the physician include

hospital consultations, hospital visits and emergency department visits

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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

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a tentative DRG is based on

admission diagnosis, scheduled procedures, age, an secondary diagnosis

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how many major diagnostic categories (MDCs) are there in the DRG- based system

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On the UB-92 claim form, code 6 (transfer from another health care facility) in block 20 is used to indicate

source of admission

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The claim form used for outpatient hospital services is the

UB-92 claim form

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PAT is an abbreviation for

Preadmission testing

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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

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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

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The _____ is the clinical resume for final progress note

discharge summary

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The Uniform bill claim form is considered a _____ statement

summary

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Medicare provides stop loss called _____ in its regulations

outliers

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The abbreviation of the phrase that indicates when claims are submitted electronically is

EDI electronic data interchange

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On the UB-92 claim form, the first digit of the three-digit bill code in block 4 indicates the type of _____

facility

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On the UB-92 claim form, 15:53 listed as the hour of admission indicates that the patient was admitted at

3:53 Pm

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On the UB-92 claim form, the number of inpatient days is indicated in block 7; these are referred to as _____ days

covered

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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

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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

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Cases that cannot be assigned an appropriate DRG because of a typical situations are called

cost outliers

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An unethical practice of upcoding a patient's DRG category for a more severe diagnosis to increase reimbursement is called

DRG creep

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____ 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

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What is the Outpatient Prospective Payment System pricing unit that is comparable to DRGs for inpatient services

ambulatory payment classification (APC)

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what are the three types of CCI edits

Column1/Column 2 code pair edits mutually exclusive edits medically unlikely edits

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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

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what is a compliance plan

a process for finding, correcting, and preventing illegal practices

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MDC is an abbreviation for

major diagnostic categories

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A software program used to assign DRGs

MS grouper

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Conditions that develop as problems related to surgery or other treatments

complications

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Average of the DRG weights for all discharged patients during a certain time period is a hospital's

case mix index (CMI)

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MCE is the abbreviation for

Medicare Code Editor

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Medicare's national policy on correct CPT coding

Correct Coding Initiative (CCI)

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Identification of services that could not have reasonably been done during a single patient encounter

CCI mutually exclusive edits

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Programs that align financial incentives with the delivery of high-quality care

pay for performance programs

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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

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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"

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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.

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When a physician offers a discount, it must apply to the total bill, not just the portion that is paid by the patient

True

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A personal check is a guarantee of payment

False

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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

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In the UCR system of payment, "Usual" is the fee that the physician usually charges for a given serive to a private patient

True

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Ambulatory Payment Classifications are based on diagnosis

False. Based on Procedures

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A patient always has the right to obatin a copy of his or her confidential health information

False

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A collection rate of 80-85% should be a goal for the practise administrator in charge of collections in the physicians office

False

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The exchange of data in a standardized format through computer connections is known as electronic data interchange

True

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Statements should not be sent to the patient who has filed for bankruptcy

True

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The purpose of the DRG based system is to hold down rising health care costs

True

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Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a workers com case

True

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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

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Confidential data should be stored only in the computer's hard drive

false

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Appeal decision on Medicare unassigned insurance claims are sent to the patient

True

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If the provider is notified by a commercial carrier that an overpayment has been made, investigate the refund request

True

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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

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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

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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

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M/C: The claim form transmitted to the insurance carrier for reimbursement for inpatient hospital services is called?

UB-04

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M/C: A group of insurance claims sent at the same time from one facility is known as a

Batch

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The most important function of a practise management system is

Accounts receivable

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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

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When a medical practise has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as

Carrier- direct

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The significant reason for which a patient is admitted to the hospital is coded using the

Principle diagnosis

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The form that accompanies the billing claim for inpatient hospital services is called

Detailed or itemized statement

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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.

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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

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What is the correct response when a relative calls asking about a patient

Have the physican return the phone call

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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

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Professional services billed by the physician include

hospital consultation, hospital visits, emergency department visits

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Pending or resubmitted insurance claims may be tracked through a

tickler file

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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)

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An example of a technical error on an insurance claim is

Duplicate dates of service; transposed numbers, missing "place of service" codes.

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The correct method to send documents for a Meedicare reconsideration (Level 2) is by what method

certified mail with return receipt request

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The average amount of accounts receivable should be

1.5 to 2.0 times the charges for 1 month of services

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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)

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RVU is

Relative Value unit

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PAT is

PreAdmission Testing

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CCI is

Correct Coding Initiative

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DRG is

Diagnosis related group

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APC is

Ambulatory payment classification

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RBRVS is

Resource based relative value scale (system)

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GAF is

Geographc Adjustment Factor

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UCR is

Usual, ustomary and reasonable

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HL7 is

Health Level 7

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EIN is

Employer's Identification Number

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Assigning a code to represent data is known as

Encryption

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When keying data, it is wise to ___ frequently to save informaton

Back-up

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If the medical practice receieves payment from an insurance company that is more than the contracted rate, it is called a ______

Overpayment

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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

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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

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How the physicians office handles the retention, removal, and disposal of paper records is a _____ safeguard

Physical

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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

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A 3 to 4 digit code representing a specific accomodation ancillary service or billing calculations related to a service is a

Revenue code

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DRGs are based on what two elements

Diagnosis and treatment

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The rangeof usual fees charged by providers of similar training and experience in a geographic area is called

Customary (UCR)

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Stealing money that has been entrusted to ones care is known as

embezzelment

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Billing for services for supplies not provided is

fraud

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A billing practice such as exccessive referrals to other providers for unnecessary services is considered

abuse

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the procedure of systematically arranging the accounts receivable by age from the date of service is called

Age analysis

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The statement "This bill is now 30 days past due. Please remit payment." This is known as what kind of message?

Dun

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A formal regulation of law setting time limits on legal actions is known as what

Statue of limitations

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in dealing with an estate claim, a call to the _____ can be made periodically to check on the status of the estate

executor

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A ____ is a claim on the property of anoher as seurity for a debt

Lien

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Employees should be required to attend a complaiance training session at least

annually

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the maximum time during which a legale collection suit may be rendered against a debtor is referred to as a

Statue of limitation

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what are the three names for the form used by inpatient billing services

UB-04; CMS-1450; 837i

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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

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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

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what does the abbreviation HIPAA stand for

health insurance portability and accountability act.

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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)

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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

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