Deck 9: Cms Reimbursement Methodologies

Question 1

Each home health resource group (HHRG) has an associated __________ that increases or decreases Medicare's payment for an episode of home health care.

A) case mix
B) cost basis
C) resource utilization
D) weight value

Answer 1

weight value

Question 2

The MMA of 2003 mandated implementation of a(n) __________ payment amount as a substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for surgical procedures performed at an ASC.

A) fee schedule
B) inpatient prospective payment system
C) outpatient prospective payment system
D) resource-based relative value scale system

Answer 2

outpatient prospective payment system

Question 3

Reimbursement according to a __________ means that hospitals reported actual charges for inpatient care to payers after discharge of the patients from the hospital.

A) prospective cost-based rate
B) prospective price-based rate
C) retrospective reasonable cost system
D) site-of-service differential

Answer 3

retrospective reasonable cost system

Question 4

Diagnosis-related groups are organized into mutually exclusive categories called __________, which are loosely based on body systems.

A) intensity of resources
B) major diagnostic categories
C) risk of mortality
D) severity of illness

Question 5

Which is associated with a particular category of patient and is established by the payer prior to the provision of health care services?

A) prospective cost-based rate
B) prospective price-based rate
C) retrospective reasonable cost system
D) site-of-service differential

Question 6

The inpatient prospective payment system (IPPS) resulted in Medicare reimbursing hospitals for inpatient hospital services according to a __________ rate for each discharge.

A) cost-based
B) per diem
C) predetermined
D) retrospective

Question 7

In 1980 Medicare authorized implementation of ambulatory surgical center __________ rates as a fee to ambulatory surgery centers (ASCs) for facility services furnished in connection with performing certain surgical procedures.

A) differential
B) payment
C) per diem
D) retrospective

Question 8

The Medicare durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) fee schedule reimburses DMEPOS either __________ percent of the actual charge for the item or the fee schedule amount, whichever is lower.

A) 20
B) 50
C) 80
D) 100

Question 9

Medicare reimburses laboratory services according to a(n) __________, which is based on the submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest.

A) ambulatory outpatient center rate
B) clinical laboratory fee schedule
C) outpatient prospective payment system
D) pathology diagnostic fee schedule

Question 10

The federal government administers several health care programs, some of which require services to be reimbursed according to predetermined reimbursement methodologies, which are established as __________.

A) cost-based rates
B) price-based rates
C) payment systems
D) reasonable cost systems

Question 11

The ambulance fee schedule payment system replaced a __________ for providers and suppliers of ambulance services.

A) prospective cost-based system
B) prospective price-based system
C) retrospective reasonable cost payment system
D) site-of-service differential system

Question 12

Home health resource groups are reported to Medicare on UB-04 using the __________ code set, which represents case-mix groups about which payment determinations are made for the home health prospective payment system.

A) CPT
B) HCPCS level II
C) HIPPS
D) ICD-10-CM

Question 13

Which is established in advance and based on reported health care charges from which a predetermined per diem rate is determined?

A) prospective cost-based rate
B) prospective price-based rate
C) retrospective reasonable cost system
D) site-of-service differential

Question 14

Home Assessment Validation and Entry (HAVEN) __________ software is then used to collect OASIS assessment data for transmission to state databases.

A) data entry
B) editing
C) encrypting
D) grouper

Question 15

The end-stage renal disease (ESRD) composite payment rate system is __________ adjusted to provide a mechanism to account for differences in patients' utilization of health care resources.

A) case-mix
B) cost-basis
C) discharge-status
D) resource-utilization

Question 16

HIPPS codes are determined after home health care patient assessments using the __________ are completed.

A) MEDPAR limited data set (LDS)
B) minimum data set (MDS)
C) outcomes and assessment information set (OASIS)
D) uniform hospital discharge data set (UHDDS)

Question 17

Which is a facility's measure of the types of patients treated and reflects patient utilization of varying levels of health care resources?

A) case mix
B) cost basis
C) discharge status
D) resource utilization

Question 18

An ambulatory surgical center (ASC) is a state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must __________ on Medicare claims.

A) accept assignment
B) assign benefits

Question 19

Which type of software is used to determine the appropriate HHRG after OASIS data is input on each patient (to measure the outcome of all adult patients receiving home health services)?

A) calculator
B) editing
C) encrypting
D) grouper

Question 20

DRG reimbursement rates are recalculated according to a(n) __________ adjustment, which results in increased Medicare payments for hospitals that treat a high percentage of low-income patients.

A) disproportionate share hospital
B) indirect medical education
C) risk of inpatient patient mortality
D) severity of inpatient illness

Question 21

Which is the extent of physiological decompensation or organ system loss of function?

A) case-mix management
B) intensity of resources
C) risk of mortality
D) severity of illness

Question 22

Which was adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs?

A) DRGs
B) AP-DRGs
C) APR-DRGs
D) MS-DRGs

Question 23

The outpatient prospective payment system reimburses services according to ambulatory payment classifications (APCs), which group services according to similar __________ and in terms of resources required.

A) clinical characteristics
B) intensity of resources
C) risk of mortality
D) severity of illness

Question 24

Which adjusts payments to account for geographic variations in hospitals' labor costs?

A) case index
B) disease index
C) morbidity index
D) wage index

Question 25

Which is the relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease?

A) case mix management
B) intensity of resources
C) risk of mortality
D) severity of illness

Question 26

Which was adopted for one year by Medicare in 2007 to reimburse hospitals for inpatient care provided to Medicare beneficiaries?

A) DRGs
B) AP-DRGs
C) APR-DRGs
D) MS-DRGs

Question 27

Which includes all outpatient procedures and services provided during one day to the same patient?

A) limited data set
B) diagnosis-related group
C) outpatient encounter
D) relative value unit

Question 28

Long-term acute care hospitals are defined by Medicare as having an average inpatient length of stay greater than __________ days.

A) 10
B) 15
C) 25
D) 30

Question 29

Hospitals that treat unusually costly cases receive increased __________ payments that are designed to protect hospitals from large financial losses due to unusually expensive cases.

A) disproportionate
B) indirect
C) outlier
D) severity

Question 30

Which is the likelihood of dying?

A) case-mix management
B) intensity of resources
C) risk of mortality
D) severity of illness

Question 31

Approved teaching hospitals receive increased Medicare payments according to a(n) __________ adjustment.

A) disproportionate share hospital
B) indirect medical education
C) risk of inpatient patient mortality
D) severity of inpatient illness

Question 32

Which rule applies when patients are discharged from the hospital directly to a postacute provider?

A) 3-day payment window rule
B) intensity of resources rule
C) severity of illness rule
D) transfer rule

Question 33

Which classifies patients into inpatient rehabilitation facility prospective payment system groups that are based on clinical characteristics and expected resource needs?

A) charge description master
B) fee schedule
C) HIPPS code set
D) patient assessment instrument

Question 34

Which replaced the reasonable cost-based payment system for long-term (acute) care hospitals?

A) cost-based system
B) per diem system
C) prospective payment system
D) retrospective payment system

Question 35

Providers that use the Diagnostic and Statistical Manual refer to diagnostic assessment criteria that are used as tools to identify __________ disorders.

A) ambulatory
B) inpatient
C) medical
D) psychiatric

Question 36

When outpatient preadmission services are provided by a hospital on the day of or during the three days prior to a patient's inpatient admission and the inpatient principal diagnosis code exactly matches that for preadmission services, the IPPS __________ rule applies.

A) 3-day payment window
B) intensity of resources
C) severity of illness
D) transfer

Question 37

Which software is used for the computerized data entry of the minimum data set about skilled nursing facility patients to create a file in a standard format that can be electronically transmitted to a state database?

A) HAVEN
B) IRVEN
C) OASIS
D) RAVEN

Question 38

Provisions of the inpatient psychiatric facility prospective payment system resulted in a __________ patient classification system that reflects differences in patient resource use and costs.

A) cost-based
B) price-based
C) per diem
D) prospective

Question 39

Inpatient rehabilitation facilities use __________ software for computerized data entry to create a file in a standard format that can be electronically transmitted to a national database.

A) HAVEN
B) IRVEN
C) OASIS
D) RAVEN

Question 40

Which is the original DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g., BlueCross BlueShield) and is based on intensity of resources?

A) DRGs
B) AP-DRGs
C) APR-DRGs
D) MS-DRGs

Question 41

An employer group health plan (EGHP) is contributed to by an employer or employee pay-all plan and provides coverage to employees and dependents without regard to the enrollee's employment status. EGHP provisions are applicable __________.

A) for reimbursing commercial claims only
B) regardless of the size of the employer
C) to employers with 100 employees or more
D) when employees only have full-time status

Question 42

A clinical nurse specialist (CNS) is a(n) __________ practice registered nurse licensed by the state in which services are provided, has a graduate degree in a defined clinical area of nursing from an accredited educational institution, and is certified.

A) advanced
B) clinical
C) limited
D) medical

Question 43

Medicare physician fee schedule payment limits were established by adjusting relative value units (RVUs) for each locality using geographic adjustment factors, and an annual dollar multiplier called a __________ changes RVUs into payments using a formula.

A) case mix
B) conversion factor
C) fee schedule
D) grouper

Question 44

Chargemaster __________ is the process of updating and revising key elements of the chargemaster to ensure accurate reimbursement.

A) computerization
B) documentation
C) maintenance
D) revenue generation

Question 45

When the Medicare program does not have primary responsibility for paying a beneficiary's medical expenses, the Medicare __________ concept applies.

A) balance billing
B) conversion factor
C) limiting charge
D) secondary payer

Question 46

When office-based services are performed in a facility, such as a hospital or outpatient setting, payments are reduced because the doctor did not provide supplies, utilities, or the costs of running the facility. This is known as the __________ differential.

A) fee schedule
B) limiting charge
C) resource utilization
D) site of service

Question 47

A nurse practitioner (NP) is a registered nurse licensed to practice as an NP in the state in which services are furnished, is certified by a national association (e.g., American Academy of Nurse Practitioners), and has a(n) __________ degree in nursing.

A) associate's
B) bachelor's
C) master's
D) doctorate's

Question 48

Services provided by nonphysician practitioners may also be reported to Medicare as __________ to the supervising physician's service, and as a result, services are reimbursed at 100 percent of the Medicare physician fee schedule and Medicare pays 80 percent of that amount directly to the physician.

A) allowable charges
B) incident
C) limiting charges
D) price-based costs

Question 49

Which reimburses providers according to predetermined rates assigned to services and is revised by CMS each year?

A) Medicare physician fee schedule
B) Medicare relative value units
C) Medicare resource-based fee schedule
D) Medicare value fee schedule

Question 50

Which communicates new or changed policies and/or procedures that are being incorporated into a specific CMS Internet-only program manual?

A) explanation of benefits
B) program transmittal
C) remittance advice
D) summary notice

Question 51

Nonparticipating provider limiting charge information appears on the Medicare __________, which notifies Medicare beneficiaries of actions taken on claims.

A) chargemaster
B) explanation of benefits
C) remittance advice
D) summary notice

Question 52

Charging write-off or adjustment amounts to beneficiaries is called __________, and it is prohibited by Medicare regulations.

A) accepting assignment
B) allowable charges
C) assigning benefits
D) balance billing

Question 53

Medicare is a secondary payer when a large group health plan (LGHP) is provided by an employer who has __________ or more employees.

A) 25
B) 50
C) 75
D) 100

Question 54

Which are preprinted on a facility's chargemaster to indicate the location or type of service provided to an inpatient?

A) CPT codes
B) HCPCS level II codes
C) ICD-10-CM/PCS codes
D) Revenue codes

Question 55

A chargemaster team jointly shares the responsibility of updating and revising the chargemaster to ensure its __________.

A) accuracy
B) compliance
C) encryption
D) revenue

Question 56

The nonparticipating provider __________ charge is calculated by multiplying the reduced Medicare physician fee schedule by 115 percent.

A) allowable
B) limiting
C) prospective
D) retrospective

Question 57

A physician assistant (PA) must be legally authorized and licensed by the state to furnish services, have graduated from an accredited physician assistant educational program, and have passed the national certification examination of the __________.

A) AHA
B) AMA
C) ANA
D) NCCPA

Question 58

Physician services standardized to measure the value of a service as compared with other services provided are called __________, and they consist of physician work, practice expense, and malpractice expense payment components.

A) allowable charges
B) physician fee schedules
C) price-based rates
D) relative value units

Question 59

The CMS Quarterly Provider Update (QPU) is an online CMS publication that contains information about __________ currently under development or completed/canceled and new/revised manual instructions.

A) classification and coding systems
B) electronic data interchange methods
C) physician fee schedules
D) regulations and major policies

Question 60

Which is a document that contains a computer-generated list of hospital-based outpatient procedures, services, and supplies with charges for each?

A) charge description master
B) electronic health record
C) physician fee schedule
D) UB-04 or CMS-1500 claim

Question 61

Medical conditions or complications that patients develop during inpatient hospital stays and that were not present at admission are called __________.​

A) ​case-mix index relative weights
B) ​hospital-acquired conditions
C) ​medical diagnostic categories
D) ​resource utilization groups

Question 62

Institutional and other selected providers submit __________ claim data to payers for reimbursement of patient services.

A) CMS-1500
B) UB-92
C) UB-02
D) UB-04

Question 63

A patient is admitted as a hospital inpatient with a diagnosis of possible cerebrovascular accident. During admission, the patient falls out of bed fractures her right arm. Which present on admission (POA) indicator applies to the right arm fracture diagnosis?​

A) ​Y (present at the time of inpatient admission)
B) ​N (not present at the time of inpatient admission)
C) ​U (documentation is insufficient to determine if condition is present on admission)
D) ​W (provider is unable to clinically determine whether condition was present on admission or not)

Question 64

A condition that exists at the time an order for inpatient admission occurs is categorized according to __________.​

A) ​case management
B) ​data analysis
C) ​present on admission
D) ​revenue cycle auditing

Question 65

Resource allocation monitoring uses data __________ to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources.

A) analytics
B) encryption
C) mining
D) warehouses

Question 66

Data analytics are tools and systems that are used to __________ clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

A) evaluate
B) encrypt
C) outsource
D) reimburse

Question 67

Which are databases that use reporting interfaces to consolidate multiple databases, allowing reports to be generated from a single request?

A) data warehouses
B) electronic health records
C) resource allocations
D) third-party administrators

Question 68

Which is an assessment process conducted as a follow-up to revenue cycle monitoring so that areas of poor performance can be identified and corrected?

A) data analytics
B) financial viability
C) resource allocation
D) revenue cycle auditing

Question 69

Revenue cycle management is the process by which health care facilities and providers ensure their financial viability by increasing __________, improving cash flow, and enhancing the patient's experience.

A) charges
B) costs
C) patient satisfaction
D) revenue

Question 70

​A hospital has 100 inpatient cases that are assigned to DRG 54, which has a relative weight of 1.540. What is the total relative weight for the cases?

A) ​83
B) ​154
C) ​5,400
D) ​8,316

Question 71

​A patient is admitted as a hospital inpatient and undergoes appendectomy surgery. The responsible physician documents acute appendicitis. Upon discharge, the patient is provided with instructions for followup and care postoperatively as well as for hyperthyroidism. Which present on admission (POA) indicator applies to the hyperthyroidism?

A) ​Y (present at the time of inpatient admission)
B) ​N (not present at the time of inpatient admission)
C) ​U (documentation is insufficient to determine if condition is present on admission)
D) ​W (provider is unable to clinically determine whether condition was present on admission or not)

Question 72

Revenue cycle monitoring involves assessing the revenue cycle to ensure __________ stability using standards of measurement (e.g., cash flow).

A) data analytics
B) financial viability
C) resource allocation
D) validation and verification

Question 73

Which is the distribution of financial resources among competing groups?

A) data analytics
B) financial viability
C) resource allocation
D) revenue cycle auditing

Question 74

The process of extracting and analyzing data to identify patterns, whether predictable or unpredictable, is called data __________.

A) allocation
B) auditing
C) mining
D) warehousing

Question 75

​A patient is admitted as a hospital inpatient for treatment of acute asthma. The patient also has hypertension, which was medically managed during the inpatient admission. Which present on admission (POA) indicator applies to the acute asthma?

A) ​Y (present at the time of inpatient admission)
B) ​N (not present at the time of inpatient admission)
C) ​U (documentation is insufficient to determine if condition is present on admission)
D) ​W (provider is unable to clinically determine whether condition was present on admission or not)