Deck 18: Hospital Billing and the UB-04

Question 1

Organizations that contract with healthcare providers to process health insurance claims,often providing consulting services for providers,are referred to as:

A) member organizations.
B) fiscal intermediaries (FIs) and/or carriers.
C) qualifying contracting agents.
D) all of the above

Answer 1

fiscal intermediaries (FIs) and/or carriers.

Question 2

A process whereby a medical institution is recognized by an external body as meeting certain predetermined standards is called:

A) accreditation.
B) certification.
C) credentialing.
D) validation.

Answer 2

accreditation.

Question 3

A medical facility smaller than a hospital,generally providing only outpatient services,and typically run by a government agency or a private physician partnership is commonly referred to as a/an:

A) clinic.
B) general hospital.
C) for-profit facility.
D) outpatient facility.

Answer 3

clinic.

Question 4

The types of accommodations offered by most of today's hospitals are:

A) private and semiprivate rooms.
B) four-bed room options.
C) wards with up to 30 beds.
D) all of the above

Question 5

An independent,nonprofit organization that assesses and reports on the quality of care offered by managed care plans is:

A) NCQA.
B) URAC.
C) AAAHC.
D) AOA/COCA.

Question 6

When a medical facility is composed of a single building or campus having a large number of beds,specialized facilities for various care types,and an emergency department,it is referred to as a:

A) clinic.
B) general hospital.
C) preferred provider organization.
D) health maintenance organization.

Question 7

A facility offering inpatient,overnight care,and services for observation,diagnosis,and active treatment of patients and requiring the daily direction or supervision of a physician is a/n:

A) acute care facility.
B) extended care facility.
C) designated trauma center.
D) community emergency center.

Question 8

The acronym for the federal law that ensures public access to emergency services regardless of ability to pay is:

A) HIPAA.
B) COBRA.
C) EMTLA.
D) AAAHC.

Question 9

Modern hospital construction is regulated by:

A) federal and state laws.
B) state health department policies.
C) city ordinances.
D) all of the above

Question 10

A skilled nursing facility (SNF)in which the type of care received may include rehabilitation services and/or specialized care for certain conditions (such as stroke and diabetes)and/or postsurgical care is a/an:

A) acute care hospital.
B) subacute care unit.
C) skilled nursing facility.
D) long-term care facility.

Question 11

A nonprofit organization that promotes continuous improvement in the efficiency and quality of healthcare delivery by accrediting certain types of healthcare organizations such as PPOs (not HMOs)is:

A) NCQA.
B) URAC.
C) AAAHC.
D) HIPAA.

Question 12

A range of medical and/or social services designed for people with disabilities or chronic care needs and provided in a person's home,in the community,or in residential facilities (e.g.,nursing homes or assisted living facilities)is referred to as:

A) hospice.
B) respite care.
C) ADL care.
D) long-term care.

Question 13

A facility that is certified by Medicare and licensed/approved under state and/or local law to provide 24-hour nursing care and rehabilitation services in addition to other medical services is a/an:

A) acute care hospital.
B) subacute care facility.
C) skilled nursing facility.
D) long-term care facility.

Question 14

An organization involved with ambulatory healthcare accreditation and that serves as an advocate for the provision and documentation of high-quality health services in ambulatory healthcare organizations is:

A) NCQA.
B) URAC.
C) AAAHC.
D) AOA/COCA.

Question 15

The type of facility where surgeries are performed that do not require hospital admission is a/an:

A) acute care hospital.
B) ambulatory surgery center.
C) skilled nursing facility.
D) long-term care facility.

Question 16

The method or system of administration or management of an organization is referred to as:

A) accreditation.
B) governance.
C) compliance.
D) ethics.

Question 17

As opposed to referring to today's healthcare consumers as patients,some may be more responsive to being referred to as:

A) users.
B) clients.
C) customers.
D) consumers.

Question 18

The service in which trained professionals or volunteers come into the home to provide short-term care for an older person to allow regular caregivers some time away from their caregiving role is called:

A) hospice.
B) respite care.
C) interval relief.
D) adult daycare.

Question 19

The discipline,or moral principles,of evaluating the merits,risks,and social concerns of activities in the field of medicine is known as medical:

A) ethics.
B) etiquette.
C) protocol.
D) courtesy.

Question 20

When hospitals provide all levels of care,they are referred to as:

A) mega-complexes.
B) total care facilities.
C) inpatient/outpatient centers.
D) vertically integrated hospitals.

Question 21

In 2000 a specific payment system was implemented for use by CMS for hospital outpatient services reimbursement called the:

A) ambulatory payment classification system.
B) hospital outpatient prospective payment system (HOPPS).
C) registered health payment system.
D) vertically integrated payment system.

Question 22

Regional companies that oversee the administration and processing of Medicare policies and process Part A claims for institutional services are called:

A) Medicare carriers.
B) Medicare review teams.
C) Medicare claims regulators.
D) regional claims intermediaries.

Question 23

How many significant procedures other than the principal procedure may be reported on the UB-04 claim form?

A) two
B) three
C) four
D) five

Question 24

When coding inpatient diagnoses,the correct manual(s)to use is/are the:

A) CPT-4.
B) HCPCS.
C) ICD-9-CM.
D) CPT-4 and HCPCS.

Question 25

United States hospitals that contract with Blue Cross and Blue Shield organizations are referred to as:

A) member hospitals.
B) cost outliers.
C) swing bed hospitals.
D) acute care hospitals.

Question 26

Medicare's payment system in which hospitals are paid a set fee for treating patients in a specific category,regardless of the actual cost of care for the individual,is:

A) APC.
B) DRG.
C) DEERS.
D) CMS.

Question 27

To facilitate the process of capturing costs for performing procedures and services,every hospital has what is known as a/an:

A) outlier.
B) crosswalk.
C) pass-through.
D) charge master.

Question 28

When a patient actively participates in choices about his or her healthcare,this is commonly referred to as:

A) informed consent.
B) preauthorization.
C) release of information.
D) registration.

Question 29

Temporary payments for specified new technologies,drugs,devices,and biologics for which costs were not available when calculating APC payment rates are called:

A) rubrics.
B) outliers.
C) pass-throughs.
D) crosswalks.

Question 30

Medicare Part A helps pay for:

A) hospital charges.
B) physician charges.
C) long-term healthcare.
D) all of the above

Question 31

Key elements or words in the patient's hospital health record that identify the medical condition that was ultimately determined,after study,to have caused a patient's admission to the hospital is called the _____ diagnosis.

A) leading
B) primary
C) principal
D) chief

Question 32

The process by which a fully informed patient can participate in choices about his or her healthcare is called:

A) recapitulation.
B) informed consent.
C) preauthorization.
D) certification.

Question 33

Many health insurance companies change both their premiums and reimbursement rates:

A) quarterly.
B) semiannually.
C) annually.
D) biannually.

Question 34

The designated spaces on the UB-04 are commonly called:

A) blocks.
B) data elements.
C) form locators.
D) code indicators.

Question 35

The name for Medicare's acute care payment system is:

A) the prospective payment system.
B) the cost share system.
C) the per diem system.
D) DEERS.

Question 36

All rules about how much Medicare Part A pays depend on how many days of inpatient care the beneficiary has during what is called a/an:

A) duration of hospitalization.
B) benefit period.
C) inpatient care.
D) length of illness.

Question 37

TRICARE patients,in certain cases,must attain a _____ if a military treatment facility is not available.

A) military waiver
B) preauthorization statement
C) statement of authenticity
D) nonavailability statement

Question 38

Groups of practicing healthcare professionals who oversee the quality of care provided to Medicare beneficiaries are called:

A) fiscal intermediaries.
B) quality review groups.
C) quality improvement organizations.
D) utilization review commissions.

Question 39

When another individual has the authority to speak on a patient's behalf,that individual is often called a:

A) volunteer.
B) fiscal intermediary.
C) covered entity.
D) surrogate.

Question 40

A Medicaid payment adjustment that reflects patient demographics,diagnostic and treatment information,and total charges is referred to as:

A) a per diem structure.
B) a swing bed configuration.
C) a case mix.
D) cost sharing.

Question 41

List at least five emerging healthcare trends that are affecting the way healthcare is delivered in terms of cost and customer satisfaction.

Question 42

Like ICD-9-CM Volume 1 and 2,Volume 3 contains a/an ___________ and a __________,and the formats of these two sections are the same.

Question 43

List at least six career opportunities that fall under the umbrella of hospital billing.

Question 44

Like ICD-10-CM codes,ICD-10-PCS codes contain _____ characters,which can be numbers or letters and are based on the type of procedure performed,the approach,body part,and other characteristics.

Question 45

Career opportunities for health insurance professionals exist in:

A) hospitals.
B) physicians' offices.
C) nursing care facilities.
D) insurance firms.
E) all of the above

Question 46

The hospital billing process begins when the patient:

A) is discharged.
B) provides his or her insurance information.
C) registers for admission.
D) schedules an appointment with his or her physician.

Question 47

Name the five major hospital payers discussed in the book and explain how a health insurance professional can obtain the most recent claims completion guidelines for each.

Question 48

When registering for hospital admission,patients typically must provide certain personal information.List at least six of these informational items.

Question 49

When the DRG rate does not apply,CHAMPVA pays _____% of the billed amount for covered services and supplies.

A) 50
B) 75
C) 80
D) 100

Question 50

Explain what a "covered entity" is and list three examples of organizations that fall under this classification.

Question 51

List the four methods Blue Cross and Blue Shield uses for establishing fees for facility services.

Question 52

Define "principal diagnosis" as defined in the Uniform Hospital Discharge Data Set (UHDDS).

Question 53

ICD-10-PCS has a ____________________,with each code character having the same meaning within the specific procedure section and across procedure sections to the extent possible.

Question 54

Discuss the purpose of the new HIPAA edit.

Question 55

Most medical clinics in the United States provide outpatient services only.

Question 56

List at least four elements that informed consent is typically based on:

Question 57

Many states base Medicaid reimbursement for hospital inpatient services on a PPS that includes DRGs and:

A) per diems.
B) severity of illness.
C) diagnostic information.
D) length of stay.

Question 58

The general index of surgical procedures in ICD-9 Volume 3,is structured in ____________ order.

Question 59

Guidelines for locating the correct procedure code in ICD-9-CM Volume 3 involve first locating the procedure in the _____________ and then cross-referencing it to the ____________,where the code selection is confirmed.

Question 60

The book discussed two relatively new rules that will affect hospital coding in the near future.What are they?

Question 61

Patients who have not already seen a healthcare provider are usually not treated in an ASC.

Question 62

The 72-hour rule states that all services provided for Medicare patients within 72 hours of hospital admission are considered part of the inpatient services and billed on one claim.

Question 63

Not all hospitals are accredited by nationally recognized accrediting agencies.

Question 64

Hospitals accredited by EMTLA are considered to be in compliance with most of Medicare's "Conditions of Participation for Hospitals."

Question 65

All state Medicaid programs use the same method to determine payment for hospital inpatient services.

Question 66

Facilities where surgeries that do not require hospital admission are performed are called ambulatory surgery centers (ASCs).

Question 67

The HIPAA Privacy Rule prohibits providers from talking to other providers about their patients.

Question 68

The primary diagnosis is defined as the condition determined,after study,to be chiefly responsible for the patient's admission to the hospital.

Question 69

A nursing home cannot qualify as a skilled nursing facility (SNF).

Question 70

Preauthorization is not necessary for inpatient hospitalization;however,it is for all outpatient procedures and diagnostic testing.

Question 71

ICD-9-CM Volume 3 is used to assign codes to inpatient hospital procedures.

Question 72

A level of maintenance care used when there is no urgent or life-threatening condition that requires medical treatment is called subacute care.

Question 73

Commercial and private insurers typically negotiate contracts establishing inpatient payment methods on a month-to-month basis.

Question 74

The hospital billing process begins when the patient is admitted to the facility.

Question 75

Privacy and confidentiality issues are equally as important in hospitals as they are in physicians' offices.

Question 76

State rules and regulations establish health and safety standards for licensed hospitals within a specific state.

Question 77

When the ICD-10 coding system is officially in place,ICD-10-PCS will be used for reporting inpatient diagnoses only.

Question 78

The same prospective payment system used for TRICARE and CHAMPVA payments is used in calculating Medicare payments.

Question 79

A nonavailability statement (NAS)is necessary for all TRICARE- and CHAMPVA-covered outpatient procedures.

Question 80

ASCs are among the more loosely regulated healthcare facilities.