Deck 17: Hospital Billing and Reimbursement

Question 1

Calculating Insurance Math
A hospital has a per diem payment arrangement with an HMO. The plan will pay the hospital $1,200 a day for inpatient care regardless of the services the hospital provides. This month, one member has been hospitalized for three days for observation and tests. The hospital charges for each of the three days are $1,275, $1,330, and $1,200.
A. What is the total hospital fee for the three days?
B. How much will the HMO pay the hospital for this patient's care?
C. How is the balance handled?

Answer 1

A. $3,805
B. $3,600
C. Written off

Question 2

Select the answer choice that best completes the statement or answers the question.
Under Medicare rules for patients in car accidents, the automobile insurance is

A) primary
B) secondary
C) supplemental
D) tertiary

Answer 2

A

Question 3

What are some of the differences in working for a hospital facility and for a physician practice? Which employment setting is more likely to have specialized job functions?

Answer 3

Students may cite differences in the employer's size, the number of people with whom to interact, and much more specialization in the hospital setting. The instructor may wish to point out that hospital billing departments are often divided either by payer or by alphabetically organized patient groups.

Question 4

Define the following abbreviations:
DRG

Question 5

Completing Claims
Based on the guidelines in Table 17.1 and the following data, complete a UB-04 for this hospitalization. Be sure to calculate the total of the charges.
Principal Dx: Single liveborn, born in hospital (Z38.00) POA: 1
Attending Provider: Thomas Wong, NPI 9100016533
Table 17.1 UB-04 Form Completion

Question 6

Define the following abbreviations:
PPS

Question 7

A patient is admitted for gastrointestinal bleeding due to diverticulitis. The initial treatment plan is for the patient to undergo a sigmoid resection, but the patient decides to postpone the surgery for personal reasons.
What is the principal diagnosis in this case? What additional diagnosis code is reported to show that the patient decided not to proceed?

Question 8

Define the following abbreviations:
SNF

Question 9

Based on the description of ICD-10-PCS, do you think it is easier to build codes using this code set rather than looking them up using ICD-10-CM?

Question 10

Define the following abbreviations:
ASC

Question 11

How are the Medicare Prospective Payment System and the use of capitated rates in managed care organizations similar? How are they different?

Question 12

Define the following abbreviations:
HHA

Question 13

Based on the guidelines in Table 17.1, assign a form locator (1-23) to each of the following data items. The first has been completed for you.
Table 17.1 UB-04 Form Completion

Question 14

Define the following abbreviations:
POA

Question 15

Select the answer choice that best completes the statement or answers the question.
When the hospital staff collects data on a patient who is being admitted for services, the process is called

A) health information management
B) registration
C) MSP
D) precertification

Question 16

Define the following abbreviations:
MS-DRG

Question 17

Select the answer choice that best completes the statement or answers the question.
Which of the following hospital departments has different procedures for collecting patients' personal and insurance information?

A) accounting department
B) surgery department
C) emergency department
D) collections department

Question 18

Select the answer choice that best completes the statement or answers the question.
Patient charges in hospitals vary according to

A) their accommodations only
B) their services only
C) their accommodations and services
D) their age and gender

Question 19

Select the answer choice that best completes the statement or answers the question.
Which of these rules governs the reporting of hospital inpatient services on insurance claims?

A) ASC
B) HIM
C) APC
D) UHDDS

Question 20

Select the answer choice that best completes the statement or answers the question.
Conditions that arise during the patient's hospital stay as a result of surgery or treatments are called

A) comorbidities
B) admitting diagnoses
C) complications
D) correlates

Question 21

Select the answer choice that best completes the statement or answers the question.
In inpatient coding, the initials CC mean

A) chief complaint
B) comorbidities and complications
C) cubic centimeters
D) convalescent center

Question 22

Select the answer choice that best completes the statement or answers the question.
The code 02103D4 is an example of which type of code?

A) CPT
B) ICD-9-CM Volume 1
C) ICD-9-CM Volume 2
D) ICD-10-PCS

Question 23

Coding Hospital Services
Follow the inpatient coding guidelines for (1) identifying the principal diagnosis, (2) coding suspected conditions, and (3) differentiating between statements of admitting, principal, comorbidity, and complication diagnoses as you analyze these cases.
A. What is the principal diagnosis for this patient?
Discharge Date: 07/03/2018
Patient: Kellerman, Larry H.
Patient is a 59-year-old male who was recently found to have some evidence of induration of his prostate gland. He was referred for urologic evaluation and admitted to the hospital for further study and biopsy. Under general anesthesia, cystoscopy revealed early prostatic enlargement, and needle biopsy was accomplished. Pathological examination of the tissue removed confirmed the presence of adenocarcinoma of the prostate.
B. What is the admitting diagnosis for this patient?
Room: S-920
Patient: Koren, Sarah I.
Admission Date: 10/09/2018
Chief Complaint: Severe, right upper abdominal pain radiating to the back.
History of Present Illness: This 38-year-old female reports having this severe pain for two weeks. She has had some nausea and vomiting. Condition worsened by previous treatment with pain medication and Tagamet. Previous ultrasound of her gallbladder showed a very thickened gallbladder wall with a large stone, impacted at the neck of the cystic duct. Her family physician has admitted her to be taken to surgery for a cholecystectomy. She notes diarrhea a few days ago but no other change in bowel habits.
Impression: Probable acute cholecystitis.
C. Identify the principal diagnosis, the principal procedure, the comorbidity diagnosis, and the complication in the following discharge statement.
Flora Raniculli is a 65-year-old female admitted to the hospital with a three-month history of cough, yellow-sputum production, weight loss, and shortness of breath. Chest X-ray reveals probable bronchiectasis. Patient may also have pulmonary fibrosis. She underwent a bronchoscopy that showed thick secretions in both lower lobes. Postbronchoscopy fever finally cleared up. She is now being discharged and will call me in one week for a progress report.

Question 24

Select the answer choice that best completes the statement or answers the question.
Under a prospective payment system, payments for services are

A) set in advance
B) based on the provider's fees
C) discounts to the provider's usual fees
D) not required from most patients

Question 25

Match the key terms with their definitions.

Question 26

Select the answer choice that best completes the statement or answers the question.
The UB-04 form locator 4 requires the

A) type of bill
B) admission hour
C) revenue code
D) patient status