Term
· In 2008, ________ MS-DRGs were created. |
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Definition
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Term
If patient's costs exceed a pre-determined cost threshold, the facility may be eligible to receive additional reimbursement added to the DRG base rate. This is known as ________________________. |
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Definition
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Term
_____________________ is a decision whether to cover a particular service. |
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Definition
Local Coverage Determination
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Term
| The Medicare Program is divided into _________ parts. |
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Definition
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| Which of the following hospitals are exempt from inpatient prospective payment systems? |
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Definition
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| A critical access hospital is a small Medicare acute care facility and is located more than ______ miles from another facility. |
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Definition
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| Which of the following is NOT a factor to consider for an inpatient admission? |
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Definition
| Type of insurance the patient has |
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Term
| The goal of ________________ therapy is to improve the patient's ability to carry on with activities of daily living. |
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Definition
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| With __________________, the circumstances for admission are reviewed before the patient is actually admitted. |
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Definition
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| Which of the following is NOT a payment methodology? |
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Definition
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Term
| _______________ is a type of HMO in which a group of physicians form together as a legal corporation to provide care to patients. |
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Definition
| Independent Provider Model |
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Term
| All of the following statements are true of MS-DRGs, EXCEPT: |
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Definition
| A patient claim may have multiple MS-DRGs. |
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Term
| ICD-10-CM codes can be updated twice yearly to allow for new technology codes. |
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Definition
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Term
| Hospitals exempt from inpatient PPS are paid based on _______________________. |
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Definition
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Term
| The Medicaid program was established in 1965 and is solely funded by the federal government. |
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Definition
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Term
| Long-term acute hospitals have an average length of stay greater than 15 days. |
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Definition
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Term
| Medical Social Services is an assessment of a patient's emotional and social conditions to determine an appropriate plan of care. |
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Definition
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Term
| Health Maintenance Organizations share their risks with ________________________. |
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Definition
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Term
| An outpatient admission begins with formal acceptance by a hospital of a patient who is to receive healthcare while receiving room, board, and continuous nursing services. |
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Definition
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Term
| With fee-based reimbursement methodology, actual charges are paid. |
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Definition
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Term
| CMS adjusts the Medicare Severity DRGs and reimbursement rates every |
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Definition
| fiscal year beginning October 1 |
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Term
| A Critical Care Unit is a special unit for inpatients who have sustained life-threatening illnesses or injuries. |
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Definition
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Term
| Disproportionate share hospitals and medical education were both created by TEFRA in the mid-1980s. |
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Definition
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Term
| Point of service plans allow patients to go out of network for a higher co-payment and/or higher deductible. |
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Definition
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Term
| How many major diagnostic categories are there in the MS-DRG system? |
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Definition
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Term
| CMS identified "Hospital-Acquired Conditions" mean that when a particular diagnosis is not "present on admission", CMS determines it to be |
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Definition
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Term
| Commercial insurance plans usually reimburse health care providers under some type of _____________________ payment system, whereas, the federal Medicare program uses some type of ________________________ payment system. |
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Definition
| retrospective, prospective |
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Term
| In which of the following payment systems is the amount of payment determined before the service is delivered? |
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Definition
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Term
| Which of the following agencies is responsible for providing healthcare services to American Indians and Alaskan natives? |
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Definition
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Term
| CHAMPVA covers healthcare costs and lost income associated with work-related injuries. |
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Definition
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Term
| Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare? |
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Definition
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Term
| Which of the following encourages subscribers to select providers from a prescribed network but also allows them to seek healthcare services from providers outside the network at a higher level of copay? |
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Definition
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Term
| The goal of social services includes the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self-determination. |
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Definition
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Term
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Definition
| Major complication and comorbidity |
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Term
| Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? |
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Definition
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Term
| Which of the following types of care is NOT covered by Medicare? |
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Definition
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Term
| Which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered? |
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Definition
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Term
| This program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children. |
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Definition
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Term
| Medicare was established: |
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Definition
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Term
| Which of the following is used to indicate level of severity in the MS-DRG system? |
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Definition
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Term
| Inpatient Rehabilitation Hospitals use grouper software known as |
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Definition
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Term
| The inpatient MS-DRG system is used to group IPF patients into _____ psychiatric MS-DRG categories. |
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Definition
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Term
| Inpatient psychiatric facilities, which serve as teaching facilities, receive an adjusted payment based on the ratio of interns and residents as compared to the average daily census. |
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Definition
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Term
| Prior to placing a patient into one of the case-mix groups, a patient is grouped into a major group reflective of the need for rehabilitation care. This is known as ______________________________. |
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Definition
| Rehabilitation Impairment Category |
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Term
| Which of the following organizations is responsible for updating the procedure classification of ICD-10-CM? |
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Definition
| Centers for Medicare and Medicaid Services |
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Term
| ________________ was designed to accomodate changes brought about by the new transaction standards for the electronic exchange of data and the adoption of ICD-10-CM. |
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Definition
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Term
| __________________ is the minimum core of data on individual, acute-care, short-term hospital discharges in Medicare and Medicaid programs. |
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Definition
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Term
| Which of the following is not one of the 4 agencies responsible for maintaining and updating the ICD-10-CM coding system. |
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Definition
| Department of State Health and Human Services |
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Term
| When a patient is discharged from the inpatient rehabilitation facility and returns within 3 calendar days (prior to midnight on the third day) this is called a(n): |
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Definition
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Term
| CMS will make an adjustment to the MS-DRG payment for certain conditions that the patient was not admitted with, but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as: |
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Definition
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Term
| This prospective payment system is for __________________________ and utilizes a PAI to classify patients into CMGs. |
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Definition
| IRF - Inpatient rehabilitation facilities |
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Term
| CMS identified "Hospital Acquired Conditions" mean that when a particular diagnosis is not "present on admission", CMS determines it to be: |
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Definition
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Term
| The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called: |
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Definition
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Term
| All long term care hospitals are paid 100% of the adjusted federal rate under the LTCH PPS. |
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Definition
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Term
| CMS provides Medicare Administrative Contractors with a _______________________ to detect and report errors in the coding of claims data. |
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Definition
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Term
| What tool is used to calculate the CMG? |
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Definition
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Term
| According to the OIG, all facilities must participate in programs designed to maintain compliance with all billing and coding regulations. |
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Definition
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Term
| Operation Restore Trust is an interdisciplinary team of both federal and state government and private-sector representatives. |
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Definition
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Term
| The Stark law prohibits hospitals from submitting claims for services provided as part of a prohibited financial relationship. |
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Definition
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| Clinical Value Compass a data quality methodology that focuses on an overall quality improvement of a service or process by eliminating variables in a process to obtain a more concise, standard output. |
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Definition
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Term
| ________________________ is the key to ensuring coding and billing compliance. |
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Definition
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Term
| ________________ is the correctness of the data and is very important to the health record |
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Definition
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Term
| All facilities should perform coding audits on at least a ____________________ basis. |
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Definition
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Term
| _____________________ is a major complication of the body's reaction to infection or trauma. |
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Definition
| Systemic Inflammatory Response Syndrome |
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Term
| Critical elements in the data quality evaluation process include all of the following EXCEPT: |
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Definition
Coding Practices and policies
Staff Qualifications
Training
Types of quality control programs |
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Term
| __________________ is innocent billing errors that result in the minimum of return of overpayments or funds received in error. |
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Definition
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Term
| The goal of compliance programs is to prevent: |
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Definition
| Accusations of fraud and abuse |
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Term
| Which of the following is NOT one of the 4 quality managment domains? |
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Definition
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Term
| ___________________ requires that the attributes and values of data be defined at the correct level of detail. |
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Definition
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Term
| _______________________ play a key role in coding data quality evaluation. |
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Definition
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Term
| This document is published by the OIG every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS' website. |
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Definition
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Term
| __________________ is sepsis with end-organ dysfunction. |
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Definition
| None: SIRS, Sepsis, Septic Shock |
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Term
| This initiative was instituted by the government to eliminate fraud and abuse and to recover overpayments and involves the use of ________________________. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government. |
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Definition
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Term
| The federal Office of the Inspector General established compliance plans for the healthcare industry. |
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Definition
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Term
| A corporate compliance program should include the development and implementation of education and training programs for all affected employees. |
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Definition
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Term
| The first step in a coding audit is to establish the approach you will use for selecting cases for review. |
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Definition
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Term
| The basis for prosecuting healthcare fraud and abuse is the Federal False Claims Act. |
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Definition
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Term
| HIM professionals must assume leadership roles for a Six Sigma program. |
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Definition
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Term
| _______________________ provides a framework for federal fraud and abuse penalties and investigations. |
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Definition
| Federal Civil False Claims Act |
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Term
| The ________________________ is the average DRG weight for a set of patients for a given time period. |
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Definition
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Term
| A facility's compliance plan, coding policy, and other policies and procedures should be reviewed at least every 5 years. |
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Definition
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Term
| ______________________ is the process by which data is translated into information that can be used for designated application. |
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Definition
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