Unbundling is the practice of using multiple codes that describe individual components of a procedure rather than?
using an appropriate single code that describes all steps of the procedure performed.
The use of audits or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas and corporate compliance is necessary to become aware of?
coding issues and stop them.
A bill cannot be generated until the coding is complete, so organizations routinely monitor the?
discharged, not final billed (DNFB) days.
Each diagnosis-related group (DRG) is assigned a?
relative weight (RW).
The RW is a multiplier that determines?
reimbursement.
Hospital Compare reports on 139 measures of hospital quality of care for heart attack, heart failure, pneumonia, and the?
prevention of surgical infections.
The hospital value-based purchasing (VBP) will measure hospital performance using?
four domains.
The domain scores are combined resulting in a?
total performance score (TPS).
A facility's TPS determines what portion of the?
hold back amount the facility will earn back.
Medical identity theft occurs when a?
patient uses another person's name and insurance information to receive healthcare benefits.
Newly insured and Medicaid-eligible patients would have potentially been?
heavily discounted self-pay or charity care prior to entering the exchanges.
In conjunction with the corporate compliance officer, the health information manager should?
provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis.
Aging of accounts is maintained in?
30-day increments
When the claim is submitted the reviewer should compare all the?
diagnoses and procedures printed on the bill with the coded information in the health record system.
A query is a routine communication and education tool used to?
advocate for complete and compliant documentation.
The query is directed to the provider who?
originated the progress note or other report in question.
Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare but?
may or may not accept assignment.
If the nonPAR physician elects to accept assignment, he or she is paid?
95 percent (5 percent less than participating physicians).
Standards of care are not defined in?
NCDs and LCDs
LCDs and NCDs are limited to certain procedures and services, but not all?
services and procedures provided to patients.
The focused review indicated areas of risk related to lower weighted MS-DRGs from triple and pair combinations which may?
be the result of a coder missing secondary diagnoses.
Optimization seeks the most accurate?
documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive.
As part of the move to pay for value, CMS developed their?
value-based purchasing (VBP) program as part of the Affordable Care Act.
This VBP program includes four domains:
safety, clinical care, efficiency and cost reduction, and person and community engagement. Each domain includes a variety of measures that must be reported to CMS regularly.
Catheter-associated UTIs and surgical site infections are part of the?
Safety Domain of the VBP program.
Late charges are any charges that have?
not been posted to the account number within the healthcare facility's established bill hold time period.
By incorporating this predicted billing delay into normal operations, the facility creates a?
preventive control to avoid under billing or having to submit late charges to the payer.
Once the claim is submitted to the third-party payer for reimbursement, the?
accounts receivable clock begins.
Verifying payment received is reflective of payment agreements to identify?
discrepancies in term application or interpretation.
Hospitals have invested in clinical documentation improvement (CDI) programs to assure the?
health record accurately reflects the actual condition of the patient.
Some of the goals of a CDI program include:
identifying and clarifying missing, conflicting, or nonspecific physician documentation related to diagnosis and procedures; promoting health record completion during the patient's course of care; and improving communication between physicians and other members of the healthcare team.
In the outpatient setting, do not code a diagnosis documented as?
probable.
code the conditions to the?
Highest degree of certainty for the encounter.
Focused selections of coded accounts are necessary for deeper understanding of?
patterns of error or change in high-risk areas or other areas of specific concern.
Optimization seeks the most?
accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive.
During a clinical documentation improvement quality review, an organization should track and monitor the following elements:
validity of queries generated, validity of working DRG assignment, validity of CDI specialist's assignment, and missed query opportunities.
Preregistration, which occurs in the front-end process, includes?
confirming eligibility and insurance benefits