Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are

physician work, practice expense, and malpractice insurance expense

Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient?

RBRVS

If the Medicare non-PAR approved payment amount is $128.00 for a proctoscopy, what is the total Medicare approved payment amount for a doctor who does not accept assignment, applying the limiting charge for this procedure?

$147.20

The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called

electronic data interchange (EDI).

Under APCs, payment status indicator "T" means

significant procedure, multiple procedure reduction applies.

Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's nonPAR fee is $57.00. How much reimbursement will the physician receive from Medicare?

$57.00

Under the inpatient prospective payment system (IPPS), there is a 3-day payment window (formerly referred to as the 72-hour rule). This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for

both diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-9-CM) exactly matches the code used for preadmission services.

The Centers for Medicare and Medicaid Services (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

present on admission.

Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group.

150%

Some services are performed by a nonphysician practitioner (such as a Physician Assistant). These services are an integral yet incidental component of a physician's treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called

Incident to" billing.

A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator is

Y = Present at the time of inpatient admission.

Assume the patient has already met his or her deductible and that the physician is a Medicare participating (PAR) provider. The physician's standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?

$ 48.00

________ offers voluntary, supplemental medical insurance to help pay for physician's services, outpatient hospital services, medical services, and medical-surgical supplies not covered by the hospitalization plan.

Medicare Part B

Use the following case scenario to answer the question.A patient with Medicare is seen in the physician's office.The total charge for this office visit is $250.00.The patient has previously paid his deductible under Medicare Part B.The PAR Medicare fee schedule amount for this service is $200.00.The nonPAR Medicare fee schedule amount for this service is $190.00.If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is

$66.50.

The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS)

cancer hospital

To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the

DNFB (discharged, no final bill).

The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.

clinical lab services

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

geographic practice cost indices.

CMS assigns one ________ to each APC and each ________ code.

payment status indicator, HCPCS

A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by

home health agencies (HHA) and inpatient rehabilitation facilities (IRF).

This is the amount the facility actually bills for the services it provides.

charges

This document is published by the Office of Inspector General (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'Web site.

the OIG's Workplan

This information is used to assign each item to a particular section of the general ledger in a particular facility's accounting section. Reports can be generated from this information to include statistics related to volume in terms of numbers, dollars, and payer types.

general ledger key

This information is printed on the UB-04 claim form to represent the cost center (e.g., lab, radiology, cardiology, respiratory, etc.) for the department in which the item is provided. It is used for Medicare billing.

revenue code

This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).

inpatient rehabilitation facilities

Health plans that use ________ reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time.

episode-of-care (EOC)

Use the following case scenario to answer the question.A patient with Medicare is seen in the physician's office.The total charge for this office visit is $250.00.The patient has previously paid his deductible under Medicare Part B.The PAR Medicare fee schedule amount for this service is $200.00.The nonPAR Medicare fee schedule amount for this service is $190.00.If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is

$40.00.

Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT changes in services offered. changes in coding rules. changes in medical staff composition. changes in coding productivity.

changes in coding productivity.

When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a

Corporate Integrity Agreement.

A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)

grouper