CRCR SECTION 3 Exam Answered 100% Correct

What does EMTALA require hospitals to do? - ANSWER-to provide a medical screening examination and stabilizing treatment to every person presenting at an ED and requesting medical evaluation or treatment What is the first critical step for all patients arriving for service, scheduled or unscheduled? - ANSWER-verifying the patient's identification with a combination of two identifiers from a valid information source Admission process forms include: - ANSWER-consent to treatment, conditions of admission, privacy notice, important message from Medicare, advance directives and medical power of attorney, patient bill of rights EMTALA prohibits inquires about health care or liability payer information if the inquiry will delay examination or treatment. What other requirements apply to the Emergency Department registration work? - ANSWER-patients are initially triaged by medical personnel and a "quick" registration initiated to allow electronic order entry and documentation, identification and verification of insurance eligibility and benefits once the medical screening has been completed, no additional registration may occur until the patient is stabilized Typical activities which must be performed when an unscheduled patient arrives for a service include: - ANSWER-identification of patient in the MPI or initiation of a new MPI record, insurance verification of eligibility and benefits, managed care screening, medical necessity screening, price estimation and financial counseling to achieve the appropriate account resolution Case managers are involved from admission with the discharge planning process. The purpose of discharge planning is: - ANSWER-to estimate how long the patient will be in the hospital, identify the expected outcome of the hospitalization and initiate any special requirements for services at or after the time of discharge The chargemaster is basically a list of services, procedures, room accommodations, supplies, drugs, tests, etc. typically associated with the billing for services rendered to patients. Challenges typically associated with the Charge master include: - ANSWER-omission of charges, obsolete or invalid codes, and the omission of required modifiers Ultimately, the services provided in the healthcare system are reduced to standard codes. The primary types of coding systems currently used in healthcare are: - ANSWER-ICD-10-CM/ICD-10-PCS; CPT/HCPCS codes There are four code sets that provide health plans with additional information as they process claims. Those code sets are: - ANSWER-condition codes, occurrence codes, occurrence span codes and value codes Each type of service has unique billing rules which come into play during the provision of service. For the skilled nursing facility, care is covered if which of the following factors are present: - ANSWER-the patient required skilled services on a daily basis and those services can only be provided on a inpatient basis in a SNF DRG's are system of classifying inpatients on the basis of diagnoses, procedures, and co-morbidities for purposes of payment to hospitals. Each DRG includes: - ANSWER-a relative weight which is multiplied by the established base payment rate to calculate the reimbursement for a specific DRG. for exceptionally costly cases over a set dollar amount, an outliner payment is added to the calculated payment PPO networks represent one form of discounting commonly used by commercial payers. The silent PPO represents: - ANSWER-a discounting scheme whereby health plans apply generic PPO rates to discount a provider's claims, even though there is no contractual arrangement between the silent PPO and the provider The concept of timely filing of claims is important to providers, payers, and patients. Thus, providers are required to comply with timely claim filing rules. Which of the following statements are NOT true about timely filing limitations? - ANSWER-payers will waive timely filing denials for claims filed over a year from date of service In what manner do case managers assist revenue cycle staff? - ANSWER-providing assistance with written appeals to health plans related to utilization and other care issues The purpose of case management - ANSWER-is to monitor the progression of high resource consumptive cases to help ensure effective utilization of resources during the care of the patient and maximize patient outcomes Case managers are often nurses with specialized training in specific areas... - ANSWER-they may become certified case managers by taking speciality examinations and having appropriate credentials and experience Because case managers (clinicians) are involved with all aspects of monitoring the patient's stay... - ANSWER-they are well-positioned to document the clinical reasons for treatment decisions for services denied by the health plan Why is it critical that a chargemaster is reviewed and updated regularly? - ANSWER-to ensure it supports and represents the services provided within the organization Level I of the HCPCS modifiers - ANSWER-the approved American Medical Association's CPT-4 codes - all CPT-4 codes are included within the HCPCS code listing - these are all 5 digits Level II of the HCPCS modifiers - ANSWER-CMS-developed codes for classifying supplies and non-physician services such as durable medical equipment, ambulance services, medical and surgical supplies, and drugs. - codes begin with a sing letter (A through V) followed by 4 numeric digits Level III of the HCPCS modifiers - ANSWER-these contain codes assigned and maintained by Medicare Administrative Contractors (MACs), these codes begin with a letter (W through Z) followed by 4 numeric digits - these codes are not common and are use basically to describe new procedures not yet developed in the other levels Why is it important to capture charges in an accurate and timely manner for the services provided? - ANSWER-this gives the most appropriate measurement of utilization of resources, and thus, resource management Why is it important to understand HCPCS codes and modifiers? - ANSWER-since their appropriate use can impact reimbursement HCPCS - ANSWER-CMS common procedure coding system - set of codes used by Medicare that describes services and procedures Claim processing - ANSWER-includes all activities required to send a request for payment to a third-party health plan for payment of benefits under a health insurance plan or liability claim (worker's compensation, automobile insurance, or premise liability) Standard hospital claim form - ANSWER-UB-04 - (81 form locators) used by institutional providers (hospitals, hospice, rural health clinics, skilled nursing facilities, etc.) to support claims Standard professional service claim form - ANSWER-CMS 1500 - form contains 33 major items, subdivided into a total of 55 detailed items and is used by physicians, allied health processionals, certified registered nurse anesthetists, home health agencies, medical equipment suppliers, etc.) not hospitals, for submitting claims for services to health plans Clean claims - ANSWER-claim that is sent to a health plan either electronically or on paper that has no defect and requires not special treatment which prevents prompt payments Prompt payment - ANSWER-can be defined by health plan contracts or by state or government rules