CRCS EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 CRCS EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ HHS Correct Answer: Health and Human Services CMS Correct Answer: Centers for Medicare and Medicaid Services HHS Correct Answer: U.S. Department of Health and Human Services NIH Correct Answer: National Institutes of Health FDA Correct Answer: Food and Drug Administration ACL Correct Answer: Administration for Community Living; one of the HHS Operating Divisions. 2 QIO Correct Answer: Quality Improvement Organization OIG Correct Answer: Office of Inspector General ACF Correct Answer: Administration for Children and Families Title XVIII Correct Answer: Medicare Title XIX Correct Answer: Medicaid AHA Correct Answer: American Hospital Association Patient's Bill of Rights Correct Answer: Patient Care Partnership HIPAA 3 Correct Answer: Health Insurance Portability and Accountability Act PHI Correct Answer: Protected Health Information TPO Correct Answer: Treatment, Payment & Operations ERA Correct Answer: Electronic Remittance Advice PSDA Correct Answer: Patient Self-Determination Act DNR Correct Answer: do not resuscitate PPACA Correct Answer: Patient Protection and Affordable Care Act CMP Correct Answer: Civil Monetary Penalty 4 TCPA Correct Answer: Telephone Consumer Protection Act Regulation Z Correct Answer: Truth in Lending Act EMTALA /Anti-Dumping Statute Correct Answer: Emergency Medical Treatment and Active Labor Act TJC Correct Answer: The Joint Commission ABN Correct Answer: Advance Beneficiary Notice of Noncoverage HINN Correct Answer: Hospital Issued Notice of Non coverage ALOS Correct Answer: average length of stay MOON Correct Answer: Medicare Outpatient Observation Notice 5 Patient Care Partnership Correct Answer: Replaces the Patient's Bill of Rights, was adopted by the AHA, and is a plain-language brochure PHI Correct Answer: Can be shared without explicit consent, cannot be shared for marketing purposes w/o explicit consent, cannot be shared with law enforcement without consent or notification to the patient, except under court order Advance Directive Correct Answer: Living will, Healthcare Power of Attorney, DNR Order Administrative Sanction for Inappropriate Behavior on the part of a provider Correct Answer: Denial or revocation of the provider number application, suspension of provider payments, application of CMP's True of TJC Correct Answer: TJC will conduct an audit of a hospital every 39 months PSDA Correct Answer: Deals with advance directives 6 ECOA Correct Answer: Prohibits credit discrimination, allowing creditors to request info but not use it to grant credit or set terms EMTALA Correct Answer: Prohibits questions about payment until an ED patient has been medically screened PPACA Correct Answer: Has primary aim to decrease number of uninsured Americans and reduce healthcare costs Regulation Z Correct Answer: Requires clear identification of APR's and finance charges HIPAA Correct Answer: Mandates patient right to examine/obtain a copy of their own health records and request corrections False Claims Act Correct Answer: Prohibits submitting false/fraudulent claims Front Office 7 Correct Answer: Acts as a liaison between the physician and the patient Primary functions and responsibilities of Patient Access Correct Answer: 1. Scheduling 2. Pre-admission and preregistration 3. Pre-certification and pre-authorization 4. Registration and admission 5. Insurance verification 6. Financial counseling 7. Collection 8. Compliance Office productivity begins with... Correct Answer: efficient patient scheduling Balance in scheduling Correct Answer: 1. Patient satisfaction 2. Collection of financial information, demographic information, and insurance information 3. Clinical services Collection process gathers Correct Answer: 1. Patient demographics 8 2. Financial information 3. Socioeconomic information Pre-admission/service testing Correct Answer: Diagnostic medical testing of patients in advance of surgical or invasive procedures to determine hospitalization/surgical situability Collection Points- Institutional Setting Correct Answer: 1. Pre-admission 2. Admission 3. In-house 4. At discharge 5. After discharge Collection Points- Professional Setting Correct Answer: 1. Pre-service 2. Time of Service 3. In-house 4. At checkout 5. Post service Advantages of a deposit collection program Correct Answer: Increased Hospital Cash Collections 9 Reduced Amount Due at Discharge Reduced Overall Accounts Receivable Reduced Financial Risk and Bad Debt NOTICE Correct Answer: Notice of Observation Treatment and Implication for Care Eligibility Act requires that hospitals must inform patients who are hospitalized for more than 24 hours if they are in observation status MOON Correct Answer: Standardized notice developed to inform beneficiaries when they are an outpatient receiving observation services and are not inpatient of hospital or critical access hospital Refusal to Sign Correct Answer: If the beneficiary refuses to sign the MOON and there is no rep to sign on behalf of the beneficiary, the notice must be signed by the staff member of the hospital or CAH (Critical Access Hospital) who presented the written notification When a service does not meet or is not expected to meet medical necessity... 10 Correct Answer: The beneficiary is given an ABN before services are furnished that states that the provider believes that Medicare will not or probably will not cover the specified item ABN Correct Answer: Contains a brief description of the service, the estimated cost, and the reason the service is not expected to be covered If a valid and signed ABN is not obtained prior to the services being rendered... Correct Answer: the provider cannot bill the beneficiary for those services and will be held financially liable if payment if not received by Medicare ABN Correct Answer: Notice of Non-coverage- Medicare's rule that a beneficiary is not protected from financial liability of a non-covered service if that person has knowledge or should have had knowledge of the non-coverage **should not be given unless there is genuine doubt of a Medicare payment**must be retained for 5 years from discharge or completion of care Don't Require an ABN or HINN Correct Answer: Screening mammogram Prostate Screening Antigen Routine Physical 11 Routine Foot Care Cosmetic Surgery Dental Care and Dentures Non-Emergent Services Chiropractic Care Ambulance Service that is considered a technical denial Services listed in the beneficiary Medicare manual Self-Administered Drugs Typical Goal for Reengineering Patient Access Correct Answer: 1. Place the focus on customer service to improve the initial patient impression 2. Identify ways to decrease wait times 3. Preregister patients whenever possible Diagnostic medical testing before surgical or invasive procedures to determine hospitalization/surgical suitability Correct Answer: Preadmission testing Precertification/Preauthorization Correct Answer: Getting auth for medical necessity, auth to treat, auth for average LOS/number of services for the patient condition Failure to preauthorize can result in total denial of claims 12 Suggested practice before seeing a patient in the office Correct Answer: Gathering information Pulling charts and preparing fee tickets Obtaining referrals for visits Needed to calculate the patient's estimated responsibility for a hospital stay Correct Answer: a. ALOS for the diagnosis b. Average cost/day by type of service c. Admitting physician's estimated LOS d. The hospital's flat rate procedures/DRG/Contractual Payer Allowance e. The daily room charge by type f. Patient third-party insurance plan benefit levels During which two collection control points is a patient most likely to pay? Correct Answer: Institution Setting 1. Pre-admission 2. Admission Professional Setting 1. Preservice 13 2. Time of service ABN Triggering Event when there is a discontinuation of services Correct Answer: Termination Critical Tasks Performed by Case Management / Utilization Review Correct Answer: a. Preventing unnecessary services or treatment b. Evaluating an individual's safety and ability to live independently at home c. Obtaining appropriate medical care d. Arranging for transportation to and from dr's appts Levels of patient care Correct Answer: INSTITUTION Inpatient- Admitted to a bed Observation- Occupy a bed, but are outpatient ER- Outpatient Recurring or Series- Repetitive types of treatment Long Term Care- Chronically ill, might be in nursing home PROFESSIONAL Office- care provided in a practitioner's place of business Outpatient- Outpatient clinics 14 Skilled Nursing Facility- separate wing of hospital, nursing home, or a freestanding facility- medicare requires that a person have been inpatient at least 3 consecutive days Hospice- Coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations Respite- short-term, temporary custodial care that allows family members to get relief from caring for a physically frail or dependent person at home Home Health- Limited part time or intermittend skilled nursing care and home health aide services, pt, ot, ect... General Consent Form Correct Answer: routine lab testing, diagnostic imaging, medical treatment Special Consent Form Correct Answer: HIV Positive Testing Major/Minor Surgery Anesthesia Nonsurgical procedures Cobalt or radiation therapy Electroshock Treatment Experimental Procedures Treatment for drug/alcohol disorders Blood Transfusions 15 actual or expressed consent Correct Answer: written or oral agreement by the patient to the treatment outlined. implied consent- in fact Correct Answer: consent by silence; the patient implies consent to the treatment by not objecting. implied consent law Correct Answer: the patient is unconscious and is taken to the ER, law allows treatment of the patient Parental/other consent Correct Answer: Parent may give consent on behalf of the child for most services Conditions preventing consent Correct Answer: intoxication unconscious declared mentally incompetent by the courts Records error Correct Answer: single line through the error, initial it, and continue the note- do not use white out 16 Clinical and medical personnel authorized to make entries in the patient's medical record Correct Answer: Treating/Attending Physical Physician Extender RN Student from an accredited health profession program EHR Correct Answer: electronic health record Verbal telephone orders can be given by Correct Answer: a physician extender a RN Verbal telephone orders must contain Correct Answer: -the date and time the order was received -the name of the ordering physician -the name of the patient and his or her status -the exact order, transcribed verbatim -the full name and designation of the staff member documenting the order NCD 17 Correct Answer: National Coverage Determination - medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare program LCD Correct Answer: Local Coverage Determination - policies developed by MAC's that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate definitive diagnosis Correct Answer: The LCD and NCD discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given non-definitive LCD/NCD Correct Answer: A policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms or ICD-9-CM codes that will be covered or non-covered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination. Until 1980 ________ was the primary payer for nearly all Medicare-covered services Correct Answer: Medicare 18 MSP Correct Answer: Medicare Secondary Payer / all info must be retained for 10 years Medicare is the secondary payer Correct Answer: The working aged Under the age of 65 who are disabled and covered by a group plan Individuals with ESRD (end stage renal disease) Work comp/black lung beneficiaries Auto, no-fault or liability plans IEQ Correct Answer: Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare. For recurring outpatient accounts... Correct Answer: an MSPQ can be completed once every 90 days if the beneficiary is receiving identical services and treatments as the month before 19 CWF Correct Answer: Common Working File; a CMS file that contains Medicare patient eligibility and utilization data. ALOS Correct Answer: Total Number of Patient Days / Number of Discharges midnight census Correct Answer: the number of patients in the hospital at midnight census; determined from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes. ADC Correct Answer: average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time. Average Daily Census (ADC) Correct Answer: Total number of Patient Days / Number of Days percentage of occupancy Correct Answer: The patient census divided by the number of beds on the unit 20 number of patients seen per day Correct Answer: total number of patient encounters / number of days The patient is terminally ill and is receiving palliative care Correct Answer: hospice care SNF Correct Answer: skilled nursing facility - continuous care to regain strength and function home health care Correct Answer: care that takes place in a person's home A patient is seen at a providers place of business Correct Answer: office To qualify for SNF coverage... Correct Answer: Medicare requires that a person to be hospital inpatient for at least three consecutive days Assignment of Benefits Correct Answer: written authorization to have insurance benefits paid directly to the provider 21 Beneficiary obligation for days 1-60 of a hospital stay - Medicare Part A Correct Answer: *$1,408 per spell of illness* Beneficiary obligation for days 61-90 of a hospital stay- Medicare Part A Correct Answer: *$352 per day* Beneficiary obligation for days 91-150 of a hospital stay-Medicare Part A Correct Answer: *$704 per day* SNF (skilled nursing facility) Correct Answer: Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies. (Patients need three midnights as an inpatient to qualify for Medicare coverage in a SNF.) Medicare A - SNF Correct Answer: Days 1 through 20: ▪ No deductible or coinsurance *$0 per benefit period* Medicare A - SNF Correct Answer: Days 21 through 100: ▪ 1/8 of current year inpatient deductible *$176 per day* 22 Medical and other services Correct Answer: Doctors services (except for routine physical exams); outpatient medical and surgical services; supplies; diagnostic tests; ambulatory surgery center facility fees for approved procedures; and DME. Also covers second surgical opinions; outpatient physical, occupational, and speech therapy; and outpatient mental healthcare. Medicare Part B Correct Answer: Medical and other services: ▪ Current year deductible, then coinsurance (20% of Medicare-approved amount, except in the outpatient setting) *$198 per year, then 20% of Medicare* Medicare Part B Correct Answer: Outpatient physical, occupational, and speech language therapy services: ▪ Coinsurance 20% of Medicare approved amount Medicare Part B Correct Answer: Outpatient mental healthcare: ▪ Coinsurance 23 20% of Medicare approved amount MAC Correct Answer: Medicare Administrative Contractor the private firms that process Medicare claims. MACs were formerly known as fiscal intermediaries or carriers. MACs also serve as the primary operational contact for providers. They enroll providers in the Medicare program, provide education on Medicare billing requirements, and answer both provider and patient inquiries Number of MAC's and DME MAC's Correct Answer: Currently there are *12 Part A / Part B MACs* and *four DME MACs jurisdictions in the program that process Medicare FFS claims based on the geographical location of the provider.* Medicare Cards Correct Answer: *The Medicare Access and CHIP Reauthorization Act of 2015 required CMS to remove Social Security Numbers (SSNs) from all Medicare cards by 2019.* The process of basing the previous Health Insurance Claim Number (HICN) on the patient's SSN violates HIPAA. 24 Information such as member name and effective dates will still be present on the Medicare card. Each person is assigned their own unique identifier, known as the MBI, Medicare Beneficiary Identifier. Starting January 1, 2020, you MUST submit claims using MBIs (with a few exceptions), no matter what date you performed the service. The new MBI will: ▪ Have the same number of characters (11) as the HICN ▪ Contain uppercase letters and numeric characters, but no special characters ▪ Occupy the same field on HICN transactions ▪ Be unique to each beneficiary (in other words, husband and wife have their own MBIs) ▪ Be easy to read and limit the possibility of misinterpretation (uppercase letters only and no commonly misread letters S, L, O, I, B, and Z) LTR Correct Answer: lifetime reserve- Part A- 60 days of inpatient hospital services that a beneficiary can opt to use after having used 90 days of of inpatient hospital services in a benefit period. *high coinsurance *can only be used once in a lifetime Medicare Part A Correct Answer: Hospital Insurance -most beneficiaries don't pay a premium 25 Medicare Part A Correct Answer: Patients pay a deductible for Part A coverage one per spell of an illness (benefit period), which begins when they enter the hospital, and ends 60 days after discharge Medicare Part B Correct Answer: Medical Insurance and Preventative Services - premium paid month Medicare Part C Correct Answer: Medicare Advantage / Replacement Plan Medicare C /Advantage Plans Correct Answer: 1. HMO 2. PPO 3. Private Fee-for-Service Plan 4. Special Needs Plan 5. Medical Savings Accounts HMO/PPO Correct Answer: Share the use of program practitioners, use of specific healthcare facilities, and precertification/preauthorization requirements 26 Medicare Part D Correct Answer: Prescription Drug Plan- covered drugs "formulary" Medicare Advantage Period - liability Correct Answer: 1. Whether the provider is included in an inpatient hospital or home health prospective payment system 2. The date of enrollment Medicare Participating Physician Program - "participation agreement" Correct Answer: Binds them to accept assignment for all services provided to Medicare patients for the following year If providers do not accept assignment they can Correct Answer: Charge more than the Medicare approved amount (max of 115% of approved amount) Advantages of participating in Medicare Participating Physician Program Correct Answer: -higher fee schedule payments -fewer collection efforts (Medicare pays 80% directly to provider) -publicity -government imprimatur/sanction/approval -accurate calculations of coinsurance 27 -lower fee maintenance Medigap Policy Correct Answer: Medicare supplemental insurance - Medicare does not pay any of the costs for obtaining a Medigap policy - only works with original Medicare Plan Medicaid provides insurance to Correct Answer: -low-income adults -children -pregnant women -elderly adults -disabled Medicaid / states have the authority to : Correct Answer: 1. Establish eligibility standards 2. Determine what benefits and services to cover 3. Set payment rates TRICARE covers unless... Correct Answer: They are eligible for Medicare NAS 28 Correct Answer: Non-Availability Statement - required before any non-emergent inpatient services may be provided to a TRICARE Extra or Standard beneficiary by a Non-Military Treatment Facility CHIP / Title XXI Correct Answer: Children's Health Insurance Program / fail to quality for Medicaid but can not afford to purchase private insurance Medicare Part B - Clinical laboratory service Correct Answer: Beneficiary Obligation- no deductible or obligation Medicare Part B - Home Health Care Correct Answer: Beneficiary Obligation - no deductible or coinsurance Medicare Part B / Home Health Care DME Correct Answer: Coinsurance - 20% of Medicare approved amount Medicare Part B / Outpatient hospital services Correct Answer: Coinsurance or fixed copay, varies Medicare Part B / Blood Correct Answer: Current blood deductible, unless the patient or someone else donates to replace the blood received, then coinsurance 29 2020 amount - First 3 pints per year, then 20% of the Medicare-approved amount Medicare Part B / Annual Wellness Visit Correct Answer: Who is covered? All Medicare beneficiaries who are more than 12 months after the effective date of their Medicare Part B coverage and who also have not received an initial preventative physical exam within 12 months Beneficiary Obligation in the Original Medicare Plan? Copayment coinsurance, and deductible waived Medicare Part B / Bone Mass Measurements Correct Answer: Who is covered? Certain beneficiaries at risk for losing bone mass or developing osteoporosis Beneficiary Obligation in the Original Medicare Plan? Copayment coinsurance, and deductible waived Medicare Part B / Cardio Disease Screening Correct Answer: Who is covered? All asymopomatic Medicare beneficiaries 30 Beneficiary Obligation in the Original Medicare Plan? Copayment coinsurance, and deductible waived Medicare Part B / Colorectal cancer screening Correct Answer: Who is covered? Beneficiaries age 50 and over Beneficiary Obligation in the Original Medicare Plan 1. FOBT, flexible sigmiodoscopy, colonoscopy- copayment, coinsurance, and deductible waived 2. Barium enema- coinsurance applies, deductible waived 3. Multitarget stool DNA test- if polyp found and removed, 20% copay applies Medicare Part B / diabetes screening test Correct Answer: Who is covered? Beneficiaries who have certain risk factors for diabetes or who have been diagnosed with pre-diabeties Beneficiary Obligation? copayment, coinsurance, and deductible waived 31 Medicare Part B / Diabetes Self Management Training Correct Answer: Who is covered? Beneficiaries who have been diagnosed with diabetes Beneficiary Obligation? Copayment, coinsurance, and deductible apply Medicare Part B / Hepatitis B Correct Answer: Who is covered? Beneficiaries who are at intermediate or hight risk for contracting Hep B- current positive members are not eligible Beneficiary ObligationCopayment, coinsurance and deductible waived Medicare B / IPPE, Welcome to Medicare Physical Exam / Once in a lifetime Correct Answer: Who is covered? All new Medicare beneficiaries within the first 12 months of their first Medicare Part B coverage period Beneficiary Obligation Copayment, coinsurance apply, deductible waived 32 IPPE with EKG- copayment, coinsurance, and deductible apply Intensive Behavioral Therapy for Obesity / Annual Correct Answer: Who is covered? Beneficiaries with a BMI>30 kg Beneficiary Obligation copayment, coinsurance, and deductible waived Medicare Part B / Lung Cancer Screening - 55-77 Correct Answer: Who is covered? Beneficiaries who show no signs or symptoms of lung cancer and who have a history of smoking at least 30 pack-years, who are current smokers, or who have quit smoking within the past 15 years. There must also be a written order for the service that meets specific criteria established by CMS. Beneficiary Obligation Coinsurance and deductible waived if all criteria are met, there is a written order, and the physician accepts assignment Medicare Part B / Mammogram screening/ One base-line screening for females between 35-39 then once every 12 months for females over age 40 33 Correct Answer: Who is covered? Female beneficiaries age 35 and older Beneficiary Obligation? Copayment, coinsurance, and deductible waived Medicare Part B / Mammogram, diagnostic - mammograms are billed on the same day a modifier, GG, should be used to show a screening mammogram was turned into a diagnostic mammogram at the time of service Correct Answer: Who is covered? Female beneficiaries when the service is medically necessary Beneficiary Obligation? coinsurance and deductible may apply Medicare Part B / Screening and behavioral counseling to reduce alcohol misuse / annual for all beneficiaries, face to face counseling up to four times/year for those who screen positive up to 4 times a year Correct Answer: Who is covered? Medicare beneficiaries who screen positive if they are competent and alert at the time counseling is provided and counseling is furnished by qualifies physicians in a primary care setting 34 Copayment, coinsurance, and deductible waived Medicare Part B / Screening for depression / annual for all beneficiaries Correct Answer: Who is covered? All Medicare Beneficiaries Beneficiary Obligation Copayment, coinsurance and deductible waived Items not covered by Medicare Part B Correct Answer: Acupuncture, deductibles/co-insurance, routine dental services, cosmetic surgery, custodial care, healthcare outside of the US, hearing aids and exams, routine foot care, routine eye care and most eyeglasses, monthly Part B premium, and supportive devices for the feet. The primary dute of the Front Office Personnel... Correct Answer: to act as a liaison between the physician and the patient 1 day payment window rule Correct Answer: Medicare requirement - applies tp inpatient psychiatric hospitals, inpatient rehabilitation facilities, LTC facilities, and children's and cancer hospitals 3-day payment window 35 Correct Answer: Medicare requirement - all outpatient services provided within 3 days off an inpatient admission must be combined to the inpatient claim when they are provided by an entity wholly owned or operated by the inpatient hospital (or by another entity under arrangements with the admitting hospital) 8371 Correct Answer: the dataset that is utilized to electronically submit hospital claims to the payer 837P Correct Answer: the billing form used to electronically submit physician and professional service claims to the payer Accounts Receivable Days Outstanding Correct Answer: an estimate of the time needed to collect the accounts receivable (AR) ACF Correct Answer: Administration for Children and Families; one of the HHS Operating Divisions. ADRR 36 Correct Answer: Average Days of Revenue in Accounts Receivable; also known as Accounts Receivable (AR) Days Outstanding; this is an estimate of the time needed to collect the accounts receivable. AHRQ Correct Answer: Agency for Healthcare Research and Quality; one of the HHS Operating Divisions APC Correct Answer: Ambulatory payment classification; A payment methodology in which services paid under the prospective payment system are classified into groups that are similar clinically and in terms of the resources they require; a payment rate is established for each APC. APR Correct Answer: Annual Percentage Rate; one of the elements of disclosure required by the Truth in Lending Act Assignment of Benefits Correct Answer: patient's written authorization giving the insurance company the right to pay the physician directly for billed charges - when assignment is not accepted, the payment will be sent to the patient and the provider will have to collect it 37 ATB Correct Answer: aged trial balance; a resource for internal collection efforts. ATSDR Correct Answer: Agency for Toxic Substances and Disease Registry; one of the HHS Operating Divisions. Average Daily Cencus Correct Answer: Average number of inpatients receiving care each day during the reporting period Average Days of Revenue in Accounts Receivable Correct Answer: an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable bad debt Correct Answer: an uncollectible account resulting from the extension of credit. beneficiary Correct Answer: a person who has healthcare insurance through Medicare Black Lungs Benefits Act 38 Correct Answer: legislation that established the Federal Black Lung Program for individuals who have been diagnosed with pnemoconiosis, or black lung disease CAH Correct Answer: Critical Access Hospital; a non-profit hospital located in a state that has established a Medicare Rural Hospital Flexibility Program; it must have 25 or fewer beds and an ALOS of 96 hours or less, be located a certain minimum distance from other hospitals, and furnish 24-hour emergency care services; Medicare pays CAHs for most inpatient and outpatient services on the basis of reasonable cost. Capitation Correct Answer: A method of paying for insurance in which a fixed amount is paid to the provider per member for a specific time period regardless of the amount of care provided Case Management Correct Answer: also known as Utilization Review; an area that performs critical tasks during registration and a patient's stay CDC Correct Answer: Centers for Disease Control and Prevention; one of HHS Operating Divisions 39 CDM Correct Answer: charge description master; the chargemaster or master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services by a healthcare facility. / Reviewed annually Chapter 7 Correct Answer: a type of bankruptcy applying to individuals and businesses that cannot pay their debts based on their income; except for exempt property as defined by state laws, the debtor's assets are auctioned to satisfy creditor claims; about 70% of all bankruptcy claims are filed under Chapter 7 Chapter 11 Correct Answer: a type of bankruptcy frequently referred to as a "reorganization"; it gives a distressed business a reprieve from creditor claims while it continues to function and works out a repayment plan. Chapter 12 Correct Answer: a type of bankruptcy for a family farmer with "regular annual income." Chapter 13 Correct Answer: a type of bankruptcy designed for individuals with regular income who desire to pay their debts, but currently are unable to do so; the debtor, under court 40 supervision and protection, may propose and carry out a repayment plan under which creditors are paid over an extended period of time. Charity Care Correct Answer: service provided that is never expected to result in cash flow. CHIP Correct Answer: Childrens Health Insurance Program - health insurance for children under 18 whose parents earn too much to qualify for Medicaid, but not enough to afford private insurance. Federal funds are distributed by CLIA Correct Answer: Clinical Laboratory Improvement Amendment; legislation requiring all clinical laboratory services furnished to Medicare beneficiaries to be performed by a provider who has a CLIA certificate CMS-1450 Correct Answer: another name for the UB-04 uniform bill form. CMS-1500 Correct Answer: the paper billing form used to submit physician and professional service claims to Medicare 41 CO Correct Answer: Compliance officer; one of OIG's seven elements of a compliance plan commercial insurance Correct Answer: health insurance that covers individuals, usually as an employment benefit but also purchased an an individual policy Common Working File Correct Answer: a CMS file that contains Medicare patient eligibility and utilization data conditional payment Correct Answer: a payment made when another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim); it prevents the beneficiary from having to pay out of pocket; Medicare then has the right to recover any payments that should have been made by another payer. courtesy discharge Correct Answer: a type of discharge in which a patient's financial considerations have been met so he or she is allowed to leave the hospital without going through the usual formalities; the patient is billed at a later date. CPT 42 Correct Answer: Current Procedural Terminology; a system of descriptive terms and five-digit, numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals Critical Access Hospital (CAH) Correct Answer: a small hospital that serves a rural community; no more than 25 inpatient beds, located more than a 35 mile drive from any hospital or CAH in an area, 24/7 service Custodial Care Correct Answer: help with bathing, dressing, toileting, and eating data mailer Correct Answer: a system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account. definitive LCD/NCD Correct Answer: a policy that discusses and lists specific diagnosis codes, IDC procedure codes, and possibly signs and symptoms to support the need for the item or service being given discharge of debtor 43 Correct Answer: a potential outcome of bankruptcy that releases the guarantor/patient from financial responsibility of any and all account balances listed on the bankruptcy petition; the account balance is to be written off to the appropriate transaction code. dismissal Correct Answer: a court ruling whereby a bankruptcy is rejected by the court; the most common reason for dismissal is the failure of the debtor to follow through on the filing process and on payment to the attorney, and failure to provide requested documentation; upon dismissal of a bankruptcy, a creditor can bill the debtor directly, refer the account to a collection agency, or pursue litigation. DME Correct Answer: Durable Medical Equipment (Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.) DMEPOS Correct Answer: Durable medical equipment, prosthetics, orthotics, and supplies DSMT Correct Answer: Diabetes Self-Management Training- Medicare Part B covered preventative service 44 Dual Eligible Correct Answer: an individual who is entitled to Medicare Part A and/or Part B, and also eligible for some form of Medicaid benefit. Durable Power of Attorney for Healthcare Correct Answer: also known as Healthcare Power of Attorney; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so. E&M Correct Answer: Evaluation and Management; both the process of and the charge for examining a patient and formulating a treatment plan ECOA Correct Answer: Equal Credit Opportunity Act, federal law prohibiting discrimination in credit/lending EGHP Correct Answer: Employer Group Health Plan Emancipation Correct Answer: a process by which a minor is freed from parental control 45 Emergency Medical Treatment and Active Labor Correct Answer: EMTALA; also known as the Federal Anti-Dumping Statue; legislation enacted in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there EOB Correct Answer: explanation of benefits; a statement sent by a health insurance company to covered individuals explaining what medical treatments/services were paid for on their behalf; similar to an RA; it may or may not have a check attached for payment of services Evaluation and Management (E&M) Correct Answer: both the process of and the charge for examining a patient and formulating a treatment plan. Fair Credit Billing Act Correct Answer: Legislation that protects consumers from inaccurate or unfair practices by issuers of open-ended credit and requires creditors to inform debtors of their rights and of the responsibilities of the creditor Fair Credit Reporting Act 46 Correct Answer: Legislation that defines what information from "consumer reports" can be used, by whom, and when; it provides the max protection of a consumer's right to privacy and confidentiality of credit reports Fair Debt Collection Practices Act Correct Answer: A law that protects consumers from abusive practices by creditors and collection agencies False Correct Answer: a type of skip generally caused by clerical error at the time of registration, such as transposed numbers in the street address, an incorrect zip code, or incomplete information False Claims Act Correct Answer: legislation that prohibits making a false record or statement to get a false/fraudulent claim paid by the government, submission of false/fraudulent claims, and conspiring to have false/fraudulent claims paid by the government. FDCPA Correct Answer: Fair Debt Collection Practices Act; legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices. 47 Federal Anti-Dumping Statute Correct Answer: another name for the Emergency Medical Treatment and Active Labor Act (EMTALA); legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there, sometimes without notifying the receiving facility. fee-for-service Correct Answer: the oldest method of payment, in which providers are paid for each medical service rendered to a patient fee schedule Correct Answer: a payment methodology for some outpatient services; the schedule lists CPT and HCPCS codes and what Medicare allows for each, before deductible and coinsurance is applied fraud Correct Answer: the intentional or illegal deception or misrepresentation made for the purpose of personal gain GAAP Correct Answer: Generally Accepted Accounting Principles. The standards and rules that accountants follow while recording and reporting financial activities. 48 Gatekeeper Correct Answer: the primary care physician or PCP HCPCS Correct Answer: Healthcare Common Procedure Coding System; a mandated transaction code set for outpatient procedures Healthcare Power of Attorney Correct Answer: also known as Durable Power of Attorney for Healthcare; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so. HHS Correct Answer: U.S. Department of Health and Human Services; the government's principle agency for protecting the health of all Americans and providing essential human services HINN Correct Answer: Hospital Issued Notice of Non coverage; a liability notice similar to ABN; hospitals give HINN's to fee-for-service inpatient hospital beneficiaries who are due to receive specific diagnostic or therapeutic procedure that are separate from treatment covered / paid / bundled into the inpatient stay 49 HIPAA Correct Answer: Health Insurance Portability and Accountability Act; it created federal standards for insurers; HMOs, and employer plans including those who are self-insured; it also established the Privacy and Security Rules HMO Correct Answer: Health Maintenance Organization; one of five types of Medicare Advantage Plans in which members must generally get healthcare from providers in the plan's network. Home Health Correct Answer: Limited part-time skilled nursing care, home health aid, physical therapy, occupational therapy, etc. Hospice Correct Answer: coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations Hospital-Issued Notice of Noncoverage (HINN) Correct Answer: a liability notice similar to an ABN; hospitals give HNNs to fee-forservice inpatient hospital beneficiaries who are due to receive specific diagnostic or therapeutic procedures that are separate from treatment covered / paid / bundled into the inpatient stay 50 HRSA Correct Answer: Health Resources and Services Administration; one of the HHS Operating Divisions. HSA Correct Answer: Health Savings Account; a bank account maintained by a patient to pay medical expenses not covered by insurance; funds and interest in the HSA are not taxed; to have an HSA, the subscriber must be enrolled in a specific, high-deductible health plan I-Bill Correct Answer: an itemized statement ICD Correct Answer: International Classification of Disease a mandated transaction code set used for diagnosis and inpatient procedures ICD-10 Correct Answer: The current version of the International Classification of Diseases used in the United States IEQ 51 Correct Answer: Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare. IHS Correct Answer: Indian Health Service; one of the HHS Operating Divisions Important Message from Medicare Correct Answer: Given by hospitals to all Medicare beneficiaries who are inpatient within two days of admission and again within two days of discharge imprest Correct Answer: petty cash incomplete claim Correct Answer: a claim with required information missing indigent Correct Answer: an individual who has no means of paying for medical services or treatments and is not eligible for benefits under Medicaid or any other public assistance program informed consent 52 Correct Answer: consent given when the risks and benefits of a treatment are understood and the patient makes an informed decision whether to receive that treatment; required unless an exception is present, such as the patient's incapacity to understand the explanation of the procedures or in an emergency situation Initial Enrollment Questionnaire (IEQ) Correct Answer: a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare. initial preventive physical examination (IPPE) Correct Answer: the "Welcome to Medicare Physical Exam" that is offered to each beneficiary once in a lifetime. Initiation Correct Answer: the beginning of the treatment for a new encounter or a new plan of care; one of the triggering events for an ABN Intentional Correct Answer: a type of skip in which someone avoids paying bills by changing his or her residency and failing to leave a forwarding address, purposely changing his or her name, or intentionally giving false information. 53 Invalid Claim Correct Answer: claim that contains complete necessary information but is illogical or incorrect involuntary bankruptcy Correct Answer: a type of bankruptcy in which a debtor can be placed under Chapter 7 or 11 if the debtor has 12 or more creditors, three of which have claims in excess of $5,000 each and are willing to force the issue, or one creditor owed at least $10,775. IPPE Correct Answer: initial preventive physical examination - Medicare IPPS Correct Answer: inpatient prospective payment system itemized statement Correct Answer: a complete listing of every service posted to a patient account with DOS, description, code, charge amount, estimated insurance amounts, patient payment amounts, and totals The Joint Commision (TJC) 54 Correct Answer: a private agency that seeks to protect and improve the quality and safety of care; CMS allows TJC to accredit hospitals; it inspects facilities and provides eduction on issues affecting patient care a safety judgement Correct Answer: a legally verified claim against a debtor validated by the court; a legal right to collect a debt that can be used to obtain a lien Local Coverage Determination (LCD) Correct Answer: policies developed by Medicare area contractors that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate. locum tenens Correct Answer: a temporary substitute, especially for a doctor or member of the clergy. liability insurance Correct Answer: coverage through property and casualty or auto insurance lien Correct Answer: a recorded claim against real or personal property, generally arising out of a debt; if the property is sold by the debtor, the creditor must be paid out of the proceeds of that sale 55 limiting charge Correct Answer: the limit on the amount non-participating physicians can charge beneficiaries; currently 115% of the fee schedule amount living will Correct Answer: A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes. Long Term Care Correct Answer: care generally provided to the chronically ill or disabled in a nursing facility or rest home; among the services provided by nursing facilities are 24-hour nursing care; rehabilitative services such as physical, occupational, and speech therapy; and assistance with daily activities like eating, bathing, and dressing. MAAC Correct Answer: maximum allowable actual charge - REPLACED BY LIMITING CHARGE MBI Correct Answer: Medicare Beneficiary Identifier; a number replacing the HICN on the Medicare card 56 MCE Correct Answer: Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted. MDC Correct Answer: major diagnostic category; one of 25 groups of DRGs (diagnosisrelated groups). MDS Correct Answer: Minimum Data Set- part of the federally required process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes Medicaid Correct Answer: XIX, administered through a state-federal parnership Medicare Correct Answer: XVIII, covers 65+, permanent disability, ESDR, or Lou Gehrig's Disease Medicare Advantage Correct Answer: Medicare Part C, which provides managed care Medicare coverage. Medicare Beneficiary Number 57 Correct Answer: a number replacing the HICN on the Medicare Card Medicare Code Editor (MCE) Correct Answer: software that edits claims to detect incorrect billing data that is being submitted. Medicare Secondary Payer (MSP) Correct Answer: The primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before Medicare is sent a claim. Medicare Summary Notice (MSN) Correct Answer: A quarterly summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided Medigap Correct Answer: health insurance plans that help pay expenses not covered by Medicare Mini Miranda Correct Answer: a statement provided by a creditor to a debtor MP 58 Correct Answer: Malpractice insurance expense MPPS Correct Answer: Medicare Prospective Payment System MSA Correct Answer: Medical Savings Account MTF Correct Answer: Military treatment facilities. Located on bases or posts, these facilities are the core of the Tricare heathcare delivery system. MUE Correct Answer: Medically Unlikely Edit; An automated edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service; it helps to prevent inappropriate payments due to clerical entries and incorrect coding based on anatomic considerations. MVPS Correct Answer: Medicare Volume Performance Standard; the element of the Resource Based Relative Value Scale (RBRVS) for the rates of increase in Medicare expenditures for physician services. 59 National Correct Coding Initiative (NCCI) Correct Answer: developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices National Coverage Determination (NCD) Correct Answer: Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations (LCDs). non-definitive LCD/NCD Correct Answer: A policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms or ICD-9-CM codes that will be covered or non-covered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination. non-standard claim Correct Answer: a claim with extraneous attachments in lieu of data entered correctly in the claim form. notifier Correct Answer: an entity that issues ABN's 60 NPI (National Provider Identifier) Correct Answer: a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS) NUBC Correct Answer: National Uniform Billing Committee; the entity that governs the UB-04 and 8371 forms Observation Correct Answer: patient occupies a bed but is an outpatient status OCE Correct Answer: Outpatient Code Editor; edits to hospital outpatient services to detect pairs of codes that cannot be billed together and pairs that require modifiers office Correct Answer: any care provided in a practitioner's place of business OIG Correct Answer: Office of Inspector General; Investigates fraud & abuse Part A 61 Correct Answer: Medicare hospital insurance Part B Correct Answer: Medicare medical insurance. Part C Correct Answer: Medicare Advantage / Replacement Plan Part D Correct Answer: Prescription drug coverage, subject to a deductible Patient Care Partnership Correct Answer: a plain-language brochure that replaces the Patient's Bill of Rights and states expectations that patients and their families can have during a hospital stay. PE Correct Answer: Practice Expense per diem Correct Answer: per day percentage of charges 62 Correct Answer: a payment methodology where a claim is paid at a predetermined percentage discount rate physician extender Correct Answer: able to make notes in a patient medical record POA Correct Answer: Present on admission- a type of indicator that helps identify nonpayable complications, such as hospital-aquired conditions PPO Correct Answer: Preferred Provider Organization; one of five types of Medicare Advantage Plans in which members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist. PPS Correct Answer: Prospective Payment System Precertification Correct Answer: the process of obtaining auth from an insurance company review organization approving the medical necessity of services private fee-for-service plan 63 Correct Answer: a type of Medicare Advantage Plan which allows members to go to any provider that accepts the plan's terms; the private company decides how much it will pay and how much members pay for services RA Correct Answer: Remittance Advice; a statement sent by a health insurance company to covered individuals explaining what medical treatments/services were paid for on their behalf; similar to an EOB; RA should have a check attached or a voucher for an electronic payment which was made directly to the provider's bank RBRVS Correct Answer: Resource Based Relative Value Scale; 1. fee for schedule physician services based on the RVU 2. MVPS 3. limiting charge Recurring Correct Answer: Series; outpatients who will be coming in regularly for repetitive types of treatment Reduction Correct Answer: a decrease in the frequency or duration of care; one of the triggering events for an ABN RUG 64 Correct Answer: Resource Utilization Group; A system to determine the payment rate for most skilled nursing care; the provider completes the Minimum Data Set as part of the federally required process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes; the MDS then determines the RUG and hence the payment; the patient is reevaluated at intervals during his or her stay and the RUG rate may be changed. RVU Correct Answer: relative value unit; the basis for the fee schedule for payment of physician services that is one of the elements of the Resource Based Relative Value Scale (RBRVS). SAMHSA Correct Answer: Substance Abuse and Mental Health Services Administration; One of the HHS Operating Divisions Self-insurance Correct Answer: a company that puts premium payments into a fund to cover services and pays a third party to administer benefits from the fund instead of purchasing group insurance Self-pay Correct Answer: Patients who have no insurance 65 skip Correct Answer: a debtor who cannot be located by a creditor; there are three types: intentional; unintentional, and false. SNF PPS Correct Answer: Skilled Nursing Facility Prospective Payment System; provider completes the MDS, which determines the RUG and hence the payment Special Needs Plan (SNP) Correct Answer: a type of Medicare Advantage Plan which limits all or most of their membership to people in some Long Term Care facilities, and who are eligible for Medicare and Medicaid spell of an illness Correct Answer: also known as the benefit period; the period of time that begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF. statue of limitations Correct Answer: the amount of time in which a claim must be collected before it is declined 66 Superbill Correct Answer: also known as an encounter form; the preprinted sheet used to record data related to a patient encounter Tort Liability Correct Answer: a liability for an injury or wrongdoing by one person to another resulting from a breach of legal duty. TPA Correct Answer: Third Party Administrator TRICARE Correct Answer: healthcare coverage for active-duty service members, their spouses, dependents, and retirees, unless they are eligible for Medicare TRICARE for Life Correct Answer: a healthcare program for qualified service retirees that acts as a supplements to Medicare triggering event Correct Answer: an event that occurs during initiation, reduction, or termination of a course of treatment that triggers the need for an ABN. 67 Truth in Lending Act Correct Answer: Regulation Z; requires disclosure of info before credit is extended UB-04 Correct Answer: the hardcopy version fo the hospital claim form; also known as *CMS1450* UCR Correct Answer: usual, customary, and reasonable unintentional Correct Answer: a type of skip in which someone moves or changes residence and fails to notify creditors; a forwarding address is normally available. unprocessable Correct Answer: a claim that is considered incomplete or invalid due to missing claim form data elements. UR Correct Answer: Utilization review; also known as Case Management; performs critical tasks VA 68 Correct Answer: The U.S. Department of Veterans Affairs Work RVU Correct Answer: Work required; 1 of 3 RVUs associated with the calculation of a payment under the MPPS. Workers Compensation Correct Answer: a plan that covers injuries sustained by a worker in the course of performing his or her job duties Two main governing bodies affecting healthcare Correct Answer: 1. Centers for Medicare and Medicaid Services (CMS) 2. Office of Inspector General (OIG) QIO required to review... Correct Answer: all written quality of service complaints The AHA Adopted a... Correct Answer: Patient's Bill of Rights PPACA requires insurance companies to cover all applicants... Correct Answer: regardless of preexisting conditions or gender 69 Fraud Correct Answer: incorrect reporting of diagnosis, procedure codes, billing for services not furnished, alerting claims to receive payment, accepting kickbacks, the routine waiver of deductible and coinsurance amounts Abuse Correct Answer: not fraudulent but inconsistent with accepted sound practicesimproper billing practices Administrative Sanctions Correct Answer: 1. Denial or revocation of the provider number application 2. Suspension of provider payments 3. Application of Civil Monetary Penalties State collection laws prevail over federal collection laws when... Correct Answer: the state government provides more protection for the consumer EMTALA regulations apply to Correct Answer: All hospital campus and all patients in a facility All qualifying providers of lab services are issued a Correct Answer: CLIA number, which should be reported on the claim 70 More stringent than CLIA Correct Answer: NY and Washington TJC can audit after initial audit... Correct Answer: 9-30 months The savings from HIPAAs simplification rules have... Correct Answer: NOT exceeded initial projections Help determine if Medicare is primary or secondary Correct Answer: MSPQ MSP must be retained by the provider for Correct Answer: 10 years The process to terminate a patient relationship should include Correct Answer: a 30 notice in writing with a return receipt requested Alternative caregiver Correct Answer: respite care palliative care Correct Answer: hospice 71 continuous care Correct Answer: SNF Entities that issue ABNs are known by CMS as... Correct Answer: notifiers ALOS Correct Answer: total number of days / number of discharges average daily census Correct Answer: Total Number of Patient Days/Number of Days Annual booklet CMS makes available for beneficiaries... Correct Answer: Medicare and You Medicare Part A... Correct Answer: Most beneficiaries do not pay a premium Two factors that determine whether Medicare Advantage is liable for payment Correct Answer: 1. If provider is included in an inpatient hospital or home health PPS 2. The date of enrollment 72 Allows sign ups anytime within the 7 month period that begins three months before turning 65 Correct Answer: Medicare Part B Helps pay for ambulance services for Medicare beneficiaries (when other transportation would endanger your health) Correct Answer: Medicare Part B Part B - Mental Health Care Correct Answer: 20% of Medicare-approved amount PSA Test / Medicare Correct Answer: Once every 12 months Screening for depression / Medicare Correct Answer: Annually for all beneficiaries MAC Correct Answer: Formerly known as "fiscal intermediaries" or "carriers" If a patient is admitted to an acute care hospital with Medicare insurance and the coverage changed to a Medicare HMO in the middle of the stay, who is responsible? Correct Answer: Medicare, not HMO 73 If patient chooses the VA over Medicare, then the provider bills who first? Correct Answer: The VA. If denied, can submit to Medicare. TRICARE is the last payer, aside from... Correct Answer: Medicaid All Medicare providers must file claims electronically with this Correct Answer: Medicare-Required Standard Transactions Healthcare Eligibility Inquiry Correct Answer: 270 Healthcare Eligibility Response Correct Answer: 271 Healthcare Claim Status Inquiry Correct Answer: 276 Healthcare Claim Status Response Correct Answer: 277 Referral Certification and Authorization 74 Correct Answer: 278 Claim Status Response Correct Answer: 354 Enrollment and disenrollment in a health plan Correct Answer: 834 Healthcare payment and remittance advice Correct Answer: 835 Dental Claim Correct Answer: 837D Institutional Claim Correct Answer: 837I Professional Claim Correct Answer: 837P Three components in selecting a level of E&M service Correct Answer: 1. History 2. Examination 75 3. Medical decision-making National Drug Code (NDC) Correct Answer: a unique, 11-digit, three segment numeric identifier that is assigned to each medication listed under the FDA First segment of NDC Correct Answer: identifies the labeler, which is the company that manufactures or distributes the drug Second segment of NDC Correct Answer: Identifies the type of product Third segment of NDC Correct Answer: identifies the size and type of the package MS-DRG Correct Answer: inpatient services / total payment for the case / 25 Major Diagnostic Categories / most widely used system today / CMS allows hospital to file inpatient adj up to 60 days Ambulatory Payment Classification (APC) 76 Correct Answer: All services paid under PPS / payment rate established for each APC / need : *HCPCS/CPT Codes *E&M Codes *Reason for visit (ICD-10 code) *Site of service Insurance Payer Contracts Correct Answer: help to get discounts off normally billed charges Locum Tenes Correct Answer: a substitute physician that can be paid for services provided to a Medicare patient as long as 1. The regular physician is unable to provide services 2. The patient had a previously-scheduled appt or treatment with the regular physician 3. The sub physician does not provide services to the patient for more than 60 days UB-04/8371 Codes Correct Answer: *Condition code* - event or condition *Occurrence code*- code and date *Occurrence span code*- code and two dates that specify a span of time *Value code*- code and its related amount or value that together clarify an event or condition related a claim 77 *Revenue code*-four digit code that specifies an accommodation or ancillary service *Type of Bill Code*- three digit code in field indicator 4 that describes type of bill the hospital is submitting to the payer 2nd Digit - Bill Classification Correct Answer: Except Clinics and Special Facilities (1-5) Clinics Only (7) Special Facilities Only (8) Revenue Code Correct Answer: 0120 - Room and Board Semi-Private 0310 - Lab Pathology General 0450 - Emergency Room UB-04 has how many data elements? Correct Answer: 81 The 837P is... Correct Answer: a description of a superbill or encounter form CMS-1500 Processing Correct Answer: 1. Report diagnosis with the appropriate ICD-10 code 2. Use correction fluid and retype information if an error is made 78 Deadline to file Medicare Claim Correct Answer: a year out RTP Correct Answer: return to provider OIG Compliance Plan Correct Answer: 1. Written policies and procedures 2. Designated Compliance Officer and compliance committee 3. Effective training and education 4. Effective lines of communication 5. Enforced standards and well-publicized disciplinary procedures 6. Auditing and monitoring 7. responding to offenses and developing corrective action plans Statute of limitations Correct Answer: amount of time in which a claim must be collected before it is deemed paid or satisfied Limitation periods... Correct Answer: *less* for open-end accounts or oral agreements *greater* for notes or written agreements 79 *greatest* for judgements Statute of Limitations may be extended by... Correct Answer: Obtaining a written "promise to pay" Obtaining a partial payment on the principal amount Reducing the account to judgement immediately Executing a new contract Effective Collection Policy... Correct Answer: admission policy minimum acceptable payments follow-up policy pr policy charity care requirements and protocols discount policy charging interest contract amount implications age/bad-debt write-off determination/verification of responsible party process for handling errors/complaints Self-Pay Options Correct Answer: cash/check/credit card 80 HSA credit union funds cash from sale of assets loan money transfer Paying with Credit Card Correct Answer: *advantages*- immediate payment, payments made more readily with option of installment payments to the credit card company, method to accept payments over the telephone, get prior auth to charge balance to credit card *disadvantages* - additional costs due to discount rate, potentially more paperwork, potential PR issue (patient objects to paying interest), f/u on payment card industry regulations Determining patient re