ch 9 CMS Reimbursement
Methodologies Questions & Answers
Reimbursement according to a ______ means that hospitals reported actual charges for
inpatient care to payersafter discharge of the patients from the hospital. -
ANSWERSretrospective reasonable cost system
Which is established in advance and based on reported health care charges from which
a predetermined per diem rate is determined? - ANSWERSprospective cost based rate
Which is associated with a particular category of patient and is established by the payer
prior to the provision of healthcare services? - ANSWERSprospective price based rate
The federal government administers several health care programs, some of which
require services to be reimbursed according to predetermined reimbursement
methodologies, which are established as ______. - ANSWERSpayment systems
The ambulance fee schedule payment system replaced a ______ for providers and
suppliers of ambulance services. - ANSWERSretrospective reasonable cost payment
systeem
An ambulatory surgical center (ASC) is a state-licensed, Medicare-certified supplier (not
provider) of surgical healthcare services that must _______ on Medicare claims. -
ANSWERSaccept assignment
In 1980 Medicare authorized implementation of ambulatory surgical center ______ rates
as a fee to ambulatory surgery centers (ASCs) for facility services furnished in
connection with performing certain surgical procedures. - ANSWERSpayment
The MMA of 2003 mandated implementation of a(n) _____ payment amount as a
substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for
surgical procedures performed at an ASC. - ANSWERSoutpatient prospective payment
system
Medicare reimburses laboratory services according to a(n) _______, which is based on
the submitted charge,national limitation amount, or local fee schedule amount,
whichever is lowest. - ANSWERSclinical laboratory fee schedule
The Medicare durable medical equipment, prosthetics/orthotics, and supplies
(DMEPOS) fee schedule reimburses DMEPOS either ______ percent of the actual
charge for the item or the fee schedule amount, whichever is lower. - ANSWERS80
, The end-stage renal disease (ESRD) composite payment rate system is _____ adjusted
to provide a mechanism to account for differences in patients' utilization of health care
resources. - ANSWERScase mix
Which is a facility's measure of the types of patients treated and reflects patient
utilization of varying levels of healthcare resources? - ANSWERScase mix
Each home health resource group (HHRG) has an associated ______ that increases or
decreases Medicare's payment for an episode of home health care. - ANSWERSweight
value
Home health resource groups are reported to Medicare on UB-04 using the _____ code
set, which represents case-mix groups about which payment determinations are made
for the home health prospective payment system. - ANSWERSHIPPS
HIPPS codes are determined after home health care patient assessments using the
_____ are completed. - ANSWERSoutcomes and assessment information set (OASIS)
Which type of software is used to determine the appropriate HHRG after OASIS data is
input on each patient (to measure the outcome of all adult patients receiving home
health services)? - ANSWERSgrouper
Home Assessment Validation and Entry (HAVEN) _______ software is then used to
collect OASIS assessment data for transmission to state databases. - ANSWERSdata
entry
The inpatient prospective payment system (IPPS) resulted in Medicare reimbursing
hospitals for inpatient hospital services according to a _____ rate for each discharge. -
ANSWERSpredetermined
Diagnosis-related groups are organized into mutually exclusive categories called
______ , which are loosely based on body systems. - ANSWERSmajor diagnostic
categories
DRG reimbursement rates are recalculated according to a(n) ______ adjustment, which
results in increased Medicare payments for hospitals that treat a high percentage of
low-income patients. - ANSWERSdisproportionate share hospital
Approved teaching hospitals receive increased Medicare payments according to a(n)
_____ adjustment. - ANSWERSindirect medical education
Hospitals that treat unusually costly cases receive increased _______ payments that
are designed to protect hospitals from large financial losses due to unusually expensive
cases. - ANSWERSoutlier
Methodologies Questions & Answers
Reimbursement according to a ______ means that hospitals reported actual charges for
inpatient care to payersafter discharge of the patients from the hospital. -
ANSWERSretrospective reasonable cost system
Which is established in advance and based on reported health care charges from which
a predetermined per diem rate is determined? - ANSWERSprospective cost based rate
Which is associated with a particular category of patient and is established by the payer
prior to the provision of healthcare services? - ANSWERSprospective price based rate
The federal government administers several health care programs, some of which
require services to be reimbursed according to predetermined reimbursement
methodologies, which are established as ______. - ANSWERSpayment systems
The ambulance fee schedule payment system replaced a ______ for providers and
suppliers of ambulance services. - ANSWERSretrospective reasonable cost payment
systeem
An ambulatory surgical center (ASC) is a state-licensed, Medicare-certified supplier (not
provider) of surgical healthcare services that must _______ on Medicare claims. -
ANSWERSaccept assignment
In 1980 Medicare authorized implementation of ambulatory surgical center ______ rates
as a fee to ambulatory surgery centers (ASCs) for facility services furnished in
connection with performing certain surgical procedures. - ANSWERSpayment
The MMA of 2003 mandated implementation of a(n) _____ payment amount as a
substitute for the Ambulatory Surgical Center (ASC) standard overhead amount for
surgical procedures performed at an ASC. - ANSWERSoutpatient prospective payment
system
Medicare reimburses laboratory services according to a(n) _______, which is based on
the submitted charge,national limitation amount, or local fee schedule amount,
whichever is lowest. - ANSWERSclinical laboratory fee schedule
The Medicare durable medical equipment, prosthetics/orthotics, and supplies
(DMEPOS) fee schedule reimburses DMEPOS either ______ percent of the actual
charge for the item or the fee schedule amount, whichever is lower. - ANSWERS80
, The end-stage renal disease (ESRD) composite payment rate system is _____ adjusted
to provide a mechanism to account for differences in patients' utilization of health care
resources. - ANSWERScase mix
Which is a facility's measure of the types of patients treated and reflects patient
utilization of varying levels of healthcare resources? - ANSWERScase mix
Each home health resource group (HHRG) has an associated ______ that increases or
decreases Medicare's payment for an episode of home health care. - ANSWERSweight
value
Home health resource groups are reported to Medicare on UB-04 using the _____ code
set, which represents case-mix groups about which payment determinations are made
for the home health prospective payment system. - ANSWERSHIPPS
HIPPS codes are determined after home health care patient assessments using the
_____ are completed. - ANSWERSoutcomes and assessment information set (OASIS)
Which type of software is used to determine the appropriate HHRG after OASIS data is
input on each patient (to measure the outcome of all adult patients receiving home
health services)? - ANSWERSgrouper
Home Assessment Validation and Entry (HAVEN) _______ software is then used to
collect OASIS assessment data for transmission to state databases. - ANSWERSdata
entry
The inpatient prospective payment system (IPPS) resulted in Medicare reimbursing
hospitals for inpatient hospital services according to a _____ rate for each discharge. -
ANSWERSpredetermined
Diagnosis-related groups are organized into mutually exclusive categories called
______ , which are loosely based on body systems. - ANSWERSmajor diagnostic
categories
DRG reimbursement rates are recalculated according to a(n) ______ adjustment, which
results in increased Medicare payments for hospitals that treat a high percentage of
low-income patients. - ANSWERSdisproportionate share hospital
Approved teaching hospitals receive increased Medicare payments according to a(n)
_____ adjustment. - ANSWERSindirect medical education
Hospitals that treat unusually costly cases receive increased _______ payments that
are designed to protect hospitals from large financial losses due to unusually expensive
cases. - ANSWERSoutlier
