CCA Exam Reimbursement Methodologies 2023 / Verified Solutions

1. How does Medicare or other third party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form?: by reviewing all the diagnosis codes assigned to explain the reasons the services were provided 2. What is the name of the organization that develops the billing form that hospitals are required to use?: National Uniform Billing Committee 3. What healthcare organization collect UHDDS data?: all non-outpatient set- tings including acute-care, short-term care, long-term care, and psychiatric hospi- tals; home health agencies; rehabilitation facilities; and nursing homes 4. What was the goal of the MS-DRG system?: To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients 5. What is the basic formula for calculating each MS-DRG hospital payment?- : Hospital payment = DRG relative weight x hospital base rate 6. What are possible add-on payment that a hospital could receive in addition to the basic Medicare DRG payment?: Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases 7. What is the name of the national program to detect and correct improper payments in the Medicare Fee for Service (FSS) program?: Recovery Audit contractors (RACS) 8. What is the maximum number of procedure codes that can appear on a UB-04 institutional claim form via electronic transmission?: 25 9. Which fails to provide a requirement for assignment of the MS-DRG?: At- tending and consulting phyisican notes 10. What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principal and secondary diagnoses?: 25 11. Which of the following situations would be identified by the NCCI edits?- : Billing for two services that are prohibited from being billed on the same day 12. A hospital needs to know how much Medicare paid on a claim so that they can bill the secondary insurance. What should the hospital refer to?: Remit- tance advice 13. A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the paid the ollowing statements is true?: Monies paid to the healthcare provider cannot exceed charges 14. The purpose of a physician query is to:: Improve documentation for patient care and proper reimbursement 15. What is it called when a Medicare hospital inpatient admission results in exceptionally high costs when compared to other cases in the same DRG?: Cost outlier 16. What is a chargemaster?: a financial management form that contains infor- mation about the organizations charges for the healthcare services it provides to patients 17. A fee schedule is: developed by third party payers and includes a list of healthcare services, procedures, and charges associated with each