CCS EXAM - Medical Billing and Reimbursement System Questions and Answers Rated A+

CCS EXAM - Medical Billing and Reimbursement System Questions and Answers Rated A+ The prospective payment system used to reimburse home health agencies OASIS (Outcome and Assessment Information Set). Home Health Agencies (HHAs) utilize a data entry software system called HAVEN (Home Assessment Validation and Entry) These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid payment status indicator When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital absorbs the loss; this is commonly known as a write-off. Code used to identify the procedure, service, or treatment HCPCS/CPT code 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 The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called APCs This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms National Provider Identifier (NPI) This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service Medicare Physician Fee Schedule (MPFS) Under APCs, payment status indicator "V" means clinic or emergency department visit (medical visits) When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called abuse When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n) interrupted stay This information provides a narrative name of the services provided item/service description Capitation System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. 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) This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes are listed in the memoranda LCD (Local Coverage Determinations) The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement ICD-10-CM/ICD-10-PCS codes Under APCs, payment status indicator "S" means a. significant procedure, multiple procedure reduction does not apply These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments hold harmless This program, formerly called CHAMPUS (Civilian Health and Medical Program-Uniformed Services), is a health care program for active members of the military and other qualified family members TRICARE What prospective payment system reimburses the provider according to determined rates for a 60-day episode of care? home health resource groups Payment Systems IPPS: inpatient prospective payment system OPPS: outpatient prospective payment system Payment calculations Resource-based reimbursement value system (RBRVS) Usual, customary, and reasonable (UCR) Capitation Fee-for-service (FFS) Episodic care Case-mix index (CMI) Resource utilization groups (RUG) Ambulatory patient classifications (APC) Medicare physician fee schedule (MPFS) A national price list for physician services established by Medicare Diagnosis-related groups (DRG) A classification system that establishes pretreatment diagnosis billing categories Ambulatory patient classifications (APC) a prospective payment system for hospital outpatient services provided to Medicare and Medicaid beneficiaries Resource utilization groups (RUG) a case-mix-adjusted system based on Minimum Data Set assessments in skilled nursing facilities (SNF) Non-PAR limiting charge for a non-participating physician who does not accept assignment, the limiting charge is 15% over the non-PAR allowed amount Remittance advice (RA) an explanation of benefits transmitted electronically by a payer to a provider Explanation of benefits (EOB) readmittance advice sent to the policyholder Claim Forms and Processes for Submission UB-04: the paper claim form used by hospitals HIPAA X12N 837I: electronic claims form of the UB-04 CMS-1500: the paper claim form used by outpatient facilities and physicians HIPAA X12N 837P: electronic claims form of the CMS-1500 CMS-1491: the paper claim form used by ambulance companies