Certified Healthcare Constructor Exam Study Guide Questions 2022/2023 | Consisting Of 348 Questions With Verified Answers From Experts

Certified Healthcare Constructor Exam Study Guide Questions 2022/2023 | Consisting Of 348 Questions With Verified Answers From Experts Federal Sentencing Guidelines - Culpability Score Aggravating Factors 1. upper-level employee participates, condones, or ignores offense 2. repeat offense 3. hinder investigation 4. awareness and tolerance of violation is pervasive Federal Sentencing Guidelines - Culpability Score Mitigating Factors 1. effective compliance program 2. reported promptly 3. cooperation with investigation 4. accept responsibility Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program 1. written standards of conduct 2. Chief Compliance Officer 3. effective education and training 4. audits and evaluations to monitor compliance 5. reporting processes and procedures for complaints 6. appropriate disciplinary mechanisms 7. investigation and remediation of systematic problems The only thing worse than not having a policy is... ...having a policy and not following it. Medicare reimbursement - hospital inpatient codes International Classification of Diseases (ICD) Medicare reimbursement - physician codes Current Procedural Technology (CPT) Questions to guide the scope of an internal investigation. 1. What is the origin of the issue? 2. When did the issue originate? 3. How far back should the investigation go? 4. Can extrapolation of a statistical sample be used? It is in the best interest of the organization to have the board _______. ...take an active rather than a passive role in compliance. Six tips for saving on future costs of compliance. 1. embed quality into existing processes 2. centralize common processes and controls 3. improve human resources infrastructures 4. improve information systems processes 5. emphasize training 6. monitor marketing and compensation Baseline Audit Process 1. outline the current operational standards 2. identify real and potential weaknesses 3. offer recommendations Compliance Program - Measures of Effectiveness 1. staff knowledge 2. all 7 elements included 3. comparing issues year to year 4. tracking and trending complaints 5. tracking corrective actions 6. reviewing current audits 7. educational session pre and post tests 8. tracking bill denials 9. organizational survey results 10. audit results 11. compliance topics on department/organization agendas Modifier a two digit alpha/numeric code used in conjunction with CPT or HCPCS codes that may increase or decrease reimbursement gives new meaning to the code International Classification of Diseases (ICD) a statistical classification system that arranges diseases and injuries into groups according to established criteria (signs and symptoms) Current Procedural Terminology (CPT) American Medical Association publishes and maintains this coding system Organized Health Care Arrangements (OHCA) HIPAA arrangement between clinically integrated setting (ex: hospitals and medical staff) Diagnosis Related Group (DRG) an inpatient classification system based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status Healthcare Common Procedure Coding System (HCPCS) for medication, maintained by CMS CMS contracts with American Medical Association to use CPT coding for the Medicare program using this expanded version Upcoding providers use a billing code that reflects a higher payment rate for a device or service provided than the actual device or service furnished to the patient Unbundling submitting bills by piecemeal or in fragmented fashion to maximize reimbursement Outlier additional payment for patients with long hospital length of stay Billing and Coding Concerns (*) 1. coding advice (if not in book - get in writing) 2. significant increases in volume (*) (find out why increase) 3. hiring external consultants (need BAA, if provide patient care - check OIG sanction list) 4. number of auditors for Part B audits 5. teaching physicians (*) (physician must be physically present and involved in managing care) 6. co-pay waivers (cannot routinely waive) 7. record does not support code 8. research payments (cannot bill Medicare for costs covered by sponsor) 9. disagreements (get 3rd party opinion) 10. DOCUMENTATION "Incident To" services services commonly furnished in a physician's office by a nurse practitioner in which there is direct physician personal supervision and are billed under the physician's provider number (does not apply in hospital setting) physician must be present to bill (*) Two-Midnight Rule CMS will consider a claim as inpatient if the patient in hospital bed over two midnights 72 Hour Rule/3 Day Window Project (*) all diagnostic outpatient charges and other related outpatient charges within 72 hours prior to an inpatient admission are bundled into inpatient stay reimbursement False Cost Reports (*) submission of charges to Medicare which are unrelated to medical care, such as administrative overhead Credit Balances - Failure to Refund (*) provider has 60 days to refund credit balances (*) PPS Transfer Project PPS transfer of patient (rather than discharge) and receiving payment Advance Beneficiary Notice (ABN) a written form that a provider gives to a Medicare beneficiary that informs the beneficiary that Medicare may not pay for an item or service must be provided and signed by patient before services are provided (or provider cannot bill patient if Medicare denies) Medicare Secondary Payer Questionnaire used to identify the correct insurance company that must pay health care bills first when Medicare pays second Hospital Outpatient Cardiac Rehabilitation physician must be present during treatment DRG Utilization (*) DRG utilization should be reviewed when the number of uses of a particular DRG is outside of the norm or average The three components of Evaluation and Management (E&M) services (*) 1. History 2. Examination 3. Medical Decision Making Evaluation & Management Codes 1. subset of CPT codes 2. privileged providers 3. describe complexity of care, place of services, and type of service Types of History or Examination 1. Problem Focused (CC & brief history) 2. Expanded Problem Focus 3. Detailed 4. Comprehensive Complexities of Medical Decision Making 1. Straight-forward (simple, 1 problem) 2. Low complexity 3. Moderate complexity (may have some complications) 4. High complexity Initial patient visit (*) 3 out of 3 key elements of E&M services must be met or exceeded in order to bill for this type of visit Established patient visit (*) 2 out of 3 key elements of E&M services must be met or exceeded in order to bill for this type of visit Inpatient Documentation Requirements 1. sufficient documentation to demonstrate signs/symptoms were sever enough to warrant inpatient care 2. preexisting medical problems or extenuating circumstances Factors to Consider When Making the Decision to Admit as Inpatient 1. severity of signs and symptoms 2. medical predictability of something adverse happening to the patient 3. need for diagnostic studies 4. availability of diagnostic procedures at the time and location where patient presents Medicare Part A Part of Medicare that reimburses primarily for inpatient services provided by institutions such as hospitals and skilled nursing facilities Medicare Part B Part of the Medicare program that reimburses covered physician and supplier services Medicare Part C (Medicare Advantage) Formerly known as Medicare + Choice, government managed care program, must have Part B Medicare Part D part of Medicare that reimburses for outpatient prescription drugs Medicare Administrative Contractor (MAC) Processes Part A and Part B claims Focused Medical Review (FMR) 1. determine if documentation supports claim 2. reviews guidelines Medicaid state health insurance that helps many people who can't afford medical care and pays for some or all of their medical bills 1500 Form Non-institutional providers must use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies used to bill Part B claims CMS 1450 or UB-04 institutional providers use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies used to bill Part A claims Fiscal Intermediary (FI) an insurance company that contracts with CMS to process Medicare Part A claims - replaced by MACs in 2003 a Carrier an insurance company that contracts with CMS to process Medicare Part B claims - replaced by MACs in 2003 Centers for Medicare and Medicaid Services (CMS) HHS agency that establishes payment policies for providers, conducts research, and evaluates the quality of care provided to beneficiaries Conditions of Participation (COP) must be in compliance in order to be reimbursed by CMS CMS Allowable how much CMS will reimburse for a particular service or procedure Third Party Carrier entity that processes the claims on behalf of CMS Disproportionate Share Hospital (DSH) hospital that provides larger amount of care to indigent population CMS provides increased reimbursement for these hospitals to cover cost of uninsured patients Common Working File (CWF) information about beneficiaries Return to Provider (RTP) Report indication of error in the claim submitted to CMS - must be corrected to receive reimbursement Health Professional Shortage Area geographic areas that have been designated as primary medical care shortage areas where physician who furnish medical care are entitled to a Medicare incentive payment Participating Provider/Supplier accepts CMS allowable as payment in full for services Certificate of Medical Necessity (*) physician statement that services are medically necessary Assignment agreement to accept payment in full - 20% copay, 80% Medicare