Reimbursement RHIA Exam Questions With Complete
Solutions
/. The case-mix management system that utilizes information from the Minimum Data
Set (MDS) in long-term care settings is called
A. Medicare Severity Diagnosis Related Groups (MS-DRGs).
B. Resource Based Relative Value System (RBRVS).
C. Resource Utilization Groups (RUGs).
D. Ambulatory Patient Classifications (APCs). - Answer-C. Resource Utilization Groups
(RUGs).
/.The prospective payment system used to reimburse home health agencies for patients
with Medicare utilizes data from the:
A. MDS (Minimum Data Set).
B. OASIS (Outcome and Assessment Information Set).
C. UHDDS (Uniform Hospital Discharge Data Set).
D. UACDS (Uniform Ambulatory Core Data Set). - Answer-B. OASIS (Outcome and
Assessment Information Set).
/.Under APCs, the payment status indicator "N" means that the payment
A. is for ancillary services.
B. is for a clinic or an emergency visit.
C. is discounted at 50%.
D. is packaged into the payment for other services. - Answer-D. is packaged into the
payment for other services.
/.All of the following items are "packaged" under the Medicare outpatient prospective
payment system, EXCEPT for
A. recovery room.
B. medical supplies.
C. anesthesia.
D. medical visits. - Answer-D. medical visits.
/.Under the RBRVS, each HCPCS/CPT code contains three components, each having
assigned relative value units. These three components are
A. geographic index, wage index, and cost of living index.
B. fee-for-service, per diem payment, and capitation.
C. conversion factor, CMS weight, and hospital-specific rate.
D. physician work, practice expense, and malpractice insurance expense. - Answer-D.
physician work, practice expense, and malpractice insurance expense.
/.The prospective payment system used to reimburse hospitals for Medicare hospital
outpatients is called
,A. APGs.
B. RBRVS.
C. APCs.
D. MS-DRGs. - Answer-C. APCs.
/.A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. The
charge for the office visit was $125. The Medicare beneficiary had already met his
deductible. The Medicare Fee Schedule amount is $100. Dr. Zachary does not accept
assignment. The office manager will apply a practice termed as "balance billing," which
means that the patient is
A. financially liable for the Medicare Fee Schedule amount.
B. financially liable for charges in excess of the Medicare Fee Schedule, up to a limit.
C. not financially liable for any amount.
D. financially liable for only the deductible. - Answer-B. financially liable for charges in
excess of the Medicare Fee Schedule, up to a limit.
/.The prospective payment system based on resource utilization groups (RUGs) is used
for reimbursement to _______________ for patients with Medicare.
A. freestanding ambulatory surgery centers
B. hospital-based outpatients
C. intermediate care facilities
D. skilled nursing facilities - Answer-D. skilled nursing facilities
/.The _____________ is a statement sent to the provider to explain payments made by
third-party payers.
A. remittance advice
B. advance beneficiary notice
C. attestation statement
D. acknowledgement notice - Answer-A. remittance advice
/.HIPAA administrative simplification provisions require all of the following code sets to
be used EXCEPT
A. ICD-10-CM
B. CDT
C. DSM
D. CPT - Answer-C. DSM
/.The computer-to-computer transfer of data between providers and third-party payers in
a data format agreed upon by both parties is called
A. HIPAA (Health Insurance Portability and Accountability Act).
B. electronic data interchange (EDI).
C. heath information exchange (HIE).
D. health data exchange (HDE). - Answer-B. electronic data interchange (EDI).
/.A computer software program that assigns appropriate MS-DRGs according to the
information provided for each episode of care is called a(n)
, A. encoder.
B. case-mix analyzer.
C. grouper.
D. scrubber. - Answer-C. grouper.
/.The standard claim form used by hospitals to request reimbursement for inpatient and
outpatient procedures performed or services provided is called the
A. UB-04.
B. CMS-1500.
C. CMS-1491.
D. CMS-1600. - Answer-A. UB-04.
The UB-04 is used by hospitals. The CMS-1500 is used by physicians and other
noninstitutional providers and suppliers. The CMS-1491 is used by ambulance services.
/.Under ASC PPS, when multiple procedures are performed during the same surgical
session, a payment reduction is applied. The procedure in the highest level group is
reimbursed at _______ and all remaining procedures are reimbursed at _______.
A. 50%, 25%
B. 100%, 50%
C. 100%, 25%
D. 100%, 75% - Answer-B. 100%, 50%
/.The _______________ refers to a statement sent to the patient to show how much the
provider billed, how much Medicare reimbursed the provider, and what the patient must
pay the provider.
A. Medicare summary notice
B. remittance advice
C. advance beneficiary notice
D. coordination of benefits - Answer-A. Medicare summary notice
/.Currently, which prospective payment system is used to determine the payment to the
"physician" for physician services covered under Medicare Part B, such as outpatient
surgery performed on a Medicare patient?
A. MS-DRGs
B. APCs
C. RBRVS
D. ASCs - Answer-D. ASCs
/.Which of the following best describes the situation of a provider who agrees to accept
assignment for Medicare Part B services?
A. The provider is reimbursed at 15% above the allowed charge.
B. The provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus
10%.
C. The provider cannot bill the patients for the balance between the MPFS amount and
the total charges.
Solutions
/. The case-mix management system that utilizes information from the Minimum Data
Set (MDS) in long-term care settings is called
A. Medicare Severity Diagnosis Related Groups (MS-DRGs).
B. Resource Based Relative Value System (RBRVS).
C. Resource Utilization Groups (RUGs).
D. Ambulatory Patient Classifications (APCs). - Answer-C. Resource Utilization Groups
(RUGs).
/.The prospective payment system used to reimburse home health agencies for patients
with Medicare utilizes data from the:
A. MDS (Minimum Data Set).
B. OASIS (Outcome and Assessment Information Set).
C. UHDDS (Uniform Hospital Discharge Data Set).
D. UACDS (Uniform Ambulatory Core Data Set). - Answer-B. OASIS (Outcome and
Assessment Information Set).
/.Under APCs, the payment status indicator "N" means that the payment
A. is for ancillary services.
B. is for a clinic or an emergency visit.
C. is discounted at 50%.
D. is packaged into the payment for other services. - Answer-D. is packaged into the
payment for other services.
/.All of the following items are "packaged" under the Medicare outpatient prospective
payment system, EXCEPT for
A. recovery room.
B. medical supplies.
C. anesthesia.
D. medical visits. - Answer-D. medical visits.
/.Under the RBRVS, each HCPCS/CPT code contains three components, each having
assigned relative value units. These three components are
A. geographic index, wage index, and cost of living index.
B. fee-for-service, per diem payment, and capitation.
C. conversion factor, CMS weight, and hospital-specific rate.
D. physician work, practice expense, and malpractice insurance expense. - Answer-D.
physician work, practice expense, and malpractice insurance expense.
/.The prospective payment system used to reimburse hospitals for Medicare hospital
outpatients is called
,A. APGs.
B. RBRVS.
C. APCs.
D. MS-DRGs. - Answer-C. APCs.
/.A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. The
charge for the office visit was $125. The Medicare beneficiary had already met his
deductible. The Medicare Fee Schedule amount is $100. Dr. Zachary does not accept
assignment. The office manager will apply a practice termed as "balance billing," which
means that the patient is
A. financially liable for the Medicare Fee Schedule amount.
B. financially liable for charges in excess of the Medicare Fee Schedule, up to a limit.
C. not financially liable for any amount.
D. financially liable for only the deductible. - Answer-B. financially liable for charges in
excess of the Medicare Fee Schedule, up to a limit.
/.The prospective payment system based on resource utilization groups (RUGs) is used
for reimbursement to _______________ for patients with Medicare.
A. freestanding ambulatory surgery centers
B. hospital-based outpatients
C. intermediate care facilities
D. skilled nursing facilities - Answer-D. skilled nursing facilities
/.The _____________ is a statement sent to the provider to explain payments made by
third-party payers.
A. remittance advice
B. advance beneficiary notice
C. attestation statement
D. acknowledgement notice - Answer-A. remittance advice
/.HIPAA administrative simplification provisions require all of the following code sets to
be used EXCEPT
A. ICD-10-CM
B. CDT
C. DSM
D. CPT - Answer-C. DSM
/.The computer-to-computer transfer of data between providers and third-party payers in
a data format agreed upon by both parties is called
A. HIPAA (Health Insurance Portability and Accountability Act).
B. electronic data interchange (EDI).
C. heath information exchange (HIE).
D. health data exchange (HDE). - Answer-B. electronic data interchange (EDI).
/.A computer software program that assigns appropriate MS-DRGs according to the
information provided for each episode of care is called a(n)
, A. encoder.
B. case-mix analyzer.
C. grouper.
D. scrubber. - Answer-C. grouper.
/.The standard claim form used by hospitals to request reimbursement for inpatient and
outpatient procedures performed or services provided is called the
A. UB-04.
B. CMS-1500.
C. CMS-1491.
D. CMS-1600. - Answer-A. UB-04.
The UB-04 is used by hospitals. The CMS-1500 is used by physicians and other
noninstitutional providers and suppliers. The CMS-1491 is used by ambulance services.
/.Under ASC PPS, when multiple procedures are performed during the same surgical
session, a payment reduction is applied. The procedure in the highest level group is
reimbursed at _______ and all remaining procedures are reimbursed at _______.
A. 50%, 25%
B. 100%, 50%
C. 100%, 25%
D. 100%, 75% - Answer-B. 100%, 50%
/.The _______________ refers to a statement sent to the patient to show how much the
provider billed, how much Medicare reimbursed the provider, and what the patient must
pay the provider.
A. Medicare summary notice
B. remittance advice
C. advance beneficiary notice
D. coordination of benefits - Answer-A. Medicare summary notice
/.Currently, which prospective payment system is used to determine the payment to the
"physician" for physician services covered under Medicare Part B, such as outpatient
surgery performed on a Medicare patient?
A. MS-DRGs
B. APCs
C. RBRVS
D. ASCs - Answer-D. ASCs
/.Which of the following best describes the situation of a provider who agrees to accept
assignment for Medicare Part B services?
A. The provider is reimbursed at 15% above the allowed charge.
B. The provider is paid according to the Medicare Physician Fee Schedule (MPFS) plus
10%.
C. The provider cannot bill the patients for the balance between the MPFS amount and
the total charges.
