CCM FINAL EXAM ACTUAL QUESTIONS AND ANSWERS
RATED A+
✔✔HHRG - ✔✔Home health resource group Medicare A case-mix classification in
which Pt characteristics and health status information are obtained from an OASIS
assessment in conjunction with projected therapy use during a 60-day episode are used
to determine Medicare reimbursement.
-Eighty HHRGs
-The Outcome & Assessment Information Set (OASIS) determines the HHRG and is
completed for each 60-period
-A predetermined base payment for each 60-day episode of care is adjusted according
to patient's HHRG
-No limit to number of 60-day episodes
-Payment is adjusted if patient's condition significantly changes
✔✔DRG - ✔✔Diagnosis-related group Managed care A unit of classifying Pts by
diagnosis, average length of hospital stay, and therapy received; the result is used to
determine how much money health care providers will be given to cover future
procedures and services, primarily for inpatient care.
-Primary diagnosis determines assignment to one of 535 DRGs
-The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major
procedures performed. DRG payment is per stay.
-Additional payment (outlier) made only if length of stay far exceeds the norm
✔✔RUG - ✔✔-Fifty-eight groups
-Each beneficiary assigned a per diem payment based on Minimum Data Set (MDS)
comprehensive assessment
-A specified minimum number of minutes per week is established for each rehabilitation
RUG based on MDS score and rehabilitation team estimates
✔✔SNF - ✔✔A facility that provides 24-hour medical care provided by registered
nurses, licensed vocational
nurses as well as nurses aides. Licensed Physical Therapists, Occupational Therapists,
and Speech
Therapists are also available. Typically for patients who require services that can only
be given by a
licensed provider such as IVABX, IV pain management, wound care, g-tube feeding or
physical
rehabilitation needed 1-3 hours a day on a daily basis. An M.D. will usually evaluate pt.
within the
first 72 hours and then monthly thereafter.
In order for Medicare to cover (and Medicare only) pt. must have a three-day qualifying
stay in the
acute setting (think midnights). As long as pt. has a skilled need and a qualifying stay
Medicare will
,cover the first 20 days at 100 percent, day 21-100 is $119.00 a day which the pt. or the
pt's secondary
insurance is responsible for.
Most SNFs also have a custodial side for pts. whose needs can no longer be met at
home or at a lower
level of care. Other than MediCal, Medicare and most private insurances, (with the
exception of long
term care insurance) will NOT cover custodial care in a SNF.
✔✔Subacute Care Unit - ✔✔For patients who no longer require the intensive
procedures of an acute care Hospital, but do require
the diagnostic or invasive procedures of an inpatient healthcare facility. Patients who
are transferred
to a sub acute facility may have a trach and require frequent suctioning. Individuals may
also need to
be weaned from a ventilator. Patients residing in this environment generally need
between four and
seven hours of skilled nursing/respiratory care each day.
Medicare does not recognize the sub acute level of care and will only reimburse on a
SNF level, so the
determination of acceptance is usually made on a case by case basis by the individual
facility.
MediCal does recognize the Sub acute level, however, the pt. must have a trach AND
another needs
i.e. feeding tube, wound care or TPN. Only a few sub cutes have dialysis available on
site.
✔✔LTAC - ✔✔Structured and programmed for medically complex and often
catastrophically ill patients. Patients are
admitted for acute care, with lengths of stay that average 25-30 days; typical of
medically complex
patients. The intensity of service will normally exceed the care needs that can be met by
a sub-acute or
skilled nursing facility.
An LTAC will generally be able to provide such services as vent weaning and
respiratory care,
complicated wound care, TPN; Surgeries such as Tracheotomies, wound debridment,
skin flaps,
PEG/GT placement, and Central line placement. An LTAC will also have an ICU as well
as telemetry
units. Pts. will be seen on a daily basis by an M.D. and will be treated by P.T., O.T., and
Speech.
The patient must have specific and realistic discharge goals from the LTAC. Mainly for
Medicare
recipients, MediCal does not recognize this level of care, and private insurance is on a
case-by-case
,basis.
✔✔Acute Rehab Unit - ✔✔Typically for neuro related diagnosis (but not always, this too
is decided on a case by case basis
dependant on insurance and accepting facility), the pt. must actively participate,
tolerate, and benefit from a MINIMUM of three hours of therapy daily (P.T., O.T., and
Speech Therapy). The pt. must
have a discharge goal of home or an assisted living facility, pt will NOT be accepted if
the goal is SNF.
✔✔Accessible - ✔✔A term used to denote building facilities that are barrier-free thus
enabling all members of society safe access, including persons with physical
disabilities.
✔✔Barrier - Free - ✔✔A physical, manmade environment or arrangement of structures
that is safe and accessible to persons with disabilities.
✔✔Activity Limitations - ✔✔Difficulties an individual may have in executing activities. An
activity limitation may range from a slight to a severe deviation in terms of quality or
quantity in executing the activity in a manner or to the extent that is expected of people
without the health condition.
✔✔Developmental Disability - ✔✔Any mental and/or physical disability that has an
onset before age 22 and may continue indefinitely. It can limit major life activities.
Individuals with mental retardation, cerebral palsy, autism, epilepsy (and other seizure
disorders), sensory impairments, congenital disabilities, traumatic brain injury or
conditions caused by disease (e.g. polio and muscular dystrophy) may be considered
developmentally disabled.
✔✔Disability - ✔✔A physical or neurological deviation in an individual makeup. It may
refer to a physical, mental or sensory condition. A disability may or may not be a
handicap to an individual, depending on one's adjustment to it.
✔✔Disability - ✔✔Diminished function, based on the anatomic, physiological or mental
impairment that has reduced the individual's activity or presumed ability to engage in
any substantial gainful activity.
✔✔Disability - ✔✔Inability or limitation in performing tasks, activities, and roles int he
manner or within the range considered normal for a person of the same age, gender,
culture and education. Can also refer to any restriction or lack (resulting from an
impairment) of ability to perform an activity in the manner or within the range considered
normal for a human being.
, ✔✔Disability Case Mangemtn - ✔✔A process of managing occupational and no-
occupational diseases with the aim of returning the disabled employee to a productive
work schedule and employment.
✔✔Disability Income Insurance - ✔✔A form of health insurance that provides periodic
payments to replace income when an insured person is unable to work as a result of
illness, injury or disease
✔✔Handicap - ✔✔The functional disadvantage and limitation of potentials based on a
physical or mental impairment or disability that substantially limits or prevents the
fulfillment of one or more major life actives, otherwise considered normal for that
individual based on age, sex and social/cultural factors, such as caring for one's self,
performing manual tasks, walking, seeing, hearing, speaking, breathing, learning,
working, etc. Handicap is a classification of role reduction resulting from circumstances
that place an impaired or disabled person at a disadvantage compared to other
persons.
✔✔Handicapped - ✔✔Refers to the disadvantage of an individual with a physical or
mental impairment resulting in a handicap.
✔✔Learning Disability - ✔✔A lack of achievement or ability in a specific learning area(s)
within the range of achievement of individuals with comparable mental ability. Most
definitions emphasize a basic disorder in psychological processes involved in
understanding and using language, spoken, or written
✔✔SSDI - ✔✔Social Security Disability Income: Federal benefit program sponsored by
the Social Security Administration. Primary factor: disability and/or benefits received
from deceased or disabled parent. Benefit depends upon money contributed to the
Social Security program either by the individual involved and/or the parent involved.
✔✔Total Disability - ✔✔An illness or injury that prevents an insured person from
continuously performing every duty pertaining to his/her occupation or engaging in any
other type of work
✔✔Case Management - ✔✔A collaborative process, which assesses, plans,
implements,
coordinates, monitors and evaluates the options and services
required to meet an individual's health needs, using communication and available
resources to promote quality, cost-effective outcomes.
✔✔Key elements to Case Management (9)
(a p cs ds l a me er po) - ✔✔• Assessment • Planning
• Coordinate Services • Deliver Services
• Linkage • Advocate
• Monitoring & Evaluating • Efficient use of Resources
RATED A+
✔✔HHRG - ✔✔Home health resource group Medicare A case-mix classification in
which Pt characteristics and health status information are obtained from an OASIS
assessment in conjunction with projected therapy use during a 60-day episode are used
to determine Medicare reimbursement.
-Eighty HHRGs
-The Outcome & Assessment Information Set (OASIS) determines the HHRG and is
completed for each 60-period
-A predetermined base payment for each 60-day episode of care is adjusted according
to patient's HHRG
-No limit to number of 60-day episodes
-Payment is adjusted if patient's condition significantly changes
✔✔DRG - ✔✔Diagnosis-related group Managed care A unit of classifying Pts by
diagnosis, average length of hospital stay, and therapy received; the result is used to
determine how much money health care providers will be given to cover future
procedures and services, primarily for inpatient care.
-Primary diagnosis determines assignment to one of 535 DRGs
-The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major
procedures performed. DRG payment is per stay.
-Additional payment (outlier) made only if length of stay far exceeds the norm
✔✔RUG - ✔✔-Fifty-eight groups
-Each beneficiary assigned a per diem payment based on Minimum Data Set (MDS)
comprehensive assessment
-A specified minimum number of minutes per week is established for each rehabilitation
RUG based on MDS score and rehabilitation team estimates
✔✔SNF - ✔✔A facility that provides 24-hour medical care provided by registered
nurses, licensed vocational
nurses as well as nurses aides. Licensed Physical Therapists, Occupational Therapists,
and Speech
Therapists are also available. Typically for patients who require services that can only
be given by a
licensed provider such as IVABX, IV pain management, wound care, g-tube feeding or
physical
rehabilitation needed 1-3 hours a day on a daily basis. An M.D. will usually evaluate pt.
within the
first 72 hours and then monthly thereafter.
In order for Medicare to cover (and Medicare only) pt. must have a three-day qualifying
stay in the
acute setting (think midnights). As long as pt. has a skilled need and a qualifying stay
Medicare will
,cover the first 20 days at 100 percent, day 21-100 is $119.00 a day which the pt. or the
pt's secondary
insurance is responsible for.
Most SNFs also have a custodial side for pts. whose needs can no longer be met at
home or at a lower
level of care. Other than MediCal, Medicare and most private insurances, (with the
exception of long
term care insurance) will NOT cover custodial care in a SNF.
✔✔Subacute Care Unit - ✔✔For patients who no longer require the intensive
procedures of an acute care Hospital, but do require
the diagnostic or invasive procedures of an inpatient healthcare facility. Patients who
are transferred
to a sub acute facility may have a trach and require frequent suctioning. Individuals may
also need to
be weaned from a ventilator. Patients residing in this environment generally need
between four and
seven hours of skilled nursing/respiratory care each day.
Medicare does not recognize the sub acute level of care and will only reimburse on a
SNF level, so the
determination of acceptance is usually made on a case by case basis by the individual
facility.
MediCal does recognize the Sub acute level, however, the pt. must have a trach AND
another needs
i.e. feeding tube, wound care or TPN. Only a few sub cutes have dialysis available on
site.
✔✔LTAC - ✔✔Structured and programmed for medically complex and often
catastrophically ill patients. Patients are
admitted for acute care, with lengths of stay that average 25-30 days; typical of
medically complex
patients. The intensity of service will normally exceed the care needs that can be met by
a sub-acute or
skilled nursing facility.
An LTAC will generally be able to provide such services as vent weaning and
respiratory care,
complicated wound care, TPN; Surgeries such as Tracheotomies, wound debridment,
skin flaps,
PEG/GT placement, and Central line placement. An LTAC will also have an ICU as well
as telemetry
units. Pts. will be seen on a daily basis by an M.D. and will be treated by P.T., O.T., and
Speech.
The patient must have specific and realistic discharge goals from the LTAC. Mainly for
Medicare
recipients, MediCal does not recognize this level of care, and private insurance is on a
case-by-case
,basis.
✔✔Acute Rehab Unit - ✔✔Typically for neuro related diagnosis (but not always, this too
is decided on a case by case basis
dependant on insurance and accepting facility), the pt. must actively participate,
tolerate, and benefit from a MINIMUM of three hours of therapy daily (P.T., O.T., and
Speech Therapy). The pt. must
have a discharge goal of home or an assisted living facility, pt will NOT be accepted if
the goal is SNF.
✔✔Accessible - ✔✔A term used to denote building facilities that are barrier-free thus
enabling all members of society safe access, including persons with physical
disabilities.
✔✔Barrier - Free - ✔✔A physical, manmade environment or arrangement of structures
that is safe and accessible to persons with disabilities.
✔✔Activity Limitations - ✔✔Difficulties an individual may have in executing activities. An
activity limitation may range from a slight to a severe deviation in terms of quality or
quantity in executing the activity in a manner or to the extent that is expected of people
without the health condition.
✔✔Developmental Disability - ✔✔Any mental and/or physical disability that has an
onset before age 22 and may continue indefinitely. It can limit major life activities.
Individuals with mental retardation, cerebral palsy, autism, epilepsy (and other seizure
disorders), sensory impairments, congenital disabilities, traumatic brain injury or
conditions caused by disease (e.g. polio and muscular dystrophy) may be considered
developmentally disabled.
✔✔Disability - ✔✔A physical or neurological deviation in an individual makeup. It may
refer to a physical, mental or sensory condition. A disability may or may not be a
handicap to an individual, depending on one's adjustment to it.
✔✔Disability - ✔✔Diminished function, based on the anatomic, physiological or mental
impairment that has reduced the individual's activity or presumed ability to engage in
any substantial gainful activity.
✔✔Disability - ✔✔Inability or limitation in performing tasks, activities, and roles int he
manner or within the range considered normal for a person of the same age, gender,
culture and education. Can also refer to any restriction or lack (resulting from an
impairment) of ability to perform an activity in the manner or within the range considered
normal for a human being.
, ✔✔Disability Case Mangemtn - ✔✔A process of managing occupational and no-
occupational diseases with the aim of returning the disabled employee to a productive
work schedule and employment.
✔✔Disability Income Insurance - ✔✔A form of health insurance that provides periodic
payments to replace income when an insured person is unable to work as a result of
illness, injury or disease
✔✔Handicap - ✔✔The functional disadvantage and limitation of potentials based on a
physical or mental impairment or disability that substantially limits or prevents the
fulfillment of one or more major life actives, otherwise considered normal for that
individual based on age, sex and social/cultural factors, such as caring for one's self,
performing manual tasks, walking, seeing, hearing, speaking, breathing, learning,
working, etc. Handicap is a classification of role reduction resulting from circumstances
that place an impaired or disabled person at a disadvantage compared to other
persons.
✔✔Handicapped - ✔✔Refers to the disadvantage of an individual with a physical or
mental impairment resulting in a handicap.
✔✔Learning Disability - ✔✔A lack of achievement or ability in a specific learning area(s)
within the range of achievement of individuals with comparable mental ability. Most
definitions emphasize a basic disorder in psychological processes involved in
understanding and using language, spoken, or written
✔✔SSDI - ✔✔Social Security Disability Income: Federal benefit program sponsored by
the Social Security Administration. Primary factor: disability and/or benefits received
from deceased or disabled parent. Benefit depends upon money contributed to the
Social Security program either by the individual involved and/or the parent involved.
✔✔Total Disability - ✔✔An illness or injury that prevents an insured person from
continuously performing every duty pertaining to his/her occupation or engaging in any
other type of work
✔✔Case Management - ✔✔A collaborative process, which assesses, plans,
implements,
coordinates, monitors and evaluates the options and services
required to meet an individual's health needs, using communication and available
resources to promote quality, cost-effective outcomes.
✔✔Key elements to Case Management (9)
(a p cs ds l a me er po) - ✔✔• Assessment • Planning
• Coordinate Services • Deliver Services
• Linkage • Advocate
• Monitoring & Evaluating • Efficient use of Resources
