CCA Exam Reimbursement Methodologies - 109 Exam Study Questions with 100% Correct Answers

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CCA Exam Reimbursement Methodologies - 109 Exam Study Questions with 100% Correct Answers How does Medicare or other third party payers determine whether the patient has medical necessity for the t ... ests, procedures, or treatment billed on a claim form? - ✔✔by reviewing all the diagnosis codes assigned to explain the reasons the services were provided What is the name of the organization that develops the billing form that hospitals are required to use? - ✔✔National Uniform Billing Committee What healthcare organization collect UHDDS data? - ✔✔all non-outpatient settings including acute-care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehabilitation facilities; and nursing homes 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 What is the basic formula for calculating each MS-DRG hospital payment? - ✔✔Hospital payment = DRG relative weight x hospital base rate 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 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) What is the maximum number of procedure codes that can appear on a UB-04 institutional claim form via electronic transmission? - ✔✔25 Which fails to provide a requirement for assignment of the MS-DRG? - ✔✔Attending and consulting phyisican notes 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 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 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? - ✔✔Remittance advice 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 The purpose of a physician query is to: - ✔✔Improve documentation for patient care and proper reimbursement 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 What is a chargemaster? - ✔✔a financial management form that contains information about the organizations charges for the healthcare services it provides to patients A fee schedule is - ✔✔developed by third party payers and includes a list of healthcare services, procedures, and charges associated with each The provider or supplier is prohibited from holding the patient responsible for charges in excess of the Medicare fee schedule. This is called - ✔✔Balanced billing If a provider believes a service may be denied by Medicare because it could be considered unnecessary, the provider must notify the patient before the treatment begins by using a - ✔✔advance beneficiary notice Assignment of benefits is a contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services and to bill the beneficiary only for ________ and to accept the Medicare payment as payment in full. - ✔✔coinsurance or deductible A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain - ✔✔Budget neutrality Reimbursement for healthcare services is dependent on patients having a - ✔✔insurance benefit Health insurance for spouses, children, or both is known as - ✔✔dependent family coverage Which of the following software applications would be used to aid in the coding function in a physician's office? - ✔✔encoder Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system? - ✔✔Resource-based relative value scale system The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150 and 58700. What error has the coder made by using these codes? - ✔✔unbundling What is the best reference tool to determine how CPT codes should be assigned? - ✔✔CPTs assistant newsletter What is the best reference tool for ICD9-CM coding advice? - ✔✔AMA's coding clinic for ICD9-CM What did the Centers for Medicare and Medicaid services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims? - ✔✔National Correct Coding Initiative (NCCI) This is a statement sent by third party payers to the patient to explain services provided, amounts billed, and payments made by the health plan. - ✔✔EOB The electronic claim format 8371 replaced which paper billing forms? - ✔✔UB-04 Which of the following fails to meet the CMS classification of a hospital-acquired condition? - ✔✔stage 1 pressure ulcers Which of the following fails to meet the CMS classification of a hospital-acquired condition? - ✔✔gram negative pneumonia Which of the following hospitals are excluded from the Medicare acute-care prospective payment system? - ✔✔children's MS diagnostic related groups are organized into? - ✔✔major diagnostic categories What reimbursement system uses the Medicare fee schedule? - ✔✔RBRVS Which classification system is in place to reimburse home health agencies? - ✔✔HHRGs In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following? - ✔✔OPPS Which of the following is not reimbursed according to Medicare outpatient prospective payment system? - ✔✔critical access hospitals Fee schedules are updated by third party payer: - ✔✔annually A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? - ✔✔counsel the coder and stop the practice immediately Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for - ✔✔the infusion procedure Which of the following actions would be best to determine present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospitals Medicare reimbursement? - ✔✔identify all the records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment In a managed fee for service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? - ✔✔prospectively precertify the necessity of inpatient services Which of the following is not an essential data ele [Show More]

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