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Relative value units, from the Resource-Based Relative Value Scale (RBRVS), establish their standards based upon what 3 components?

Physician work, practice expense, and malpractice insurance expense

What is the more common name for the resource-based relative value scale (RBRVS)?

Medicare Physician Fee Schedule (MPFS)

Define these abbreviations:
a. ABN:
d. MSP:
c. TOS:
b. POS:
Which one of these abbreviations is used on the CMS-1 500 to indicate where services were provided?

MSP: Medicare Secondary Payer
POS: place of service
TOS: type of service
ABN: Advanced Beneficiary Notice

POS

What do these terms mean:
d. Claims:
b. Capitation:
c. Chargemaster:
a. Case mix:
Which one of these determines the anticipated care needs of patients?

Case mix: the type or mix of patients treated by a hospital or unit
Capitation: provider accepts pre-established payments for providing healthcare svcs over a period of time
Chargemaster: term hospitals use to describe a patient encounter form
Claims: an itemized statement of services and costs from a healthcare provider submitted to insurance for payment
C - chargemaster

On the UB-04 form, the type of bill that is entered in FL4 has how many digits?

4

Which PPS provides a predetermined payment that depends on the patient's diagnosis, comorbidities, and principal and secondary procedures?

MPFS - Medicare physician fee schedule

Define these words:
d. Day sheet:
b. Chargemaster:
c. Ledger card:
a. Encounter form:

Encounter form: a list of procedures and charges for a patients visit
Day sheet: summary of transactions posted to patients acct. for a specific day
Ledger card
: a record that shows all financial transactions between the patient and the practice
Chargemaster: term hospitals use to describe a patient encounter form

How long is the episode of care in the home health prospective payment system (HHPPS)?

60 days

Inpatient prospective payment system was implemented in what year?

1983

Know how these reimbursement systems establish rates:
a. Retrospective reasonable cost system:
d. Fee-for-service based rates:
c. Prospective cost-based rates:
b. Prospective price-based rates:

Retrospective reasonable cost system: 80% of actual charges
Prospective price-based rates: by the payer
Prospective cost-based rates: reported healthcare costs
Fee-for-service based rates:

What type of hospital is excluded from the inpatient prospective payment system?

Cancer hospitals

Medicare Part B radiology services payments vary according to:

place of service

Why does Medicare establish a limiting charge for nonPARS?

Is to offer financial protection for Medicare enrollees

Is a physician assistant or a nurse practitioner a physician?

No

Medicare is primary to

secondary payers

What is another name for a secondary diagnosis?

Concurrent condition

Local coverage determinations (LCD5) contain

diagnosis and procedure services.

The acronym SOAP stands for what?

Subjective, objective, assessment, plan

What type of information is found in each section of the SOAP?

S- Symptom information
0- observations about patient
A- Judgment, opinion from HC provider
P- Plan to resolve problem

If a procedure is medically unnecessary, what form must a Medicare patient sign?

ABN

Nonparticipating providers are restricted to billing at or below the

limiting charge

Define these terms:
a. Write off:
b. Fee adjustment:
c. Limiting charge:
d. Neutral charge:
Which one is the difference between the fee reported and the payment received for Medicare participating providers?

Write off: is the difference between total charge and the allowable amount by the insurance
Limiting charge: maximum fee a physician may charge
Fee adjustment: to adjust what a patient was charged
Neutral charge:

Limiting charge

Is it acceptable to delay a documentation entry in the patient record to provide additional information for clarification?

No

What is the coinsurance amount Medicare patients pay for code 99213 listed on Medicare physician fee schedule for $100?

...

What would be the nonPAR allowed charge be for the CPT code 99213 listed on the fee schedule for $100?

...

Anesthesia services payments are based on the American Society of Anesthesiologists' relative value system and the

actual time an anesthesiologist spends with a patient

When other insurers are initially liable for payment on medical services or supplies provided to a patient, Medicare classifies them as the

secondary payer

Since Medicare reimburses 80% of the allowable amount, how much would they reimburse for the CPT code listed on the Medicare physician fee schedule: code 99213 for $100. The participating physician's usual charge is $125. How much will Medicare reimburse?

$80

What does the concept of medical necessity mean?

Proper linking of ICD-9-CM codes with CPT codes on a claim

The first-listed diagnosis reported on the CMS-1 500 form is the:

major reason the patient was treated

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