Health Insurance Today

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Hospital Billing and the UB-04 Study Guide for end of Mod 10-11-10

Construction of today's modern hospital is regulated by

Federal, State laws, State Health dept. policies, and City ordinances

Today's hospitals typically offer

Private and semiprivate rooms

Hospitals that provide all levels of care are referred to as

Vertically integrated hospitals

A popular designation given to today's health-care patients is

Customers

General Hospital

A single building or campus, typically having a large number of beds, specialized facilities for various medical care types, and an emergency department

A medical facility smaller than a hospital is typically referred to as a

Clinic

Acute Care Facility

a health-care facility that is equipped and staffed to respond immediately to critical situations and provide continuous care to patients with "Worst -Case" scenarios

Sub-acute Care Facility

A facility designed four patients who have had acute events as a result of an illness, injury or exacerbation of a disease process

Sub-acute Care Facility

The type of facility in which patients have the advantage of constant access to nursing care as they move toward recovery and return to their home

SNF (Skilled Nursing Facility)

A facility that is licensed or approved under state or local law that is primarily engaged in providing experienced nursing care and related services

Respite Care

Temporary relief for an individual providing health-care to a family member

Long-Term Care

The type of care provided for adults who are chronically ill or disabled and are no longer able to manage in independent living situations

EMTLA

The acronym for the federal act that ensures public access to emergency services regardless of ability to pay

The voluntary process through which an organization is able to measure the quality of its services and performance against nationally recognized standards is called

ACCREDITATION

The independent, nonprofit organization that performs quality-oriented accreditation reviews on HMO's and similar types of managed care plans is

NCQA

AAAHC

The acronym for the organization (formed in 1979) to assist ambulatory health-care organization improve the quality of care provided to patients

URAC

The independent, nonprofit organization that promotes continuous improvement in the quality and efficiency of health-care delivery through the establishment of standards, education, and communication

How any organization is run is, in its simplest definition, referred to as

Governance

Moral principles that govern the practice of medicine by physicians and other health-care practitioners are commonly referred to as medical

Ethics

Fiscal Intermediaries or Carriers

Medicare hospital claims are processed by contracted non-government organizations or agencies that commonly are referred to

Medicare Part A pays towards

Hospital Charges

Medicare's acute care payment system is called

Prospective payment system (PPS)

An inpatient hospital coding system that groups related diagnoses and their associated medical/surgical treatment is referred to as

DRGS

A Case Mix

Many MEDICAID programs adjust payments to reflect such things as patient demographics, diagnostic and treatment information, and total charges

If a military treatment facility is unavailable, TRICARE patients, in many cases, must obtain a

NON-AVAILABILITY STATEMENT (NAS)

Most third-party payers typically change their reimbursement rates

Annually

Most U.S. hospitals contract with Blue Cross and Blue Shield and are referred to as

Member Hospitals

The designated spaces on the UB-04 are called

Form locators

The revised universal claim form for current use in inpatient hospital claims is the

UB-92

The process by which a patient can participate in choices about his or her health-care is commonly referred to as

Informed consent

An individual who has the legal authority to speak on a patient's behalf is called a

SURROGATE

The manual(s) used for inpatient diagnostic coding is (are) the

ICD-9-CM, Volume 3

The manual(s) used for inpatient procedural coding is (are) the

ICD-9-CM, VOLUME 3

Coders must distinguish key elements or words in the patients hospital health record that identify the

Principal diagnosis

The "sections" in ICD-9-CM Volume 3 are organized by

Anatomy sites

A table or search engine that maps the relationships and equivalencies between two or more data formats is called

Rubric

What type of codes is found in the INDEX to EXTERNAL Causes

E- Codes

The hospital claim form may report how many significant procedures other than the principal procedure

5

Hospital outpatient prospective payment system (HOPPS)

The payment system implemented in 2000 and used by the Centers for Medicare and Medicaid Services (CMS) to reimburse for hospital outpatient services

HOPPS (or OPPS) allows for temporary payment of new tech, drugs, devices and biological for which no ambulatory payment classification (APC) payment rate is available, CALLED

PASS-THROUGHS

IT IS TRUE THAT

CLINICS GENERALLY PROVIDE OUTPATIENT SERVICES ONLY

IT IS TRUE THAT

Ambulatory surgery centers (ASCs) are facilities where surgeries are performed that do not require hospital admission

IT IS TRUE THAT

Licensed hospitals must provide care within the minimum health and safety standards established by state rules and regulations

IT IS TRUE THAT

Hospitals accredited by The Joint Commission are considered to be in compliance with most of Medicare's "Conditions of Participation for Hospitals"

IT IS TRUE THAT

Each state's Medicaid program determines the method it uses
to pay for hospital inpatient services.

IT IS TRUE THAT

An NAS is no longer necessary for most outpatient procedures

IT IS TRUE THAT

Pre-authorization is necessary for inpatient hospitalization and some outpatient procedures and diagnostic testing

IT IS TRUE THAT

The principal diagnosis is defined as the condition determined as the condition determined after study to be chiefly responsible for the patient's admission to the hospital

IT IS TRUE THAT

V codes indicate the reason for the encounter

IT IS TRUE THAT

An E code can never be a principal (first-listed) code

IT IS TRUE THAT

Hospitals submitting claims electronically must do so in a format that is HIPAA- compliant.

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