Chapter 5

A specified group of invoices or statements processed at one time is called a:
Methods used by government programs to provide reimbursement to hospitals for outpatient and inpatient services include
Reimbursement methods commonly used by commercial payers for inpatient services include:
Fee schedule, UCR, case rate, per diem, and contract rate.
Coding systems were developed to standardize descriptions of conditions, services, and items for t consistent reporting and tracking procedures and conditions
Reimbursement methods commonly utilized by managed care plans for outpatient and inpatient hospital services include
Contract rate and capitation.
Diagnosis codes provide an explanation of the patient's condition or other reason for services, which is essential to establishing medical necessity. This statement describes the relationship between:
Diagnosis codes and medical necessity.
What is the payment system implemented in 1983 that bases reimbursement for hospital inpatient services on predetermined amounts?
Inpatient Prospective Payment System (IPPS)
The admission process includes patient registration, patient care/order entry, charge capture, and charge submission.
What computerized system is designed to capture charges for all services and items provided for the purpose of posting charges to the patient's account and billing those charges on the claim form?
The detailed itemized statement is an outline of all services and items posted to the patient's account during the patient stay
HIM coding professionals review the patient medical record for the purpose of identifying and verifying charges, abstract and code the patient's diagnosis and significant procedures, and assign DRG or APC groups.
The Charge Description Master (CDM) does not include procedure codes.
Four sections of information reported on the CMS-1500 are Section I: facility, patient, admission, discharge, occurrence, and value; Section II: charge; Section III: payer, insured, employer, and authorization; and Section IV: procedure, diagnosis, and provider information.
The purpose of the hospital billing process is to obtain appropriate reimbursement for services rendered.
What is the claim form used to submit charges for outpatient professional services provided by a hospital-employed provider?
Accurate completion of the claim helps to ensure accurate reimbursement
OPPS is a Prospective Payment System (PPS) implemented in 2000 to provide reimbursement for hospital
Outpatient services.
The chargemaster is usually automated and linked with the billing system. Items in the chargemaster are generally organized by department. Each item in the chargemaster is associated with the appropriate procedure code, revenue code, service or item description, charge, and other information required for submission of hospital facility charges
Which phase starts the billing process and is critical to obtaining information required to submit claims to payers and bill patients?
Admission-Patient registration