Question 1

Clinical pathways are based on all of the following EXCEPT:

Accepted Answer

A)  Experience 
B)  Reimbursement method 
C)  Research 
D)  Successful outcomes 
A)  Experience 
B)  Reimbursement method 
C)  Research 
D)  Successful outcomes

Question 2

The process of determining the most accurate DRG payment is ___________.

Accepted Answer

The answer of The process of determining the most accurate...

Question 3

A managed care organization that contracts with a network of health care providers to render services to its members is a ___________.

Accepted Answer

preferred

Question 4

What is meant by "resource intensity"?

Accepted Answer

The demands and costs of treat

Question 5

The amendment to the Social Security Act that established Medicaid is _________.

Accepted Answer

The answer of The amendment to the Social Security Act...

Question 6

To standardize and facilitate accurate billing, health care facilities maintain a database of all potential services to a patient called a _________.

Accepted Answer

The answer of To standardize and facilitate accurate billing, health...

Question 7

After assignment of the MDC, what occurs next in the grouping process?

Accepted Answer

The grouper "examine

Question 8

A specified dollar amount for which the patient is personally responsible, before the payer reimburses for any claims, is called the __________.

Accepted Answer

The answer of A specified dollar amount for which the...

Question 9

The patient was admitted to the hospital in congestive heart failure with the approval of the patient's insurer. After 3 days, utilization review, in conjunction with the patient's insurer, informed the physician that there was insufficient documentation in the patient's record to justify further hospitalization and that no additional charges would be reimbursed. Utilization review's action in this case is called:

Accepted Answer

A)  Discharge planning 
B)  Admission denial 
C)  Continued stay denial 
D)  Managed care 
A)  Discharge planning 
B)  Admission denial 
C)  Continued stay denial 
D)  Managed care

Question 10

Describe how a case is assigned to a Major Diagnostic Category.

Accepted Answer

In most in

Question 11

Why would a coder or coding manager automatically review and/or revise patients assigned to DRG 469 and/or DRG 470?

Accepted Answer

A)  The hospital might not be entitled to the reimbursement for these DRGs. 
B)  The federal government reviews these DRGs for fraud and abuse. 
C)  There is something incorrect with the codes assigned and/or data when a patient is grouped into either of these DRGs. 
D)  Both a and b are true. 
A)  The hospital might not be entitled to the reimbursement for these DRGs. 
B)  The federal government reviews these DRGs for fraud and abuse. 
C)  There is something incorrect with the codes assigned and/or data when a patient is grouped into either of these DRGs. 
D)  Both a and b are true.

Question 12

A hospital's case mix index is derived by:

Accepted Answer

A)  Organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth 
B)  Adding all DRG relative weights together and then dividing by the total number of cases discharged in a given time period 
C)  Neither a nor b; case mix index is assigned by the federal government using special software 
D)  Both a and b 
A)  Organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth 
B)  Adding all DRG relative weights together and then dividing by the total number of cases discharged in a given time period 
C)  Neither a nor b; case mix index is assigned by the federal government using special software 
D)  Both a and b

Question 13

Match between columns
                        Premises: A federally funded health care insurance plan for the elderly and for certain categories of chronically ill patients
A managed care organization that contracts with a network of health care providers to render services to the PPO's members
A federally mandated, state-funded program providing access to health care for the poor and the medically indigent
A managed care organization characterized by the ownership or employer control over the health care providers
A uniform reimbursement to a health care provider based on the number of patients contractually in the physician's care, regardless of diagnoses or services rendered
A collection of health care descriptions organized into statistically similar categories

Accepted Answer

The Answer of PPO and Medicaid and HMO and MS-DRG is...

Question 14

A savings account in which health care and certain child care costs can be set aside and paid using pretax funds is a __________.

Accepted Answer

flexible b

Question 15

Title XVIII is the amendment to the Social Security Act that established:

Accepted Answer

A)  Medicare 
B)  Medicaid 
C)  Capitation 
D)  The prospective payment system 
A)  Medicare 
B)  Medicaid 
C)  Capitation 
D)  The prospective payment system

Question 16

It is the coder's responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must:

Accepted Answer

A)  Follow all software prompts that will add a "cc" code. The software program is written so that the coder does not have to review the medical record. 
B)  Use coding software to sequence the best principal diagnosis for the highest reimbursement. 
C)  Code and sequence according to the documentation in the medical record, using the software only to assist this process. 
D)  do both a and b. 
A)  Follow all software prompts that will add a "cc" code. The software program is written so that the coder does not have to review the medical record. 
B)  Use coding software to sequence the best principal diagnosis for the highest reimbursement. 
C)  Code and sequence according to the documentation in the medical record, using the software only to assist this process. 
D)  do both a and b.

Question 17

The basis for payment for skilled nursing facility (SNF) services for Medicare patients is:

Accepted Answer

A)  RUGs 
B)  RBRVS 
C)  MDS 
D)  UHDDS 
A)  RUGs 
B)  RBRVS 
C)  MDS 
D)  UHDDS

Question 18

Which of the following is NOT a way in which managed care organizations may influence and/or control the patient's choices in selecting health care services:

Accepted Answer

A)  The patient's PCP must be a participating provider. 
B)  Only approved services may be reimbursed. 
C)  The managed care organization decides what services are "medically necessary." 
D)  The managed care organization only pays for services provided by the PCP. 
A)  The patient's PCP must be a participating provider. 
B)  Only approved services may be reimbursed. 
C)  The managed care organization decides what services are "medically necessary." 
D)  The managed care organization only pays for services provided by the PCP.

Question 19

The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is:

Accepted Answer

A)  Health information management 
B)  Utilization review 
C)  Patient registration 
D)  Patient accounting 
A)  Health information management 
B)  Utilization review 
C)  Patient registration 
D)  Patient accounting

Question 20

A patient was admitted to an acute care facility for congestive heart failure. The patient stayed in the facility for 3 days. The actual charges incurred were $6,500. The PPS rate is $5,500. The per diem rate is $1,500 per day. For this case, Medicare will most likely pay:

Accepted Answer

A)  $4,500 
B)  $5,500 
C)  $6,500 
D)  None of the above 
A)  $4,500 
B)  $5,500 
C)  $6,500 
D)  None of the above

Clinical pathways are based on all of the following EXCEPT:

The process of determining the most accurate DRG payment is ___________.

A managed care organization that contracts with a network of health care providers to render services to its members is a ___________.

What is meant by "resource intensity"?

The amendment to the Social Security Act that established Medicaid is _________.

To standardize and facilitate accurate billing, health care facilities maintain a database of all potential services to a patient called a _________.

After assignment of the MDC, what occurs next in the grouping process?

A specified dollar amount for which the patient is personally responsible, before the payer reimburses for any claims, is called the __________.

Describe how a case is assigned to a Major Diagnostic Category.

Why would a coder or coding manager automatically review and/or revise patients assigned to DRG 469 and/or DRG 470?

A hospital's case mix index is derived by:

A savings account in which health care and certain child care costs can be set aside and paid using pretax funds is a __________.

Title XVIII is the amendment to the Social Security Act that established:

It is the coder's responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must:

The basis for payment for skilled nursing facility (SNF) services for Medicare patients is:

Which of the following is NOT a way in which managed care organizations may influence and/or control the patient's choices in selecting health care services:

The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is:

A patient was admitted to an acute care facility for congestive heart failure. The patient stayed in the facility for 3 days. The actual charges incurred were $6,500. The PPS rate is $5,500. The per diem rate is $1,500 per day. For this case, Medicare will most likely pay:

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Acute Care Records

Health Information Management Processing

Code Sets

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters

Exam 7: Reimbursement

Clinical pathways are based on all of the following EXCEPT:

The process of determining the most accurate DRG payment is ___________.

A managed care organization that contracts with a network of health care providers to render services to its members is a ___________.

What is meant by "resource intensity"?

The amendment to the Social Security Act that established Medicaid is _________.

To standardize and facilitate accurate billing, health care facilities maintain a database of all potential services to a patient called a _________.

After assignment of the MDC, what occurs next in the grouping process?

A specified dollar amount for which the patient is personally responsible, before the payer reimburses for any claims, is called the __________.

Describe how a case is assigned to a Major Diagnostic Category.

Why would a coder or coding manager automatically review and/or revise patients assigned to DRG 469 and/or DRG 470?

A hospital's case mix index is derived by:

A savings account in which health care and certain child care costs can be set aside and paid using pretax funds is a __________.

Title XVIII is the amendment to the Social Security Act that established:

It is the coder's responsibility to assign codes completely and accurately so that a facility receives the reimbursement to which it is entitled. To meet this responsibility, a coder must:

The basis for payment for skilled nursing facility (SNF) services for Medicare patients is:

Which of the following is NOT a way in which managed care organizations may influence and/or control the patient's choices in selecting health care services:

The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is:

A patient was admitted to an acute care facility for congestive heart failure. The patient stayed in the facility for 3 days. The actual charges incurred were $6,500. The PPS rate is $5,500. The per diem rate is $1,500 per day. For this case, Medicare will most likely pay:

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Acute Care Records

Health Information Management Processing

Code Sets

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters