Question 1

RAC stands for __________.

Accepted Answer

Recovery A

Question 2

A preexisting condition that is present on admission and may lead to increased resource use is a ____.

Accepted Answer

A) comorbidity 
B) complication 
C) provisional diagnosis 
D) morbidity 
A) comorbidity 
B) complication 
C) provisional diagnosis 
D) morbidity

Question 3

A listing of the services,procedures,drugs,and supplies that can be applied to a patient's hospital bill is called a ____.

Accepted Answer

A) chargemaster 
B) charge description number 
C) department number 
D) revenue code 
A) chargemaster 
B) charge description number 
C) department number 
D) revenue code

Question 4

A(n) ____________________ is a preexisting condition (present on admission) of hospitalization.

Accepted Answer

The answer of A(n) ____________________ is a preexisting condition (present...

Question 5

Quality improvement organizations are NEVER required to conduct individual case reviews;it is ALWAYS a combined case review.

Accepted Answer

A) True 
 B)False

Question 6

The Quality Improvement Organizations function under ___-year contracts called SOW.

Accepted Answer

A) 1 
B) 3 
C) 6 
D) 9 
A) 1 
B) 3 
C) 6 
D) 9

Question 7

A four-digit code that is used on the UB-04 to indicate a particular type of service is called a ____.

Accepted Answer

A) chargemaster 
B) charge description number 
C) department number 
D) revenue code 
A) chargemaster 
B) charge description number 
C) department number 
D) revenue code

Question 8

What is Uniform Bill-04 (UB-04)?

Accepted Answer

The claim form used

Question 9

The old payment method or ____ was based on charges or a percentage of charges that did not promote best practices and quality care because the hospital was paid based on charges;the higher the charges were,the higher was the payment.

Accepted Answer

A) retrospective payment system 
B) prospective payment system 
C) preferred provider organization 
D) Tax Equity and Fiscal Responsibility Act 
A) retrospective payment system 
B) prospective payment system 
C) preferred provider organization 
D) Tax Equity and Fiscal Responsibility Act

Question 10

One of the goals of a clinical documentation improvement program is to improve a facility's case mix.

Accepted Answer

A) True 
 B)False

Question 11

The ____________________ Act was responsible for the establishment of the Medicare program.

Accepted Answer

The answer of The ____________________ Act was responsible for the...

Question 12

____ is the process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled based on the documentation in the health record.

Accepted Answer

A) Comorbidity 
B) Complication 
C) Maximization 
D) Optimization 
A) Comorbidity 
B) Complication 
C) Maximization 
D) Optimization

Question 13

Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service are known as ____.

Accepted Answer

A) good documentation 
B) charge description master 
C) medical necessity 
D) department number 
A) good documentation 
B) charge description master 
C) medical necessity 
D) department number

Question 14

Medicare is responsible for more than ___% of patients.

Accepted Answer

The answer of Medicare is responsible for more than ___%...

Question 15

Specialized software (called "groupers") is used to assign the appropriate MS-DRG.Groupers are often part of encoder or coding software that is used to assign the diagnosis and procedure codes.

Accepted Answer

A) Both statements are true 
B) Both statements are false 
C) The first statement is true;the second statement is false 
D) The first statement is false;the second statement is true 
A) Both statements are true 
B) Both statements are false 
C) The first statement is true;the second statement is false 
D) The first statement is false;the second statement is true

Question 16

A patient with COPD is admitted to the hospital.Two days after admission,the COPD becomes exacerbated.The exacerbation of COPD should be designated as present on admission.

Accepted Answer

A) True 
 B)False

Question 17

When errors in coding occur,the hospital may resubmit the billing data with revised codes on the claim or UB-04.

Accepted Answer

A) True 
 B)False

Question 18

Match the following terms to the correct definitions.
-This refers to a preexisting condition (i.e.,it is present on admission)

Accepted Answer

A) Complication 
B) Comorbidity 
C) Quality Improvement Organization (QIO) 
D) PEPPER-Program for Evaluating Payment Patterns Electronic Report 
E) Postacute Transfer Policy 
A) Complication 
B) Comorbidity 
C) Quality Improvement Organization (QIO) 
D) PEPPER-Program for Evaluating Payment Patterns Electronic Report 
E) Postacute Transfer Policy

Question 19

Which of the following is a factor in determining how sick the patient is and is an interrelated part of case-mix?

Accepted Answer

A) Severity of illness 
B) Prognosis 
C) Need for intervention 
D) All of the above 
E) None of the above 
A) Severity of illness 
B) Prognosis 
C) Need for intervention 
D) All of the above 
E) None of the above

Question 20

Medicare has medical necessity guidelines that outline the criteria for what services are to be determined to be reasonable and necessary.

Accepted Answer

A) True 
 B)False

Exam 26: Reimbursement Methodologies

RAC stands for __________.

A preexisting condition that is present on admission and may lead to increased resource use is a ____.

A listing of the services,procedures,drugs,and supplies that can be applied to a patient's hospital bill is called a ____.

A(n) ____________________ is a preexisting condition (present on admission) of hospitalization.

Quality improvement organizations are NEVER required to conduct individual case reviews;it is ALWAYS a combined case review.

The Quality Improvement Organizations function under ___-year contracts called SOW.

A four-digit code that is used on the UB-04 to indicate a particular type of service is called a ____.

What is Uniform Bill-04 (UB-04)?

The old payment method or ____ was based on charges or a percentage of charges that did not promote best practices and quality care because the hospital was paid based on charges;the higher the charges were,the higher was the payment.

One of the goals of a clinical documentation improvement program is to improve a facility's case mix.

The ____________________ Act was responsible for the establishment of the Medicare program.

____ is the process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled based on the documentation in the health record.

Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service are known as ____.

Medicare is responsible for more than ___% of patients.

Specialized software (called "groupers") is used to assign the appropriate MS-DRG.Groupers are often part of encoder or coding software that is used to assign the diagnosis and procedure codes.

A patient with COPD is admitted to the hospital.Two days after admission,the COPD becomes exacerbated.The exacerbation of COPD should be designated as present on admission.

When errors in coding occur,the hospital may resubmit the billing data with revised codes on the claim or UB-04.

Match the following terms to the correct definitions. -This refers to a preexisting condition (i.e.,it is present on admission)

Which of the following is a factor in determining how sick the patient is and is an interrelated part of case-mix?

Medicare has medical necessity guidelines that outline the criteria for what services are to be determined to be reasonable and necessary.

The Rationale for and History of Coding

The Health Record As the Foundation of Coding

ICD-10-Cm Format and Conventions

Basic Steps of Coding

General Coding Guidelines for Diagnosis

General Coding Guidelines for Medical and Surgical Procedures

General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Certain Infectious and Parasitic Diseases

Neoplasms

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Endocrine, Nutritional, and Metabolic Diseases

Mental, Behavioral, and Neuro developmental Disorders

Diseases of the Nervous System,Diseases of the Eye and Adnexa,and Diseases of the Ear and Mastoid Process

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous Tissue

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

Certain Conditions Originating in the Perinatal Period and Congenital Malformations, deformations, and Chromosomal Abnormalities

Injuries and Certain Other Consequences of External Cases and External Causes of Morbidity

Burns, adverse Effects, and Poisonings

Complications of Surgical and Medical Care

Out patient Coding

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