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Exam 9: Cms Reimbursement Methodologies

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Question 21

Multiple Choice

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The nonparticipating provider __________ charge is calculated by multiplying the reduced Medicare physician fee schedule by 115 percent.

A) allowable
B) limiting
C) prospective
D) retrospective

E) A) and C)
F) All of the above

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Question 22

Multiple Choice

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Medicare physician fee schedule payment limits were established by adjusting relative value units (RVUs) for each locality using geographic adjustment factors, and an annual dollar multiplier called a __________ changes RVUs into payments using a formula.

A) case mix
B) conversion factor
C) fee schedule
D) grouper

E) C) and D)
F) B) and D)

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Question 23

Multiple Choice

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Which is the relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease?

Which is a document that contains a computer-generated list of hospital-based outpatient procedures, services, and supplies with charges for each?

Medical conditions or complications that patients develop during inpatient hospital stays and that were not present at admission are called __________.​

Data analytics are tools and systems that are used to __________ clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

Which is an assessment process conducted as a follow-up to revenue cycle monitoring so that areas of poor performance can be identified and corrected?

​A hospital has 100 inpatient cases that are assigned to DRG 54, which has a relative weight of 1.540. What is the total relative weight for the cases?

When outpatient preadmission services are provided by a hospital on the day of or during the three days prior to a patient's inpatient admission and the inpatient principal diagnosis code exactly matches that for preadmission services, the IPPS __________ rule applies.

Nonparticipating provider limiting charge information appears on the Medicare __________, which notifies Medicare beneficiaries of actions taken on claims.

Which is established in advance and based on reported health care charges from which a predetermined per diem rate is determined?

Services provided by nonphysician practitioners may also be reported to Medicare as __________ to the supervising physician's service, and as a result, services are reimbursed at 100 percent of the Medicare physician fee schedule and Medicare pays 80 percent of that amount directly to the physician.

Medicare is a secondary payer when a large group health plan (LGHP) is provided by an employer who has __________ or more employees.

Which was adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs?

The outpatient prospective payment system reimburses services according to ambulatory payment classifications (APCs) , which group services according to similar __________ and in terms of resources required.

Which rule applies when patients are discharged from the hospital directly to a postacute provider?

The end-stage renal disease (ESRD) composite payment rate system is __________ adjusted to provide a mechanism to account for differences in patients' utilization of health care resources.

Which is the likelihood of dying?

The CMS Quarterly Provider Update (QPU) is an online CMS publication that contains information about __________ currently under development or completed/canceled and new/revised manual instructions.

Providers that use the Diagnostic and Statistical Manual refer to diagnostic assessment criteria that are used as tools to identify __________ disorders.