Heath Insurance Today Chapter 18
Clinics generally provide outpatient services only.
An ASC treats patients who already have seen a healthcare provider and patients who have not.
A subacute care facility provides a level of maintenance care at which there is no urgent or life threatening condition that requires medical treatment.
Licensed hospitals must provide care within the minimum health and safety standards established by state rules and regulations
Critical access hospitals are certified under a different set of Medicare conditions of participation (CoP) that are more flexible than those of acute care hospitals.
The HIPPA Privacy Rule is not intended to prohibit providers from talking to other providers and to their patients.
A NAS is necessary for all outpatient procedures.
Most third party payers require preauthorization for inpatient hospitalization and some outpatient procedures and diagnostic testing .
The hospital billing process begins when the patient is discharged from the facility.
An ICD-10 coding, some body system categories include codes for nonspecific conditions, which should be ignored.
CPT-4/HCPCS codes are used only in physicians offices and outpatient clinics.
APC is the grouping system that the CMS developed for facility reimbursement of hospital outpatient services.
Hospitals submitting claims electronically can use any format available.
The law requires electronic processing of all documents between the healthcare provider and the insurance carrier, without exception.
Like ICD-10-CM codes, ICD-10-PCS codes contain seven characters, which can be numbers, or letters and are based on the type of procedure performed, the approach, the body part and other characteristics.
Today’s hospitals mainly offer:
private and semiprivate rooms
A popular designation given to today’s healthcare patient is:
A medical facility smaller than a hospital is typically referred to as a(n):
A facility designed for patients who have had acute events as a result of an illness, injury, or exacerbation of a disease process is a(n):
Subacute care 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 is a(n):
Skilled nursing facility
The type of care facility for adults who are chronically ill or disabled and are no longer able to manage in independent living situation is referred to as:
The voluntary process through which an organization is able to measure the quality of its services and performance against nationally recognized standards is called:
The acronym for the organization formed in 1979 to assist ambulatory healthcare organizations improve the quality of care provided to patients is the :
How any organization is run, in its simplest definition, is referred to as:
Medicare hospital claims are processed by contracted nongovernment organizations or agencies that are commonly referred to as:
All of these options: fiscal intermediaries, Medicare carriers and Medicare administrative contractors
Medicare’s acute care payment system is called:
Prospective payment system
Many Medicaid programs adjust payments to reflect such things as patient demographics, diagnostic and treatment information, and total charges, which is referred to as:
A case mix
Most third party payers reimbursement rates are subject to change:
The designated spaces on the UB-04 are called:
The process by which a patient can participate in choices about his or her healthcare is commonly referred to as:
The manual currently used for inpatient diagnostic coding is the:
ICD-10-CM volume 3
Coders must distinguish key elements or words in the patients hospital health record that identify the:
The overall data stream of the electronic UB-04 file is known as a(n):
That condition established after study to be chiefly responsible for the occasioning the admission of the patient to the hospital for defines the:
OOPS (or HOPPS) allows for temporary payment of new technologies, drugs, devices, and biologics for this no ambulatory payment classification (APC) payment rate is available, which is called:
Identify the program implemented by CMS in 1996 to control improper coding that leads to inappropriate increased payment for healthcare services:
National correct coding initiative
Identify the congressional act that stipulated that hospitals cannot charge uninsured patient more for the same treatment that what those with health insurance are billed:
The affordable care act
According to the textbook, the implementation date for the ICD-10 coding system is:
October 1, 2015
Regardless of the coding system used, diagnosis codes must be supported by:
Identify the number of significant procedures other than the principal procedure that may be reported on the UB-04 claim form:
A condition that coexists at the time of admission and/or develops and requires one or more of the following : clinical evaluation, Therapeutic treatment, diagnostic procedures, etc. is known as primary diagnosis.
All hospitals must seek accreditation by nationally recognized accrediting agency.
The process that a fully informed patient can participate in choices about his/her healthcare is a general consent.
The NCQA is an independent , nonprofit organization that provides quality accreditation reviews on Health Managed Care Organizations and similar types of managed care programs.
Inpatient TRICARE payments are calculated using the same PPS as medicare.
The outpatient prospective payment system is the Medicare prospective payment system used for hospital based outpatient services and procedures.
The 72-hour rule states that all diagnostic services provided for medicare patients within 72 hours of hospital admission must be billed separately from inpatient charges.
A code of conduct for the healthcare professional, demonstrating basic principles that usually include showing respect for patient autonomy, not inflicting harm on patients, contributing to the welfare of patients, etc. is medical ethics.
The duration of time which a Medicare beneficiary is eligible for Part A benefits for services incurred in a hospital, SNF, or both is a benefit period.
Each character in the structure of the ICD-10 PSC code must be alphabetical.
Voluntary process though which an organization is able to measure the quality of services and performance against nationally recognized standards: The process by which a private or public agency evaluates and recognized an institution as fulfilling applicable standards is the Accreditation Association for Ambulatory Health Care.
Computerized data bank that lists all active and retired military service members and is checked before processing claims for patient eligibility to TRICARE benefits is DEARS:
An ambulatory surgery center is a medical facility that is smaller than a hospital and is often run by a government agency or private partnership of physician, generally providing outpatient services.
Hospitals that provide all levels of care are referred to as:
Vertically integrated hospitals
An individual that has legal authority to speak on patients behalf is called a:
The listing of every type of procedure and service the hospital can provide to patients, including procedures, pharmaceuticals, supplies, and room charges is:
Charge Description Master
When a patients medical state becomes unstable it is referred to as:
A hospital that is set up to handle the care of many kinds of diseases and injuries and is typically a major healthcare facility in the region, providing care for immediate threats and emergency medical services is:
Defined by the joint commission as "any individual permitted by the law and by the organization to provide care and services without direction or supervision within the scope of the individuals license and consistent with individually granted clinical privilege" is:
Licensed independent Practitioner.
The program that consists of quality expert physicians, consumer, hospitals and other caregivers to refine care delivery system to ensure patients get the right care at the right time.
Quality Improvement Organizations
In what type of a facility may a patient receive long-term care:
Individuals own home, Adult Day Care Centers, Assisted living facilities, hospice facilities.