In what situation(s) should a provider NOT use a modifier? - CPT already indicates 2-4 lesions - CPT indicates multiple extremities
3 multiple choice opt
... Show More
ions
What are other names for Three-Day Payment Window? ALL OF THE ABOVE
72-hour rule, DRG window, Three-Day Window, 1 day window or 24-hour rule
3 multiple choice options
What happens during the post-service stage? Final coding, preparation and submission of claims, payment processing, balance
billing and resolution.
3 multiple choice options
What are the below tasks part of? - Educate patients - Coordinate to avoid duplicate patient contacts - Be consistent in key aspects of account resolution - Follow best practices for communication
Best practices created by the Medical Debt Task Force
3 multiple choice options
Which option is NOT a main HFMA Healthcare Dollars &
Sense® revenue cycle initiative?
Process Compliance
3 multiple choice options
Which option is NOT a continuum of care provider?
A. Physician
B. Health Plan Contracting
C. Hospice
D. Skilled Nursing Facility
B. Health Plan Contracting
3 multiple choice options
What is "implied certification"? When it is implied that a provider met all compliance standards before submitting a
claim
3 multiple choice options
Which of the following are essential elements of an A. Established compliance standards and procedures.
effective compliance program?
C. Oversight of personnel by high-level personnel.
A. Established compliance standards and procedures.
B. Designation of a compliance officer employed within the E. Reasonable methods to achieve compliance with standards, including monitoring
Billing Department. systems and hotlines.
C. Oversight of personnel by high-level personnel. 3 multiple choice options D. Automatic dismissal of any employee excluded from
participation in a federal healthcare program.
E. Reasonable methods to achieve compliance with
standards, including monitoring systems and
hotlines.
When was Health Information Technology for Economic
and Clinical Health (HITECH) Act signed into law?
When did HITECH Act become effective?
FEB 17, 2009
3 multiple choice options
2013
3 multiple choice options
Annually, the OIG publishes a work plan of compliance
issues and objectives that will be focused on throughout the
following year. Identify which option is NOT a work plan task
mentioned in this course.
A. Payments to Physicians for Co-Surgery Procedures
B. Denials and Appeals in Medicare Part D
C. Medicare Hospital Payments for Claims Involving the
Acute- and Post-Acute-Care Transfer Policies
D. Standard Unique Employer Identifier
D. Standard Unique Employer Identifier
3 multiple choice options
2/
32
3/
32
What Plan are the tasks below a part of?
- Medicare Payments Made Outside of the Hospice Benefit - Denials and Appeals in Medicare Part C and Part D - Medicare Part B Payments for End-Stage Renal Disease
Dialysis Services - Review of Home Health Claims for Services With 5 to 10
Skilled Visits
The 2020 OIG Work Plan
3 multiple choice options
When was the Preservation of Access to Care for Medicare
Beneficiaries and Pension Relief Act signed into law?
JUNE 25 2010
3 multiple choice options
What is the Medicare DRG Three-Day Payment Window? All Diagnostic services provided to a Medicare patient by a hospital on the Date of
the patient's Inpatient admission or during the 3 calendar days (or in the case of a non-IPPS hospital: 1 calendar day) immediately BEFORE the Date
of Admission are REQUIRED to be included on the bill for the IP stay (unless there is no Part A coverage)
3 multiple choice options
Do Outpatient Non-Diagnostic Services qualify for
separate payments if provided with the Three-Day
Payment Window?
No
What is modifier 59? Used to identify CPTs OTHER THAN E&M services, NOT normally reported
together, but are appropriate under the circumstances.
Documentation must support a different session, different procedure or surgery,
different site or organ system, separate.
3 multiple choice options
What is condition code 51? Code noted on the separate UB-04 OP claim, thus indicating the charge is unrelated
to the admission.
3 multiple choice options
What kind of hospitals are the following:
Cancer treatment facilities, psychiatric, IP rehabilitation,
LTC and children's hospitals for examples
Non-IPPS hospitals
3 multiple choice options
What are the 3 types of medical necessity screenings and
noncoverage notifications required in the Medicare program?
1. Advanced Beneficiary Notice of Noncoverage (ABN) for Part B services.
2. SNF ABN for Part A SNF services.
3. HINN - Hospital-Issued Notice of Non-Coverage (Part A)
What is Medicare Part B ABN? Used to explain to a Medicare patient that the ordered test or services probably
WILL NOT be covered by the Medicare b/c the DX info provided by the Dr. does
NOT support the need for these services.
****May also be used for voluntary notifications, in place of the Notice of Exclusion
for Medicare Benefits (NEMB).
What is the Two-Midnight Rule? Hospital admissions spanning 2 midnights would be considered appropriate for
payment under the IPPS rule
3 multiple choice options
What are some MSP claims that require additional review by
the OIG to ensure compliance? - W/C - Black Lung Program services - Veterans Affairs (VA) services - Federal grant programs - Public Health Service programs (i.e Medicaid)
4/
32
What are some cases where Medicare is the Secondary
Payer? - Working Aged (commercial insurance is Primary) - Accident or other liability (car/tort) - End-Stage Renal Disease (ESRD) - Disability
3 multiple choice options
What code must be provided on UB-04 when billing
Medicare as Primary for accident or injury?
Occurrence Code 05 - ACCIDENT / NO MEDICAL OR LIABILITY COVERAGE
3 multiple choice options
How long should a provider wait to bill Medicare after billing
liability insurance(s)?
120 days
After 120 days, the provider has the option to CX liability claim and bill Medicare.
Medicare will process the claim under IPPS rules and recover payment from the
liability health plan.
3 multiple choice options
What is the Correct Coding Initiative (CCI)? The CCI ensures that the most comprehensive groups of codes, rather than the
component parts, are billed.
What is a CCI edit? The edits are built in the OP code editor, check for mutually exclusive code pairs. The
unit-of-service edits determine the max allowed # of services for each Healthcare
Common Procedure Coding System (HCPCS) code.
1 multiple choice option
What are examples of Coding initiatives? Modifiers, Exception, and modifiers used for OPPS (Outpatient Prospective Payment
System)
What is the Beneficiary Notices Initiative (BNI)? Beneficiary Notices Initiative (BNI) details the 9 different types of financial liability
notices required under both the traditional Medicare and Medicare Advantage
programs.
3 multiple choice options
What are modifiers? 2-digit #s OR alpha character that are appended to a CPT/HCPCS code to provide
more info about the service without changing its definition or code.
Can a service or procedure have both professional and
technical component?
Yes
How many levels of modifiers are used for OPPS (Outpatient
Prospective Payment System)?
2 Levels
3 multiple choice options
What are Level 1 Modifiers? - Provides info about PERFORMANCE of a procedure - Apply to CPT Codes - Has 2 numbers (ex. Modifier 59)
3 multiple choice options
What are Level 2 Modifiers? - Provides info about an ANATOMICAL or about a procedure/service - Apply to HCPCS Codes - Has 2 Letters (ex. Modifier XU, XE) - Has 2 Letter + 1 Number
3 multiple choice options
When does Level 2 Modifiers apply to Medicare? When Medicare is the Primary or Secondary payer (append to CPTs).
3 multiple choice options
5/
32
Why should providers use Level 2 anatomical modifiers? Add specificity to the reporting of CPTs performed on eyelids, fingers, toes, and
arteries.
How should claim lines be coded if more than one Level 2
Modifiers need to be reported for 1 single code?
HCPCS code need to be repeated on another line with the appropriate Level 2
Modifier.
Ex. Code 26010 (drainage of finger abscess; simple) done on the left thumb and
second finger would be code:
26010FA
26010F1
3 multiple choice options
In order to promote the use of correct coding methods on a
national basis and prevent payment errors due to improper
coding, CMS developed what?
The Correct Coding Initiative (CCI)
3 multiple choice options
A mother sees a charge on her hospital bill for a
circumcision for a newborn girl. This is an example of
falsifying medical records to boost reimbursement. True or
False
False.
A physician documents a fictitious epidural in a patient's
medical record in an effort to receive additional payments. This
an example of miscoding claims. True or False
False.
Several unauthorized claims are sent to a health plan with
the wrong procedure codes. This is an example of
overcharging. True or False
True.
What do business/organizational ethics represent?
A. Principles and standards by which organizations operate
B. A healthcare provider's practices and principles
C. An employee's actions influenced by experiences and value
system
D. The patient privacy standard within healthcare
A. Principles and standards by which organizations operate
3 multiple choice options
What is the ACA and when was it signed into law? The Patient Protection and Affordable Care Act, also known as the Affordable Care Act
- Signed into law in 2010
What is the ACA's purpose? Reform the healthcare system into a system that rewards greater value, improves the
quality of care and increases efficiency in the delivery of services.
3 multiple choice options
What provisions did the ACA create? - Improve the quality of care. - Reform the healthcare delivery system. - Encourage pricing transparency and modernized financing systems. - Address the issues of waste, fraud, and abuse.
3 multiple choice options
How does the ACA improve quality of care improvements? - Reducing hospital readmissions. - Reducing hospital acquired conditions. - Comprehensive Joint Replacement and Cardiac Services - Improving physician quality reporting.
3 multiple choice options
6/
32
.
What is an Accountable Care Organization (ACO)? Delivery system of physicians, hospitals, and other healthcare providers, who work
collaboratively to manage and coordinate the care of a patient population
3 multiple choice options
What is the purpose of the below tasks?
- Establishing regulations for the development and
financing of Accountable Care Organizations (ACOs).
- Developing new approaches to payment and delivery
systems through the Center for Medicare and Medicaid
Innovation (CMSI)
Reformations to the healthcare delivery system.
3 multiple choice options
What is considered a qualifying ACO? For Medicare, a qualifying ACO requires a minimum of 5,000 beneficiaries.
3 multiple choice options
What is Medicare Shared Savings Program (MSSP)? A program that facilitates coordination and cooperation among providers to improve
care for Medicare Fee-for-Service (FFS) beneficiaries and reduce unnecessary costs.
3 multiple choice options
What is Comprehensive ESRD Care Model? A program designed to identify, test, and evaluate new ways to improve care for
Medicare beneficiaries with End-Stage Renal Disease (ESRD).
3 multiple choice options
What is the Hospital Readmission Reduction Program? CMS is required to reduce payments to hospitals with excessively high rates of
avoidable readmissions for certain conditions.
2 multiple choice options
What is Bundled Payment for Care Improvement (BPCI)? Developed by the CMSI to link payments for multiple services beneficiaries receive
during an episode of care. Has 4 Models.
What is Comprehensive Care for Joint Replacement (CJR) Tests bundled payment and quality measurement for an episode of care associated
model? most common IP SX for Medicare beneficiaries: hip and knee replacements (also
called lower extremity joint replacements or LEJR).
3 multiple choice options
What is Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)?
Survey asks recently discharged adult patients 32 QUESTIONS about aspects of their
hospital experience that they're uniquely suited to address.
Contains: - 21 items = asks "how often" or whether patients experienced a critical aspect of
hospital care. - 4 items = direct patients to relevant questions - 5 items = adjust for the mix of patients across hospitals - 2 items = support Congressionally-mandated reports.
What is the purpose of Patient Reported Outcome (PRO) - Assess post-operative functional outcomes.
Data? - Collect data from the pt's perspective, data that is necessary to finalize and test
the specifications of a hospital-level, risk-adjusted patient-reported outcome performance measure (PRO-PM) for primary elective THA/TKA
surgical procedures
7/
32
What is the intended outcome of collaborations made
through an ACO delivery system?
A. To ensure appropriateness of care, elimination of
duplicate services, and prevention of medical errors for a
population of patients.
B. To create cost-containment provisions to reform the
healthcare delivery system.
C. To reform the healthcare system into a system that
rewards greater value, improves the quality of care and
increases efficiency in the delivery of services.
D. To provide financial incentives to physicians for reporting
quality data to CMS.
A. To ensure appropriateness of care, elimination of duplicate services, and prevention
of medical errors for a population of patients.
3 multiple choice options
What are the governing bodies of financial reports? - The Securities and Exchange Commission (SEC) - The Financial Accounting Standards Board (FASB) - Generally Accepted Accounting Principles (GAAP)
What are the most commonly used financial statements? - Balance Sheet - Income Statement - Cash Flow Statement
What is accural accounting? Revenue is recorded when it's earned.
3 multiple choice options
What is cash accounting? Revenue is recorded when payment's received.
3 multiple choice options
What is fund accounting? Record-keeping method to manage categories of net assets to ensure compliance with
the restrictions on those funds.
What is Gross Revenue? Gross revenue is the total incurred charges entered for all pts for the services they
received.
What is Net Revenue? REVENUE minus Contractual, Discount or Allowances
What change was brought by the implementation of ASC 2 types of adjustment to incurred charges: Explicit price concessions & Implicit price
606? concessions
3 multiple choice options
What are Explicit Price Consessions? The discounted contractual agreements between the provider and the payers which
specify the payments due from the payers
3 multiple choice options
What are Implicit Price Consessions? A concession applied to amounts that are to be paid by patients based on the expected
payment results for a specific portfolio of receivables
3 multiple choice options
What are price concessions? Contractual Adjustments, Bad Debts, and Charity.
3 multiple choice options
8/
32
Which of these statements describes the new methodology C. Net patient service revenue is defined as the total incurred charges, less the
for the determination of net patient service revenue: explicit price concession, less any applicable implicit price concession(s) as applied
to the specific portfolio of accounts.
A. Net patient service revenue is defined as the average 3 multiple choice options payment amount for the payer but not recorded until the
end of the month processing is completed.
B. Gross patient service revenue is recorded as net patient
service revenue until such time as all payments are
received.
C. Net patient service revenue is defined as the total
incurred charges, less the explicit price concession, less
any applicable implicit price concession(s) as applied to
the specific portfolio of accounts.
D. Net patient service revenue is gross revenue minus any
contractual adjustments applicable to the account. Any
additional adjustments are not recorded until the account
reaches a zero balance.
E. Net patient service revenue is the sum of the balances
of all charges and payments recorded in the accounting
period.
What is benchmarking? Compare KPIs in an org to an agreed upon average, or expected standard, within the same
industry.
What are hospital and system MAP Keys and who is it led Stragetic KPIs that set standards for patient-centric revenue cycle excellence in the
by? HC industry.
Led by HFMA, developed by industry leaders.
How many keys are in the MAP Keys? 29 keys (KPIs)
3 multiple choice options
What are the 5 major groups in KPIs? 1. Patient Access
2. Pre-Billing
3. Claims
4. Account Resolution
5. Financial Management
What is DNFB? Days in Total Discharged Not Final Billed
What is DNSP? Days in Total Discharged Not Submitted to Payer
What is FBNS? Final Billed Not Submitted to Payer
Claims that are held in a claim scubber for additional editing prior to being released to the health plan or govt payer
Ex. Claims held in Relay for missing ICN or has been flagged as Duplicate to previous claim
What are Net Days in A/R? How fast receivables are collected Other name: A/R
days
9/
32
t
Formula for calculating Net Days in A/R. Net Patient Accounts Receivables / Avg
Daily Net Patient Service Revenue
*Net Pt A/R = the Balance Sheet
*Average Daily Net = Income Statement
What is A/R Aging Analysis? Aging reports divide the A/R into categories of 0-30, 31-60, 61-90, 91-120 and >120
days based on the date of service/discharge.
3 multiple choice options
What are some activities that places an account in DNFB status? - Incomplete charge postings - Incomplete final mec rec coding - Incomplete verification of ins eligibility/benefits
3 multiple choice options
What is Cost to Collect? Revenue Cycle Cost
divided by
Total Pt Service Cash Collected
*Revenue Cycle Cost = Pt Access Expense, Pt Accounting Expense and HIM expense
What is "suspense" period? Set by a provider to hold a claim to allow the completion of pre-billing activities.
3 multiple choice options
What is Cash Collected as Percentage of Net Revenue? Net Collection Rate (NCR)
Definition: how much cash you collected as a % of what was available to collect (ratio
of Cash to Net Revenue)
*type of KPI
What is Point of Service (POS) Cash? Represents % of pt Cash collected at or up to SEVEN days after an occasion of service
as a % of Total Self Pay cash collected for the period.
What is a good POS collections result? Between 25.7% to 45.5% of total Self-Pay collections.
3 multiple choice options
What is an acceptable percentage of first submission claim
denials?
<2%
3 multiple choice options
What is the formula to calculate days outstanding for
Credit Balances?
Dollars in Credit Balance (Days Outstanding)
divided by
3-Month Daily Avg of Total Net Pt Service Revenue
What is acute care? Short-term medical and nursing care provided in an inpatient hospital setting to
trea the acute (brief but severe) phase of a patient's injury or illness.
3 multiple choice options
What is non-acute care? Ongoing and long-term health treatment - not any urgent or ED treatment.
3 multiple choice options
Accurate identification of the patient is the first step in the
scheduling process.
Identifiers used in various combination to achieve accurate
patient identification include?
Full Legal Name, DOB, Sex and SSN
10
/
Which of the following statements accurately describes the
various Medicare benefits programs:
Medicare Part A : IP services, SNF, and HHA Medicare
Part B : OP and Professional services Medicare Part C :
Managed Care (Advantage) Medicare Part D : RX
Medicaid categories are restricted to children, pregnant women
and elderly in nursing homes. True or False?
False
Examples of managed care plans include:
- HMO, PPO and EPO plans - POS, Concierge plans, Medicare Advantage plans - Direct contracting for specific services from specific
providers - All of the above
All of the above
Patient Financial Communications best practices include
all of the following activities EXCEPT:
A. Communicating the details of the patient's insurance
coverage including eligibility and benefits
B. Collecting payment or initiating the process to immediately
remove the patient from the service schedule
C. Discussing unpaid balances and providing financial
assistance information, as appropriate
D. Providing financial counseling including assistance with
potential Medicaid eligibility processing
B. Collecting payment or initiating the process to immediately remove the patient
from the service schedule
Which statement includes the required components of an
accurate pricing determination?
A. T/C and discounts, if any, that may be applicable
B. Insurance eligibility, DX and CPT codes, total estimated
charges, adjudication calculations based on average payments
from the insurance carrier for the service
C. Insurance coverage and benefits, service or test
involved, DX and CPT codes, total estimate charges,
adjudication calculations based on the patient's benefits
package
D. Chargemaster pricing less the provider's standard
discounting amount(s) for hospital services
C. Insurance coverage and benefits, service or test involved, DX and CPT codes, total
estimate charges, adjudication calculations based on the patient's benefits package
3 multiple choice options
What is resource coordination? Resource coordination can include:
- Reserving rooms and/or equipment - Ordering devices or supplies - Staffing availability: physicians, nurses, and/or technicians
Can a Direct Admit be considered scheduled? Yes, if the physician calls ahead of time to notify that the pt is coming.
What is the requirement for patients to be scheduled for
Inpatients under managed care plans?
Approval/authorization PRIOR to service.
What is considered Scheduled Outpatients? - Services receive do NOT involve overnight stay - If overnight, the pt does NOT meet IP acuity criteria (medical necessity)
Ex. Ultrasound, CT Scan, PET Scans, MRI, Pulmonary Function Testing,
Interventional Radiology, EKGs, EEGs, cathererizations, stress tests, neurology,
Ambulatory SX, Pain Management, Lab Tests
11
/
What are Scheduled Recurring/Series Patients? - TXs that are ongoing and duration >30 days. - Must be considered as 1 "episode" of care by same ordering physician and DX
+Charges related to treatment are entered on 1 acct for multiple DOS
+Monthly claim is submitted.
Ex. physical therapy, occupational therapy, speech therapy, cardiac rehab svcs, pulmonary rehab, nutrition counseling, behavioral health day
programs, IV therapy, chemo, radiation therapy
What are unscheduled patients? - Unscheduled IP or urgent patients - Unscheduled OP or walk-in patients - ED - Observations - Newborns
What is a Direct Admit? Physician sends the pt directly to the hospital b/c the pt's medical condition meets
the required acuity level for admission.
Upon admission: URGENT ADMISSION
What is the time frame requirement for notification of
admission for most health plans?
Usually within 24 hours or next Business Day
When is Observation used? - Evaluate pts for possible IP admission - Resolve medical problems so pt can be D/C - Treatment expected to last <24hrs - Treat complications following OP SX or procedures
When is Observation considered NOT an appropriate status? - Substitute for IP admission or for continuous monitoring
Show Less
Google