The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called

APC

This accounting method attributes a dollar figure to every input required to provide a service.

COST ACCOUNTING

The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled "comprehensive codes" and "component codes." According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service

• do not code either one.
• code only the component code.
• code only the comprehensive code.
• code both the comprehensive code and the component code.

• code only the comprehensive code.

A fiscal year is a yearly accounting period. It is the 12-month period on which a budget is planned. The federal fiscal year is

October 1st through September 30 of the next year

This is the amount the facility actually bills for the services it provides.

CHARGES

To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the

• geographic practice cost index.
• conversion factor.
• case-mix index.
• relative weight for the MS-DRG.

The relative weight is a number assigned to each MS-DRG published in the Federal Register, and it is used as a multiplier to determine reimbursement. Each hospital's prospective payment system (PPS) rate is a dollar amount based on that hospital's costs of operating as determined by several blended factors. This base payment rate is multiplied by the MS-DRG's (relative) weight to calculate that hospital's reimbursement for a given MS-DRG. Additional payments are made if applicable (such as disproportionate share, teaching hospital, cost outlier, etc.). The prospective payment system used to reimburse the "hospital" for outpatient surgery is APCs. The prospective payment used to reimburse a "free-standing surgery center" for outpatient surgery is ASCs. The prospective payment system used to reimburse the "physician" for outpatient surgery is RBRVS.

Under the APC methodology, discounted payments occur when

there are two or more (multiple) procedures that are assigned to status indicator "T", and modifier-73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.

You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The only other information you need is

THE NATIONAL COVERSION FACTOR

LIFETIME RESERVE DAYS ARE

• the patient has a total of 60 lifetime reserve days.
• lifetime reserve days are not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges.
• lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay.

Lifetime reserve days are applicable for hospital inpatient stays that are payable under Medicare Part A, not Medicare Part B.

You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM for billing purposes. You find this "theoretically" reasonable because DSM

codes are also valid ICD-10-CM codes.

Diagnostic and Statistical Manual of Mental Disorders, (DMS)

The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ________ years, unless state law specifies a longer period.

6 YRS.

This is the difference between what is charged and what is paid.

CONTRATUAL ALLOWANCE

The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that the patient was not admitted with, but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as

PRESENT ON ADMISSION

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS'Web site.

OIG'S WORKPLAN

Currently, which prospective payment system is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient?

RBRVS

When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service.

CRITRICAL CARE

When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a

Corporate Integrity Agreement.

HIGHEST TOTAL PROFIT------ can not determine

highest total reimbursement------ patients XMS-DRG

X

Some services are performed by a nonphysician practitioner (such as a Physician Assistant). These services are an integral yet incidental component of a physician's treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called

INCIDENT TO BILLING

Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers,

• providers must file all Medicare claims.
• collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim.
• fees are restricted to charging no more than the "limiting charge" on nonassigned claims.

Under Medicare Part B, Congress has mandated special incentives to increase the number of health care providers signing PAR (participating) agreements with Medicare. One of those incentives includes a 5% higher fee schedule for PAR providers than for nonPAR (nonparticipating) providers.

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

geographic practice cost indices.

The three relative value units are physician work, practice expense, and malpractice expense. These are adjusted by multiplying them by the geographical practice cost indices. Then, this total is multiplied by the national conversion factor.

The present on admission (POA) indicator is required to be assigned to the ________ diagnosis(es) for ________ claims on ________ admissions.

principal and secondary, Medicare, inpatient