RHIA Reimbursement Practice Exam

These questions are part of the practice quiz. Start practicing

• The limiting charge is a percentage limit on fees that nonparticipating physicians may bill Medicare beneficiaries above the non-PAR fee schedule amount. What is the limiting charge?
• What is the correct POA indicator for a decubitus ulcer documented on nursing assessment but not on physician documentation until later?
• What is the process called that involves gathering charge documents from all departments to ensure patient services are billed correctly?
• When documentation is incomplete or insufficient in the chart, what is the most common way of communicating with the physician for answers?
• Which of the following payment systems is primarily designed for outpatient surgeries for Medicare patients?
• What system utilizes information from the Minimum Data Set (MDS) in long-term care settings?
• What coding system is used in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology?
• Which classification is primarily used to facilitate the reimbursement of outpatient services?
• A three-digit code that describes a classification of a product or service is known as what?
• What does the charge/service code represent?
• Which statement about MS-DRGs is false?
• What is the function of the general ledger key in the billing process?
• Under the outpatient PPS, which CPT code can replace the code for a medical visit when critical care services are provided?
• This prospective payment system is designed specifically for which type of facility?
• How much will a nonparticipating physician receive from Medicare for a service with a standard fee of $120, if the Medicare non-PAR fee is $57?
• Who is responsible for making coinsurance payments as determined by a specified ratio?
• Which coding system is utilized in the MS-DRG prospective payment methodology for proper reimbursement?
• What statement shows how much the provider billed, how much Medicare reimbursed, and what the patient owes?
• What helps to determine the reimbursement received from Medicare for a service?
• Which MS-DRG brings in the highest total profit to the hospital according to the provided volume data?
• Which statement is NOT true regarding the concept of "capitation"?
• If the MS-DRG payment received by a hospital is lower than the actual charges for inpatient services, what happens next?
• What does the acronym HAVEN stand for in the context of Medicare home health?
• When a provider bills Medicare for a procedure listed under both comprehensive and component codes, which should they code?
• What is defined as the total amount collected by a facility for services billed?
• What happens when all of a patient's lifetime reserve days are used?
• Which of the following is a characteristic of Medicare Severity Diagnosis Related Groups (MS-DRGs)?
• What is the term for a hospital document that lists procedures, services, charges, and revenue codes?
• What type of billing requires a physician to remain actively involved in ongoing care for services billed?
• What is the case-mix index (CMI) for the top 10 MS-DRGs?
• Which type of facility uses HIPPS codes along with home health agencies?
• What is the standard identifier for physicians issued to all HIPAA-covered entities?
• Under the inpatient prospective payment system, what is required for preadmission services to be covered by the IPPS MS-DRG payment?
• When are global payments typically made?
• If a nonparticipating physician does not accept assignment, how much might the patient be liable for if the total charge is $250.00?
• What does the abbreviation "PAR" stand for in the context of Medicare providers?
• What is the term for when a patient is discharged from an inpatient rehabilitation facility and returns within three calendar days?
• The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of how many years?
• What characterizes a provider who agrees to accept assignment for Medicare Part B services?
• What is the significance of the Hospital-Acquired Conditions (HACs) payment provision?
• What software system do Home Health Agencies (HHAs) utilize for data entry?
• What agreement is a provider placed under when found guilty under civil false claims statutes?
• Lifetime reserve days under Medicare are applicable for which type of stays?
• What does the term "hard coding" specifically refer to?
• A Medicare Summary Notice (MSN) is sent to whom as their explanation of benefits (EOB)?
• What are the three components contained within each HCPCS/CPT code under RBRVS?
• What code is used to identify medical services for billing purposes?
• Under which of the following circumstances would a decubitus ulcer be recorded as not present on admission?
• Accounts Receivable (A/R) refers to what?
• Which document is published by Medicare Administrative Contractors (MACs) to outline service coverage conditions?
• What do the acronyms LCD and NCD stand for in relation to Medicare coverage policies?
• What is the main effect of aged receivables on a healthcare facility?
• What does the present on admission (POA) indicator "Y" signify?
• What is the process called that ensures financial viability for health care facilities?
• Under the CMS system, what determines the reimbursement rates for procedures?
• What type of payment system do commercial insurance plans typically use?
• What is the name of the health care program for military members and their families?
• Which payment indicator would reflect a service that isn’t separately billable under the APC system?
• What is the prospective payment system used for Medicare hospital outpatients?
• In terms of coding accuracy, what issue can negatively impact a facility's CMI?
• Which element is not one of the criteria for high-quality clinical documentation?
• If a patient has paid his deductible under Medicare Part B, what percentage of coinsurance is the patient liable for during an office visit?
• Which part of Medicare offers supplemental medical insurance for outpatient services?
• Payment status indicator "C" is used for which type of services?
• What does EFT stand for when discussing reimbursement payments?
• Which of the following is an example of medical necessity in healthcare reimbursement?
• What is the name of the data-entry software used for patient assessments in home care under Medicare?
• In a global payment methodology, which component is NOT included as part of the "technical" components of procedures?
• Which electronic format is NOT used for health care claims transactions?
• What must a nonparticipating physician do to ensure they receive the correct reimbursement from Medicare?
• State Medicaid programs must provide medical assistance for which group?
• What provides a uniform system for identifying procedures, services, or supplies?
• What factor does NOT contribute to changes in case-mix index (CMI)?
• Which type of insurance typically involves the concept of coinsurance payments?
• Which of the following code sets is NOT required as part of HIPAA administrative simplification provisions?
• When a patient with a documented malignant neoplasm is admitted, which POA indicator applies?
• What does DNFB stand for in the context of hospital billing?
• Bilateral procedures under ASC PPS are reimbursed at what percentage of the payment rate?
• If a physician's standard fee is $120.00 and the PAR fee is $60.00, how much will the physician be reimbursed by Medicare after the patient’s deductible is met?
• What is the primary role of Recovery Audit Contractors (RAC)?
• What is the standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures?
• What type of insurers does the category "Commercial payers" include?
• What term describes financial protections ensuring certain facilities recover losses due to APC payment discrepancies?
• How is a contractual allowance defined in healthcare reimbursement?
• What does payment status indicator "X" under APCs signify?
• Which of the following is associated with inappropriate billing practices resulting in higher costs to Medicare?
• What are errors in medical care that are clearly identifiable, preventable, and serious in consequences called?
• Which service must be directly supervised by a physician to be billed as "incident to"?
• The RUGs system is primarily used for reimbursement to which type of facility for Medicare patients?
• Which classification system groups inpatient hospital cases that are expected to require similar resources?
• What adjustment does CMS make to MS-DRG payments regarding conditions acquired during the hospital stay?
• What is the out-of-pocket expense for a patient if the PAR Medicare Fee Schedule amount is $200.00 and they are responsible for 20% coinsurance?
• Which type of claims must nonparticipating providers file according to Medicare Part B rules?
• What does CMS identify "Hospital-Acquired Conditions" to be when a diagnosis is not "present on admission"?
• For a nonparticipating physician who does not accept assignment, what is the maximum amount the physician can charge over the non-PAR Medicare Fee Schedule amount?
• What does EDI stand for in the context of health information exchange?
• When a participating physician accepts assignment, what is the patient's financial liability for a visit costing $200.00 under the PAR Medicare Fee Schedule?
• What type of notice is sent to clarify reimbursement details to patients?
• ICD-10-PCS procedure codes are reported on which form to detail services provided to a patient?
• What does the acronym APC stand for in relation to payment systems?
• What is the total amount that a facility bills for the services it renders?
• Which payment system method focuses on a global fee covering all aspects of care, including professional and technical component?
• When multiple procedures are performed during the same surgical session under ASC PPS, what is the reimbursement rate for the highest level group?
• What type of reimbursement method issues lump sum payments for all health care services related to a specific illness?
• If a participating provider's usual fee is $700.00 and the Medicare allowed amount is $450.00, how much is written off?
• Which individual MS-DRGs has the highest reimbursement?
• If a patient has met their deductible, which of the following payments is typically covered by Medicare?
• What is the term for the computer-to-computer transfer of data between providers and third-party payers?
• Under APCs, payment status indicator "V" refers to which type of visit?
• Which of the following services is not included in Ambulatory Patient Classifications (APCs) for reimbursement?
• Which prospective payment system reimburses providers according to predetermined rates for a 60-day episode of care?
• When a third-party payer refuses payment to a provider, what is this called?
• Terminally ill patients can opt for hospice services if they have a life expectancy of how long?
• Who signs the Advance Beneficiary Notice (ABN) indicating their decision about Medicare services?
• This government initiative aims to eliminate fraud and abuse, involving audits to identify Medicare overpayments:
• What accounting method assigns a dollar value to every input needed to provide a service?
• Revenue codes are primarily used for what purpose in health care billing?
• What does payment status indicator "S" indicate?
• How is the total financial liability calculated for a patient with Medicare who sees a nonparticipating physician?
• The DNFB report includes patients who have been discharged but for whom the billing process is not complete. What does DNFB stand for?
• Which prospective payment system determines payment for physician services covered under Medicare Part B?
• What is the narrative name for services provided on a claim form called?
• If a nonparticipating physician charges $125 and the Medicare Fee Schedule is $100, what does "balance billing" mean for the patient?
• Which type of condition must hospitals report if it is present on admission?
• Which of the following describes the process of revenue cycle management?
• The POA indicator must be assigned to which types of diagnoses for inpatient claims?
• Which law prohibits a physician from referring Medicare patients to clinical laboratory services where they or a family member have a financial interest?
• Which rule states that hospitals receive a graduated per diem rate during a patient’s hospitalization?
• Which of the following is NOT a claim form used by physicians?
• When does CMS adjust the Medicare Severity DRGs and reimbursement rates?
• What does the acronym POA stand for in medical documentation?
• What act addresses false claims made to obtain financial benefits from government programs?
• In the case of a patient who develops a pulmonary embolism postoperatively, what is the POA indicator?
• This payment system replaced the "customary, prevailing, and reasonable" charge system for physicians:
• The MS-DRG system is used to classify which of the following cases?
• If the Medicare non-PAR approved payment amount is $128.00 for a proctoscopy, what is the total approved payment amount for a doctor who does not accept assignment?
• What is the purpose of a remittance advice?
• If a participating physician who accepts assignment charges $250.00 for a service with a PAR Medicare Fee Schedule amount of $200.00, what is the total amount the physician will receive?
• Which of the following terms is associated with the length of time a patient stays within a bundled payment system?
• Which statement describes an action that can be categorized as fraud?
• Which type of care is typically eligible for coverage under Medicare's inpatient rehabilitation facility payment system?
• Which of the following is assigned by CMS for each APC?
• Under retrospective payment systems, how are payments calculated?
• Which of the following items is NOT included as "packaged" under the Medicare outpatient prospective payment system?
• What is the main role of the Medicare Summary Notice for beneficiaries?
• What report is frequently generated to monitor timely claims processing in a hospital?
• What is the purpose of a revenue code on the UB-04 claim form?
• What is the minimum retention period for health insurance claims under HIPAA unless otherwise specified by state law?
• What is the primary role of LCDs in the Medicare system?
• What represents the highest level of reimbursement that a physician can receive for a single service under Medicare?
• What does the present on admission (POA) indicator indicate for conditions acquired during hospital stays?
• Under the APC methodology, when do discounted payments occur?
• What is a lump-sum payment distributed among physicians and facilities known as?
• What term describes when a provider uses practices inconsistent with accepted medical practice that results in unnecessary costs to Medicare?
• Which of the following is considered a hospital-acquired condition (HAC)?
• What is the term for when a provider bills separately for procedures that are part of a major procedure?
• What is the purpose of the HIPPS code used by home health agencies?
• Who is responsible for negotiating settlements when providers are guilty under civil false claims?
• Under the RBRVS, what does the term 'malpractice insurance expense' refer to?
• What is the primary objective of a reimbursement methodology?
• What system has been developed for payment purpose for non-Medicare populations, such as neonates?
• Which type of hospital can receive waivers from CMS, making it excluded from the inpatient prospective payment system?
• What classification system is used for inpatient prospective payment?
• What should be utilized for clear item descriptions in the billing process?
• What is a joint federal and state program that provides health care coverage to low-income populations?
• What must match the level of service codes reported by physicians in a hospital setting?
• What is applied to all procedures in ASC PPS after the highest level procedure is reimbursed at 100%?
• In terms of reimbursement, what does capitation involve?
• Which software program is used to assign appropriate MS-DRGs based on the information provided for each episode of care?
• Which services are excluded under the Hospital Outpatient Prospective Payment System?
• What describes the difference between what is charged and what is actually paid?
• Based on the patient volume, which MS-DRG brings in the highest "total" reimbursement to the hospital?
• Which assessment tool is used for home health agencies to reimburse Medicare patients?
• In cases where a physician does not accept assignment, how is the patient's financial liability calculated?
• Which organization typically utilizes OASIS for data collection?
• How many lifetime reserve days does a Medicare beneficiary have?
• In the context of APCs, what does a payment status indicator "N" signify?
• What type of indicator is assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system?
• Which term indicates that a service or procedure is necessary and reasonable for treatment according to accepted standards of care?
• What are the three relative value units in physician reimbursement calculations?
• What does payment status indicator "T" indicate about significant procedures?
• Which statement about modifiers with CPT codes is FALSE?
• What practice involves knowingly making false statements to obtain a benefit for which no entitlement exists?
• Which type of hospital receives reimbursement under the Inpatient Rehabilitation Prospective Payment System?
• What is the role of the Medicare Administrative Contractors (MACs)?
• Which prospective payment system (PPS) was developed to manage costs for inpatient psychiatric facilities?
• Which statement regarding nonparticipating physician providers under Medicare Part B is FALSE?
• Under ASC-PPS, what percentage of the national median charge is the patient responsible for paying as coinsurance?
• What does the OIG's Workplan detail?