Hospital And Clinic Billing! CPAT Trivia Quiz

Per diem refers to a reimbursement method where a fixed rate is paid per day spent in the hospital, regardless of the actual charges or costs incurred. This means that the reimbursement amount remains the same regardless of the medical procedures or services provided during the hospital stay.

If the HICN ends with a C, it would indicate that the cardholder is a child. The HICN is an identifier used in healthcare systems, and the letter at the end of the HICN is used to determine the relationship of the cardholder. In this case, the "C" indicates that the cardholder is a child.

Medigap is the correct answer because it refers to a health insurance policy sold by private insurance companies to cover Medicare deductibles and coinsurance. Medicaid is a different program that provides health coverage for low-income individuals and families. Secondary refers to insurance that covers costs not covered by the primary insurance. Tricare is a health insurance program for military personnel and their families.

A fee schedule is a comprehensive list of fees that are charged for specific services that are provided. It outlines the cost of each service and helps to ensure transparency and consistency in pricing. This allows individuals or organizations to know in advance how much they will be charged for a particular service. Capitation refers to a fixed payment per person for a specific period of time, while per diem refers to a daily rate. Fee for service means that payment is made for each individual service provided.

During each benefit period, the patient is responsible for paying $1132 for a hospital stay of 1 to 60 days. This means that regardless of the length of the hospital stay within this range, the patient will be responsible for paying the same amount.

The correct answer is "Both A and C." NCCI, which stands for National Correct Coding Initiative, identifies codes that should not be billed together (A) and mutually exclusive codes (C). Codes that should not be billed together refer to codes that should not be reported on the same claim because they represent services that are considered inclusive or overlapping. Mutually exclusive codes refer to codes that describe similar procedures or services and should not be reported together because they are considered redundant. Therefore, NCCI identifies both types of codes that should not be billed together.

To obtain Medigap coverage, the beneficiary must have both Part A and Part B of Medicare. Medigap, also known as Medicare Supplement Insurance, is designed to help cover the out-of-pocket costs that Original Medicare (Part A and Part B) does not pay for, such as deductibles, copayments, and coinsurance. Therefore, having both Part A and Part B is necessary to be eligible for and benefit from Medigap coverage.

If the HICN (Health Insurance Claim Number) ends with an A, it indicates that the cardholder is the wage earner. The HICN is a unique identifier for individuals who have health insurance, and the letter at the end of the number is used to determine the relationship of the cardholder. In this case, the A signifies that the cardholder is the primary wage earner in the family.

Medicare Part B covers a wide range of services, including preventive screenings and vaccinations. It covers mammograms for breast cancer screening, glaucoma screenings to detect eye diseases, and pneumonia vaccinations to prevent respiratory infections. However, it does not cover routine eye exams for eyeglasses or contact lenses. Eye exams for medical conditions such as cataracts or macular degeneration may be covered, but not for routine vision care.

MUEs (Medically Unlikely Edits) were designed to achieve two main objectives: reduce clerical errors and reduce incorrect coding based on anatomic consideration. By implementing MUEs, healthcare providers can minimize mistakes made during the billing and coding process, ensuring accurate reimbursement and reducing the risk of coding errors related to anatomical considerations. Therefore, the correct answer is "Both A and C."

The patient is responsible for $147.50 for care received in a skilled nursing facility for days 21-100 during each benefit period. This means that after the initial 20 days, the patient will have to pay this amount out of pocket for each day of care in the facility.

The correct answer is National Correct Coding Initiative. NCCI is an acronym that stands for National Correct Coding Initiative. This initiative was developed by the Centers for Medicare and Medicaid Services (CMS) to promote correct coding methodologies and prevent improper coding practices. It includes a set of coding edits and guidelines that help ensure accurate and consistent coding of medical procedures and services.

Medicare has four parts: Part A, which covers hospital insurance; Part B, which covers medical insurance; Part C, which offers Medicare Advantage plans; and Part D, which covers prescription drugs. These four parts provide different types of coverage to meet the healthcare needs of individuals.

The components of an E/M code include examination, medical decision making, and history. Time is not considered as one of the components for determining an E/M code.

APC stands for Ambulatory Payment Classification. Ambulatory refers to medical services provided on an outpatient basis, meaning that the patient does not require an overnight stay in a hospital. Payment Classification refers to the system used to categorize and determine the reimbursement for healthcare services. Therefore, Ambulatory Payment Classification is a system used to classify and determine payment for outpatient services provided by healthcare providers.

NCCI, or the National Correct Coding Initiative, was introduced to achieve several goals, including identifying codes that may be potential sources of fraud and abuse, establishing standards of medical billing, and identifying codes that should not be billed together as they are components of another code. However, increasing reimbursement is not one of the objectives of NCCI.

If the HICN (Health Insurance Claim Number) ends with a B, it indicates that the cardholder is a wife. The HICN is a unique identifier for individuals who have health insurance. The suffix B is used to identify the cardholder as a wife, while other suffixes may be used for different categories such as husband, non-wage earner, or child.

Capitation is a method of payment for health services where a healthcare provider is paid a fixed per capita amount for each person serviced, regardless of the actual number or nature of services provided. This means that the healthcare provider receives a set amount of money for each individual they provide services to, regardless of how many services are actually provided. This payment model incentivizes healthcare providers to focus on prevention and cost-effective care, as they are not reimbursed based on the quantity of services rendered.

A hospital cannot bill a beneficiary for units of service in excess of MUE (Medically Unlikely Edits) limits because MUE limits are set by Medicare to prevent excessive billing or potential fraud. These limits determine the maximum number of units of service that can be billed for a specific procedure or service. Even if the hospital has an ABN (Advanced Beneficiary Notice) on file, it cannot override the MUE limits and bill the beneficiary for the excess units of service.

Medicare Part A actually covers inpatient hospital services, not outpatient services. It pays for things like hospital stays, skilled nursing facility care, and hospice care. Outpatient services, on the other hand, are covered under Medicare Part B. Therefore, the given statement is false.

Ancillary services refer to support services that are provided in a healthcare facility to assist in the diagnosis, treatment, and management of patients. This typically includes services such as radiology, laboratory testing, and blood administration. The operating room, however, is not considered an ancillary service as it is a specialized area where surgical procedures are performed. It is a distinct department within a healthcare facility and not typically categorized as an ancillary service.

Fee for service is a method of payment for health services where providers are paid a set fee for each service or procedure they perform. This means that the healthcare provider is reimbursed based on the specific services rendered, regardless of the actual cost incurred. It allows for flexibility in choosing healthcare providers and services, as patients are not limited to a specific network or set of providers. This method is commonly used in private healthcare systems where patients have insurance coverage and can choose their preferred providers.

During the first 20 days of each benefit period, the patient is not responsible for any amount for care received in a skilled nursing facility. This means that the cost of care during this period is fully covered by the insurance or Medicare, and the patient does not have to pay anything out of pocket.

Bone mass measurements are covered by Medicare Part B. Medicare Part B covers medically necessary services and preventive services, including bone mass measurements for individuals at risk for osteoporosis. Therefore, bone mass measurements are not excluded from Medicare Parts A and B.

If the Health Insurance Claim Number (HICN) starts with a number, it means that the first position is already occupied by a numeric value. Therefore, to have a total of 9 numeric positions, the remaining 8 positions must also be numeric.

The Medicare Part B deductible is $162. This deductible is an annual amount that Medicare beneficiaries must pay out of pocket before Medicare starts to cover their medical expenses. Once the deductible is met, Medicare will typically pay 80% of the approved amount for covered services, while the beneficiary is responsible for the remaining 20%. The deductible amount may change each year, so it is important for beneficiaries to stay updated on any changes in Medicare costs.

The correct answer is 48 hours. This is the maximum time that a Medicare beneficiary can spend in outpatient observation before they must be admitted as an inpatient. This limit is in place to ensure that beneficiaries receive appropriate care and are not kept in observation status for an extended period of time without a clear plan for their treatment.

The question is asking for the defining components that are not included in the given list. The options provided are Time, Cost, Coordination of Care, and History. The correct answer is Cost because it is the only option that is not a defining component. Time, Coordination of Care, and History are all important factors that contribute to defining components in various contexts, such as healthcare or project management. However, Cost is not typically considered a defining component, but rather a factor that may influence or be influenced by the defining components.

The level of an E/M (Evaluation and Management) service is defined by seven components. These components include history, examination, medical decision making, counseling, coordination of care, nature of the presenting problem, and time. Each of these components plays a role in determining the appropriate level of service provided by a healthcare professional during an E/M encounter.

QMB coverage stands for Qualified Medicare Beneficiary coverage. This program helps eligible individuals with limited income to pay for their Medicare premiums, deductibles, and coinsurance. Therefore, the correct answer is "Premiums, deductibles, and coinsurance." This coverage does not include Medigap, which is a separate insurance policy that helps fill the gaps in Medicare coverage.

If the HICN starts with a letter, it means that the first position is occupied by a letter. Since the question asks how many positions must be numeric, it implies that all the positions after the first one must be numeric. Therefore, the correct answer is 6.

NCCI reviews claims before they are paid. This means that they assess the claims and their validity before any payment is made. By reviewing the claims beforehand, NCCI ensures that only eligible and accurate claims are processed for payment, reducing the risk of fraud or errors in the payment process. This proactive approach helps maintain the integrity and efficiency of the payment system.

Hospital outpatient services that are provided to a patient classified as DOA (Dead on Arrival) are not covered by Medicare Part B, even if the patient has been pronounced dead prior to arrival. Medicare Part B only covers services that are provided to living patients. Therefore, the correct answer is False.

Medicare considers an item or service as medically necessary if it is consistent with the symptoms or diagnosis, not furnished primarily for the convenience of the patient, and medically necessary. The exception in this case is that it does not have to be ordered by the physician. This means that even if the physician did not specifically order the item or service, it can still be considered medically necessary by Medicare as long as it meets the other guidelines.

The correct answer is Clinical Laboratory Improvement Amendment. CLIA is an acronym that stands for Clinical Laboratory Improvement Amendment, which is a federal law that regulates laboratory testing and requires clinical laboratories to meet certain quality standards. This law was enacted to ensure the accuracy, reliability, and timeliness of patient test results in order to protect public health and safety.

SLMB coverage, also known as Specified Low-Income Medicare Beneficiary, is a program that helps individuals with limited income to pay for their Medicare Part B premiums. Therefore, the correct answer is "Medicare Part B premiums." This coverage assists eligible individuals in affording their healthcare expenses by covering a portion or the entirety of their Part B premiums. It is important for individuals with low income to be aware of and take advantage of programs like SLMB to ensure they can access necessary healthcare services.

CLIA numbers, which stands for Clinical Laboratory Improvement Amendments, have 10 digits. These numbers are assigned to laboratories in the United States that perform testing on human specimens for health assessment or diagnosis. The 10-digit CLIA number helps to identify and track laboratories, ensuring they meet quality standards and comply with regulations.

The correct answer is "Condition codes" because in order to assign an Ambulatory Payment Classification (APC), condition codes are necessary. Condition codes provide additional information about the patient's condition or circumstances that may affect the payment for the services provided. These codes help to ensure accurate reimbursement and appropriate classification of the services rendered.

Per Medicare timely filing regulations, a claim for date of service June 23, 2009 must be submitted within 12 months from the date of service. Therefore, the correct answer is Dec 31, 2010.

The correct answer is "Both A and B" because examples of Never Events include both conducting a wrong surgery on a patient and performing surgery on a wrong body part. These events are considered serious medical errors that should never occur and are preventable with proper protocols and procedures in place. The answer choice "All of the above" is not correct as it includes the option of administering incorrect medication, which is not mentioned in the examples provided.

According to Medicare timely filing regulations, a claim for a specific date of service must be submitted within a certain timeframe. In this case, the claim for a date of service on October 1, 2010 must be submitted by December 31, 2012. This means that the healthcare provider has 2 years from the date of service to submit the claim to Medicare for reimbursement.

To determine whether the waiver of liability provision is applicable, all of the following provisions must be confirmed: the service or item must be covered, the service must be determined to be unreasonable or unnecessary for the diagnosis, a physician can only render the treatment, and the carrier has not previously denied coverage. By confirming all of these provisions, one can ascertain whether the waiver of liability provision applies in a given situation.

To qualify for Medicaid, a patient must have a monthly income below certain limits and assets not more than $4000. Part A and B are not requirements for Medicaid eligibility.

The correct answer is "Both A and D" because APCs (Ambulatory Payment Classifications) apply to both Inpatient Hospitals and Ambulatory Care Facilities. Inpatient Hospitals refer to facilities where patients are admitted and stay overnight for medical treatment, while Ambulatory Care Facilities provide medical services on an outpatient basis, meaning patients do not stay overnight. Therefore, APCs are applicable to both types of facilities.

The correct answer is Medicare Part B premiums. This means that QI1 coverage will cover the cost of Medicare Part B premiums.

Medicare is a health insurance program that provides coverage for people with End-Stage Renal Disease (ESRD), which is the final stage of chronic kidney disease. ESRD requires regular dialysis or a kidney transplant for survival. Medicare ensures that individuals with ESRD have access to necessary medical treatments and services. Therefore, the correct answer is "People with End- Stage Renal Disease."