It replaces the "Patient's Bill of Rights.'
It was adopted by the AHA
It outlines what a provider can expect from a patient.
It is a plain-language brochure.
It addresses patient expectations from admission to dismissal only.
It refers only to any single piece of data that could directly match patients with their medical information.
It can be shared without explicit consent for treatment, payment, or healthcare operations (TPO).
It cannot be shared for marketing purposes without explicit consent.
It cannot be shared with law enforcement agencies without consent or proper notification to the patient, expect under court order.
Patient Care Partnership brochure
Healthcare Power of Attorney or Durable Power of Attorney for Healthcare.
Denial or revocation of the provider number applications.
Suspension of provider payments.
Application of CMPs.
Inclusion in a published "watch" list of providers.
All hospitals must be accredited by TJC.
TJC will conduct an audit of a hospital every 39 months.
TJC will conduct an audit of a laboratory every 36 months.
TJC can audit a healthcare facility without advance notice as early as 6 months after its initial audit.
Assignment of benefits
Authorization of payments
The person is an emancipated minor.
The person is uninsured.
The person is intoxicated.
The person is declared mentally incompetent by the courts.
A physician extender
A licensed, registered nurse
A financial counselor
A student from an accredited health profession program (under the supervision of his or her clinic instructor.
National Coverage Determination
National Coverage Department
New Coverage Determination
New Coverage Direction
Until 2010, Medicare was the primary payer for nearly will Medicare-covered services.
Before becoming entitled to Medicare, beneficiaries receive an IEQ that asks about any other healthcare coverage that might be primary to Medicare.
Medicare considers it a fraudulent or abusive practice to regularly submit claims that are the responsibility of another insurer under the MSP provision.
The CWF is a CMS file that contains Medicare patient eligibility and utilization data from the IEQ and ongoing MSPQs.
They should describe the provider's policies in general terms only to allow for flexible legal interpretation
They should clearly state when charges are due and payble; provide discount information; define acceptable methods of payment; outline charity guidelines and application procedures; and explain how accounts may be sent to a collection agency.
Patient Access/Front Desk staff should not discuss these policies with patients; instead, they should refer patients to a designated Billing staff member.
An effective policy for collecting at the time of service will improve cash flow and will reduce AR days, the cost of patient statements, bad debt, and follow-up time.
It is also known as the benefit period
It is also known as the deductible period
It begins when a beneficiary enters the hospital and ends 30 days after discharge from the hospital or from a SNF
It begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF
Chiropractic services (limited)
Routine eye care and most eyeglasses in the absence of disease
Kidney dialysis and kidney transplants
Hearing aids and exams
Use of program practitioners
Use of specific healthcare facilities
State-mandated coverage limits
They are the private firms that process Medicare claims
They were formerly known as fiscal intermediaries or carriers
They enroll providers in the Medicare program, provide education on Medicare billing requirements, and answer both provider and patient inquiries
There is one MAC in each of the 50 states
Services covered by workers' compensation
Care related to an accident for which liability or no-fault coverage exists
Patients 65 or older with group coverage from their own or their spouses' employment with an employer who has 20 or more employees
A patient admitted to an acute care hospital with Medicare insurance and the coverage changes to a Medicare HMO in the middle of the stay
Group health plans are always secondary to Medicare
Medicaid is always the payer of last resort except for Indian Health Service
TRICARE is also the payer of last resort except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs or plans as identified by the TRICARE Management Activity
Almost all payers are secondary to any liability or property and casualty insurance
The coverage of the older parent is primary
The coverage of the younger parent is primary
The coverage of the parent with the first birthday in the calendar year is primary
The coverage of the parent with the last birthday in the calendar year is primary
ICD stands for International Classification of Diagnoses
The code set contains 68,000 codes for great specificity in coding
They should reflect the principal diagnosis and discharge diagnosis to the highest level of specificity
They should reflect any coexisting diagnosis to the lowest level of specificity
Non-payable condition (NPC)
Hospital-acquired complication (HAC)
Present on admission (POA)
Diagnosis complication code (DCC)
A. Inpatient claims
B. Outpatient claims
A. The HCPCS is divided into three levels
B. Level I of HCPCS is the CPT, a five-digit numeric code that identifies medical services and procedures furnished by physicians and other healthcare professionals
C. Level I of HCPCS includes codes for items or services that are regularly billed by suppliers other than physicians
D. Level II of the HCPCS is five-digit alpha/numeric code that identifies products, supplies, and services not included in the CPT codes when used outside a physician's office
A. History, examination, and counseling
B. Examination, medical decision-making, and counseling
C. History, examination, and medical decision-making
D. Examination, medical decision-making, and coordination of care
A. They can define HCPCS and CPT codes to a broader level
B. They are two-digit numeric or alphanumeric code
C. They can indicate that a service or procedure was altered by some circumstance that impacts reimbursement
D. They can clarify the anatomic site of a procedure
A. Drug labeler, type of product, and size and type of package
B. Type of product, size and type of package, and expiration date
C. Drug labeler, type of product, and related ICD-10 code(s)
D. Type of product, size and type of package, and storage requirement
A. Work required (Work RVU)
B. Practice expense (PE)
C. Malpractice insurance expense (MP)
D. Geographic indicator (GI)
D. Per diem
A. They must maintain no more than 25 inpatient beds that may be used for swing bed services
B. They may operate a rehabilitation/psychiatric DPU, each with up to 10 beds
C. They can have an ALOS of 72 hours or less per patient for acute care (excluding swing bed services and beds within DPUs)
D. They must furnish 24/7 emergency care services
A. Description and price of an item and its CPT or HCPCS codes
B. General ledger account an item impacts
C. Inventory control information for supplies and medications
D. NPIs of providers authorized to use an item
A. The review should be done at least every other year
B. The review should check for items to be added or deleted
C. The review is important because assigning an incorrect code could be construed as fraud
D. Departments directors/managers should be included in the review
A. The regular physician is unable to provide service
B. The locum tenens physician is part of the regular physician's practice
C.The patient had a previously-scheduled appointments or treatment with the regular physician
D. The substitute physician does not provide services to the patient for more than 60 days
E. The patient would prefer to see someone other than the regular physician
A. Condition code
B. Occurrence code
C. Occurrence span code
D. Revenue code
A. First digit of the bill code in field locator 4
B. Second digit of the bill code in field locator 4
C. Third digit of the bill code in field locator 4
A. Itemized statement
B. Data mailer
A. Medicare is listed as the secondary payer
B. The claim is for services that were provided outside of the United States
C. The provider attempted to obtain a signed ABN but the beneficiary refused to sign it
D. The provider has been debarred or excluded from the Medicare program
A. January 1, 2019
B. September 23, 2019
C. December 31, 2019
D. December 31, 2020
A. The patient is billed for the entire remaining balance
B. The claim is written off, as billing the patient is not allowed
A. 3-Day Payment Window Rule
B. 3-Day Bundle Rule
C. 5-Day Payment Window Rule
D. 7-Day Combined Charges Rule
A. Inpatient psychiatric hospitals
B. Teaching hospitals
C. Children's hospitals
D. Inpatient rehabilitation facilities
A. It results in faster entry into the payer system
B. It offers proof of receipt
C. It facilitates the process of sending attachments
D. There can be challenges with payer acceptance and upload/download issues
A. National Clean Claims Initiative
B. New Clinical Code Institute
C. Non-payable Claim Coding Indentifiers
D. National Correct Coding Initiative
A. They are a unit of service edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service
B. Adding an appropriate modifier may allow an MUE claim to be processed appropriately
C. They are a post-payment edit to alert a beneficiary of potential fraud or abuse on a claim
D. In many cases, they cannot be appealed
A. Routed to provider
B. Routed to payer
C. Returned to provider
D. Returned to payer
A. Written policies and procedures
B. Pre-employment background checks
C. Effective training and education
D. Responding to offenses and developing corrective action plans
A. The period of time is usually less for open-end or oral agreements, greater for judgments, and greatest for notes or written agreements
B. The period is usually less for open-end or oral agreements, greater for notes or written agreements, and greatest for judgments
C. A statue of limitations may not be extended under any circumstances
D. A statue of limitations may be extended by obtaining a partial payment on the principal account
A. Minimum acceptable payments
B. Charity care requirements and protocols
C. Discount policy
D. Courtesy discharge policy
E. Age when an account is considered uncollectible and prepared for a bad-debt write-off
A. It releases the guarantor/patient from financial responsibility of any and all account balances listed on the bankruptcy petition
B. The account balance is to be written off to the appropriate transaction code
C. It covers any patient accounts that occur within six months following the notification
D. It is usually entered within six months when a Chapter 7 bankruptcy is deemed to have no assets
A. It is a court ruling whereby the bankruptcy is rejected
B. The most common reason for dismissal is the debtor agreeing to pay each creditor a portion of the debt owed
C. It means a creditor can bill the debtor directly
D. It means a creditor can refer the account to a collection agency or pursue litigation
A. The responsible party is the adult patient him/herself, even in the case of injuries caused by the negligence of another party
B. In some states, spouses are responsible for each other's debts incurred during the marriage, even if the marriage ends or the other spouse dies
C. Adult children of a deceased person are legally responsible for any debts related to the deceased person's medical bills
D. Both parents are jointly and fully responsible for a minor patient, whether married or not and regardless of the language in a divorce decree
A. Check if a legitimate estate exists and file an appropriate caveat to the estate
B. Check the register of wills for an estate
C. Change the mailing address to "The family of [patient name]"
D. If there is no estate and no one assumes financial responsibility, write off any self-pay balance remaining after insurance liability is paid
A. It improves patient-hospital relations
B. It improves traffic flow
C. It reduces need for additional staff at peak discharge times
D. It results in more billing errors because there is one less opportunity to validate information
A. Bill never received by payer
B. COB or MSP problems
C. Medical record/chart needed for review
D. Contractual requirement to hold a claim for a certain number of days
A. Call frequently and have all questions and facts ready
B. Start with accounts with lower balances and work up to those with high balances
C. Fax needed documents and then call to ensure they were received
D. Maintain and review correspondence about denials, delays, disputes, and so on
A. Collection acknowledgment
B. Collector warning
C. Mini Miranda
D. Statue of collection
A. Intentional skip
B. Unintentional skip
C. False skip
A. Endorse checks immediately with "Payable to [name of office] Only"
B. Issue receipts to customers on all cash payments and deposit them the same day as received
C. Store payments before they are deposited and other valuables in a fireproof safe
D. Maintain a payment log
E. Segregate duties
A. Average Patient Charge (APC)
B. Average Daily Revenue (ADR)
C. Average Days of Revenue in Accounts Receivable (ADRR)
D. Average Days Cash on Hand (ADCH)