chapter 2 self review
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Valencia College *
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1110
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Medicine
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Feb 20, 2024
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Textbook Review Questions
Self-Review 2.1
1.
What is the difference between hospital inpatient care and hospital-based ambulatory care?
Inpatient short-term acute care is the type of care generally associated
with hospitals. Patients who are in need of around-the-
clock acute care are
admitted as hospital
inpatients upon the order of a physician.
Hospital-based ambulatory care can
involve outpatient surgical care, clinic care, or emergency room care.
2.
When a patient is admitted for observation services, the physician must determine whether the patient meets inpatient criteria within what timeframe? 24 Hours
3.
What does PHP stand for, and how does it differ from inpatient care? PHP stands for a partial hospitalization program, in which the patient may receive a variety of services such as individual or group therapy; occupational therapy; diagnostic services; services of
social workers, psychiatric nurses, and other staff; along with other types of services on an outpatient basis.
4.
Name and discuss three types of patients.
(
1) Hospital inpatients are acutely ill individuals
who are treated in an area of the hospital where patients generally stay overnight. (2) A hospital outpatient is a patient who is evaluated or treated
at a hospital facility but is not admitted as an inpatient. (3) Long-term acute care hospital patients are admitted to a long-
term care hospital (LTCH) and are generally more acutely ill than patients in other long-term care settings.
5.
What is a hospitalist, and what is the advantage to the patient when a hospital has one? A hospitalist is a physician who provides comprehensive care
to hospitalized patients but who ordinarily does not see patients outside
of the hospital setting. The advantage to the patient is that the hospitalist is a specialist in dealing with conditions that require hospitalization and is not distracted by
the duties of seeing patients in the clinic setting.
Self-Review 2.2
1.
What is the difference between licensure and accreditation?
Hospitals must be licensed by the state
in which they are located. Hospitals voluntarily seek accreditation to demonstrate to their
patients, to their communities, to insurers, to managed care organizations, and to others that their organizations are providing quality care.
2.
What federal requirements must an organization meet to receive Medicare payments? Conditions of Participation
3.
What three accrediting organizations are “deemed” to be in compliance with the federal Conditions of Participation?
The Joint Commission, the AOA's Healthcare Facilities Accreditation Program (HFAP), and DNV Healthcare's NIAHO
program
Self-Review 2.3
1.
True or False? A medical history and physical examination must be recorded in the medical record
within 12 hours after a procedure is performed.
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2.
True
or False? When emergency, urgent, or immediate care is provided, the time and means of arrival also must be documented in the medical record.
3.
True
or False? The Code of Federal Regulations contains the basic rules that regulate Medicare payments to teaching physicians.
Self-Review 2.4 1.
Payment policies developed by A/B MACs help educate health care providers on how to submit accurate claims for reimbursement. These payment policies are called? Payment policies developed by A/B MACs help educate health care providers on how to submit accurate claims for
reimbursement. These payment policies are called ______.Local Coverage Determinations (LCDs) or Local Medical Review Policies (LMRPs)
2.
What does MS-DRGs stand for? Medicare severity-diagnosis-related groups
3.
What is the 72-hour rule? What are pass-through payments? When a hospital provides services to a Medicare patient as an outpatient within 72 hours of a related inpatient admission, charges for those outpatient services must not be billed separately. What are pass-through payments? Pass-through payments are additional payments to
cover the costs of innovative medical devices, drugs, and biologicals.
4.
In what ways are LTC-DRGs similar and different from inpatient DRGs?
LTC-DRGs differ from inpatient DRGs in relative weights and in their associated lengths of stay.
LTC-DRGs also are similar to inpatient DRGs in that they are based on the patient's principal diagnosis, additional diagnoses, procedures performed during the stay,
age, sex, and discharge status.
Self-Review 2.5
5.
True
or False? Revenue codes are reported on the UB-04 to indicate the general nature of the service provided, such as pharmacy, room and board, or intensive care. 6.
What is the purpose of CCI edits? The purpose of the CCI (Correct Coding Initiative) edits is to prevent improper payment when incorrect code combinations are reported1. The CCI edits are a set of rules based on
clinical and coding guidelines that identify code combinations that should not be used together2. The CCI was implemented by the Centers of Medicare and Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate payments for Part B provider claims3
The purpose of the CCI edits is to prohibit unbundling of procedures, a practice that results in excessive payment to the provider when multiple codes are reported
instead of a combination code.
7.
What piece of legislation included a Medicare and Medicaid incentive program for health care providers who demonstrate the ability to “meaningfully use” EHRs?
The Medicare and Medicaid incentive program for health care providers who demonstrate the ability to “meaningfully use” EHRs was included in the American Recovery and Reinvestment Act of 2009 (ARRA)
1. The program was developed to encourage eligible professionals (EPs) and eligible hospitals and critical access hospitals (CAHs) to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified electronic health record technology (CEHRT) 2. The program was later renamed to Promoting Interoperability Program2. It includes the HITECH Act, which outlines the requirements for the EHR Incentive Program, designed to incent Medicare and Medicaid eligible hospitals (EHs), Critical Access Hospitals (CAHs) and eligible professionals (EPs) to electronically collect, store, transmit, and use health care information in a meaningful, secure, and
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timely way with other health entities and government agencies.1Priority areas include e-prescribing, and the exchange of lab results and clinical summaries.
1.
When were Medicare providers scheduled to be penalized for not meeting meaningful use requirements? Medicare eligible professionals who are not meaningful users will be subject
to a payment adjustment beginning on January 1, 2015.
2.
What are the two basic data sets that apply to hospital-based care? The Uniform Hospital Discharge Data Set (UHDDS) and the Uniform Ambulatory Care Data Set (UACDS)
3.
What data set is specific to the emergency department setting?
The Data Elements for Emergency Department Systems (DEEDS)
Self-Review 2.6
1.
True
or False? Fulfilling HOP QDRP requirements is necessary to receive the full payment update
for the OPPS. 2.
What are HACs, and how are they identified? Hospital-acquired conditions (HACs) are identified through the Present on Admission (POA)
indicator associated with additional diagnoses coded on
the hospital bill for inpatient services.
3.
What is the name for staff members most directly responsible for monitoring utilization management? Case Managers
4.
True or False
? When a patient is not available, a message containing clinical information (such as test results) should be left via voicemail or with a close family member/friend so the health care provider can remain HIPAA-compliant. 5.
What does EMTALA stand for, and what is its purpose?
EMTALA stands for Emergency Medical Treatment and Labor Act. It is a federal law enacted by Congress in 1986 to ensure that patients receive appropriate medical care in emergency situations, regardless of their ability to pay.
Self-Review 2.7 1.
Name various areas within a hospital setting that have possible roles for HIM professionals. Health Information Services, Performance Improvement, Cancer Registry, Trauma Registry,
Information Systems, and Financial Services
2.
True
or False? To meet HIPAA requirements, hospitals should have a privacy officer and a security
officer. 3.
What kind of services does a HIPAA compliance officer and his/her staff provide? A HIPAA compliance officer and his/her staff can provide HIPAA training; develop policies, procedures, and forms; or monitor the hospital's ongoing compliance with the HIPAA privacy, security, and/or EDI regulations. Auditing is another important activity of the compliance program, whether auditing
records against codes
submitted, auditing release of information for appropriate authorization, or auditing the appropriateness of employee access to electronic health information
4.
True or False
? Because much of the coding for an ambulatory patient’s bill is generated automatically by the hospital’s chargemaster, it is not necessary for someone with a knowledge of coding to be involved in chargemaster maintenance.
Review Questions Knowledge-Based Questions
1.
UHDDS
Uniform Hospital Discharge Data Set for inpatients
2.
UACDS
Uniform Ambulatory Care Data Set for outpatients
3.
DEEDS
Data Elements for Emergency Department Systems are standards of emd
4.
HETS
HIPAA Eligibility Transaction System is
data standards for Medicare; maintained by MACs
1.
True or False? When a patient is not available, a message containing clinical information (such as test results) should be left via voicemail or with a close family member/friend so the health care provider can remain HIPAA-compliant.
2.
True or False? A medical history and physical examination must be recorded in the medical record
within 12 hours after a procedure is performed.
1.
False—Should be placed before a procedure is performed.
3.
True
or False? When emergency, urgent, or immediate care is provided, the time and means of arrival also must be documented in the medical record
.
4.
True
or False? The Code of Federal Regulations contains the basic rules that regulate Medicare payments to teaching physicians.
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5.
True
or False? Revenue codes are reported on the UB-04 to indicate the general nature of the services provided, such as pharmacy, room and board, or intensive care.
6.
True
or False? Fulfilling HOP QDRP requirements is necessary to receive the full payment update for the OPPS.
7.
True or False? Because much of the information for an ambulatory patient's bill is generated automatically by the hospital's chargemaster, it is not necessary for someone with a knowledge of coding be involved in chargemaster maintenance.
8.
True
or False? To meet HIPAA requirements, hospitals should have a privacy officer and a security
officer.
9.
What has been the trend in the utilization of hospital-based services? What factors help to account for this trend?
1.
The trend that has been utilized in the hospital based service is from long term acute care hospital. to providing services of inpatient short-term care to now a common practice that takes place in hospital based ambulatory care for quality improvements. As technology advances this enables providers to perform several types of surgery on an ambulatory basis that is referred to the
"same- day" thereby utilization increases the ambulatory outpatient facilities than to where it was once consider as inpatient care. A factor that considers this trend is third-party payers reimburses surgical procedures only when performed in ambulatory setting. Another factor hospital ancillary services such as hospital laboratory or the radiology department may perform tests on hospital outpatients as well as inpatients. Federal regulators and private accrediting organizations have placed a renewed focus on quality improvement initiatives with health care organizations. Reimbursement rates to report data that is made available to the public via Internet. Electronic Health records are accelerating due to ARRA. One trend that cuts across several areas - documentation, coding, reimbursement and revenue cycle management. In addition to Increasing coding and payment issues by auditing indicatives such as Recovery Audit Contractor (RAC) and Medicaid Integrity Programs (MIP).
2.
In recent years, there has been a sharp increase in the use of ambulatory services that are located in medical facilities. The driving elements behind this approach are improvements in research generation and modifications to reimbursement structures that encourage the delivery of treatment in the most affordable location. The use of hospitalists to treat hospital inpatients is one of the current trends. Applications that connect the best treatment and payment are currently popular. Electronic fitness information is being adopted more quickly, in part due to ARRA incentives. A trend related to cost-cutting plans for Medicare and Medicaid is the increased quantity and breadth of auditing jobs. 3.
Emergency services
4.
Subsidiary services
5.
Outpatient department services
6.
Referred patient services
7.
In - patient services The trend that has been utilized in the hospital based service is from long
term acute care hospital.
to providing services of inpatient short-term care to now a common practice
that takes place in hospital
based ambulatory care for
quality improvements. As technology advances this enables providers to perform several types of surgery on an ambulatory basis that is referred to the
“sameday” thereby utilization increases the ambulatory outpatient facilities than to where it was once consider as inpatient care. A factor that considers this trend is
third-party payers reimburses surgical procedures only when performed in ambulatory setting. Another factor hospital ancillary services such as hospital laboratory or the radiology
department may perform tests on hospital outpatients as well as inpatients. Federal regulators and private accrediting organizations have placed a renewed focus on quality improvement initiatives with health care organizations. Reimbursement rates to report data that is made available to the public via Internet. Electronic Health records are accelerating due to ARRA. One trend that cuts across several areas - documentation,
coding, reimbursement and revenue cycle management. In addition to Increasing coding and payment issues by auditing indicatives such as Recovery Audit Contractor (RAC) and Medicaid Integrity Programs (MIP).
10.
List and describe five different types of outpatient services?
1.
Hospital Outpatient Unit - An organizational unit of a hospital providing health services to patients who are generally ambulatory and who are not currently inpatients Hospital Outpatient Clinic - A type of hospital outpatient unit generally organized based on the clinical specialty of the care providers or the types of services needed by the patient Hospital Emergency Unit- An organizational unit providing medical services needed on an urgent or emergency basis Hospital Observation Unit - An organizational unit for monitoring unstable patients and assessing whether or not they require inpatient admission Hospital Ambulatory Surgery Unit - An organizational unit for performing elective
surgical procedures on patients who generally do not stay at the hospital overnight
11.
What organization accredits the majority of hospitals in the United States? Which accrediting organization most recently received “deeming authority” from CMS for its hospital accreditation program? 1.
The Joint Commission accreditation is the organization that accredits majority of hospitals in the United States. National Integrated accreditation of Healthcare Organizations (NIAHO), a program of DNV Healthcare, Inc., an international organization originating in Norway
12.
What key components must both inpatient and outpatient records contain in the documentation of surgery? 1.
The key components of both inpatient and outpatient records must contain the following documentation for surgery are: History and physical examination report; Operation report; Anesthesia record; Operation recovery notes; Pathology reports that is needed for appropriation.
13.
What are the key issues with regard to documentation of services rendered by teaching physicians? 1.
The teaching physician's documentation necessity in hospitals is that residents learn during their graduate medical education in participating with teaching physicians in caring of patients. For example, the Code of Federal Regulations contains the rudimentary of Medicare payment to teaching physicians along with acceptable or unacceptable documentation applies to Medicare Claims Processing Manual. Therefore, the participation
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of evaluation and management services that teaching physician must be present during key portion of services for the patient’s care. Countersigning the resident’s note is inadequate documentation to justify payment. This includes that the teaching physician was present at the time the service furnished when resident is documenting in the patient’s
record. The presence of th teaching physician during procedures may be demonstrated by
the notes in the medical records made by a physician, resident, or nurse. The services must be furnished in a center that is located in an outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities included in determine intermediary payment to a hospital.; Physician must have completed more than 6 months of an approved residency program. Physician must not direct the care of more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability
14.
What is the hospital chargemaster or charge description master? 1.
The chargemaster is consider as a billable service that is a computerized data table known as the Charge Description Master. This bill includes services that have been performed by nursing, and other health professional staff including room and board charges, ancillary services, lab testing, radiology imaging, medical equipment and any other additional supplies needed for a patient’s are. It is important to properly maintain the chargemaster file, making sure that it reflects current codes and reasonable charges.
15.
What are DRGs? What are APCs? What is their impact on hospital reimbursement? 1.
Hospital Inpatient Prospective Payment System (HIPPS) which pays the hospital “per case” according to the diagnosis related group – DRGs that is assigned to each patient stay which determines the payment receives under HIPPS. Hospital Outpatient Prospective Payment System (OPPS) is “Medicare’s payment system for hospital outpatient services for the basic unit of OPPS is the ambulatory payment classification (APC) of each service provided”. APC establishes groups of outpatient procedures and services that have similar clinical characteristics and costs. APC represents a significant procedure that is discounted when other procedures are performed with it and assign more
than one APC per encounter. 16.
What coding systems are used in hospital-based care?
1.
International Classification of Diseases (ICD-9-CM and PC); Healthcare Common Procedural Coding System (HCPCS); Current Procedural Terminology (CPT); Revenue Codes and Coding edits MCE, OCE, NCCI)
17.
What is EMTALA? 1.
EMTALA - A federal law that imposes a legal duty on hospitals to screen and stabilize, if necessary, any patient who arrives in the emergency department. The purpose of EMTALA is to prevent the " anti-dumping" of patients who may not be able to pay for emergency department services which facilities are not to delay screening to check insurance and must treat and stabilize a woman in labor generally means deliver of infant before transfer.
18.
What is ARRA?
1.
ARRA is American Recovery and Reinvestment Act- A federal law that, among other things, created an incentive program for health care providers to utilize EHR to improved patient care. This
is a Medicare and Medicaid incentive program for health care providers who demonstrate the ability to "meaningful use" EHR recommendations. Therefore, more hospitals will be expected to adopt to electronic health records that will be fast, accurate, and accessible to health care providers and patients; if not meeting the meaningful use requirements of an EHR facilities will be penalized
19.
What factors should be considered to avoid legal risk in hospital-based care? 1.
The factors should be considered to avoid legal risk in a hospital-based care is to protect the facility from financial loss that can occur from potentially compensable events (PCEs), that may result in litigation against a health care provider from a compensate injured individual. Hospitals have incident reporting system for risk managers to track PCEs. Also making sure that records are meeting all regulatory requirements for authentication from providers are properly signing, dating and timing documentation. Taking caution of appropriate screenings as for ambulatory care following up with a phone to patients after procedures a next day routine call. Not to leave any voice messages of a patient abnormal test result. In addition to, these factors are tools that will help facilities to avoid any legal matter in considering the Quality Assessment and performance Improvement (QAPI) from the Risk Management Department; Incident reporting system; Policy and procedures; Telephone contact; Proper Documentation and Emergency Medical Treatment and Active Labor Act (EMTALA).
20.
If The Joint Commission requires that “the hospital initiates and maintains a medical record for every individual assessed or treated,” what factors allow a hospital to maintain minimal data, such as test results in the case of some referred outpatients?
If the patient requires urgent, emergency or immediate care , the hospital can have minimal data documented such as his/her time and means of arrival, when the patient under immediate care is left against medical device and the conclusion at the termination of treatment.
21.
Select two of the three hospital accrediting organizations mentioned in this chapter, and write a brief essay comparing and contrasting the two organizations that you selected. Use outside resources, if necessary, but remember to think critically and avoid relying heavily on marketing or promotional information.
Accreditation:
Accreditation is a method of reviewing or evaluating the performance level of health care organization. The purpose is to improve effectiveness, efficiency, and quality of health care organization.
The Joint Commission (TJC):
The Joint Commission (TJC) is an independent entity that accredits several health care organizations. The purpose is to improve the safety of patient and quality
of care.
Healthcare Facilities Accreditation Program (HFAP):
Healthcare Facilities Accreditation Program is a recognized accreditation association with deeming authority from centers for Medicare and Medicaid services (CMS).
Similarity between the joint commission and healthcare facilities accreditation program:
The common goal of both accreditation organizations is to enhance the patient’s care and improve patient safety. The organizations take extra care on the safety
of the patients.
Difference between the joint commission and healthcare facilities accreditation program:
The main purpose of TJC is to enhance specific improvement in patient care whereas; the purpose of HFAP is to
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maintain the standards in the care of patient.
TJC provides various accreditation programs for healthcare organization whereas HFAP provides accreditation program specifically for clinical laboratories, hospitals, and acute care settings.