Medicare Payment Systems: Key Quiz for Healthcare Professionals

Question 1 5 out of 5 points Which of the following types of hospitals are excluded from the Medicare acute-care prospective payment system? Selected Answer: Children's hospitals Answers: Children's hospitals Small, community hospitals Tertiary hospitals Trauma hospitals Response Feedback: Children's hospitals are excluded from the Medicare acute- care PPS because the PPS diagnosis-related groups do not accurately account for the resource costs for the types of patients treated (Hazelwood and Venable 2020, 230–240). Question 2 5 out of 5 points What are the possible add-on payments that a hospital could receive in addition to the basic Medicare DRG payment? Selected Answer: Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases. Answers: Additional payments may be made for locum tenens, increased emergency room services, stays over the average length of stay, and cost outlier cases. Additional payments may be made to critical access hospitals, for higher-than-normal volumes, unexpected hospital emergencies, and cost outlier cases.

Additional payments may be made for increased emergency room services, critical access hospitals, increased labor costs, and cost outlier cases. Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases. Response Feedback: Medicare provides for additional payment for other factors related to a particular hospital's business. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the MS-DRG adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve these areas. Hospitals that have approved teaching hospitals also receive a percentage add-on payment for each Medicare discharge paid under IPPS, known as the indirect medical education (IME) adjustment. The percentage varies, depending on the ratio of residents to beds. Additional payments are made for new technologies or medical services that have been approved for special add-on payments. Finally, the costs incurred by a hospital for a Medicare beneficiary are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases (Schraffenberger and Palkie 2022, 727). Question 3 5 out of 5 points The purpose of a physician query is to _____. Selected Answer: Improve documentation for patient care and proper reimbursement Answers: Identify the MS-DRG Identify the principal diagnosis

Improve documentation for patient care and proper reimbursement Increase reimbursement as form of optimization Response Feedback: The purpose of a physician query is to improve documentation to support services billed (Brinda 2020, 186). Question 4 5 out of 5 points A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain _____. Selected Answer: Budget neutrality Answers: Moderate rate increases Market basket increases Budget neutrality Sustainable growth rate Response Feedback: Budget neutrality must be maintained annually when the relative value units (RVUs) are adjusted (Hazelwood and Venable 2020, 232–234). Question 5 5 out of 5 points Each HCPCS code has been assigned a(n) _____ that establishes how a service, procedure, or item is paid in the outpatient prospective payment system (OPPS). Selected Answer: Payment status indicator (SI)

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Answers: Payment status indicator (SI) Ambulatory Payment Classification (APC) Outpatient Code Editor (OCE) Cost-to-charge ration (CCR) Response Feedback: OPPS requires that facilities use HCPCS code to report services or procedures performed. Each code in HCPCS has been assigned a payment status indicator (SI) that establishes how a service, procedure, or item is paid (Casto and White 2021, 105–117). Question 6 5 out of 5 points Which of the following software applications would be used to aid in the coding function in a physician's office? Selected Answer: Encoder Answers: Grouper Encoder Pricer Diagnosis calculator Response Feedback: An encoder is a computer software program designed to assist coding professionals in assigning appropriate clinical codes and to help ensure accurate reporting of diagnoses and procedures (Sayles 2020, 75). Question 7 5 out of 5 points The front end of the revenue cycle management process does not include

_____. Selected Answer: Claims appeals Answers: An enterprise-wide scheduling system Claims appeals An order tracking system A financial function system Response Feedback: The front end of the revenue cycle management process includes scheduling and registration, insurance verification, preauthorization, financial counseling and pre-encounter services. Claims appeals are a back-end process (Casto and White 2021, 233–264). Question 8 5 out of 5 points Identify the correct ICD-10-CM diagnosis code(s) and sequencing for a patient with disseminated candidiasis secondary to AIDS-related complex. Selected Answer: B20, B37.7 Answers: B20, B37.7, Z20.6 B37.7, B20 B20, B37.7, Z21 B20, B37.7

Response Feedback: Only confirmed cases of HIV infection or illness are reported, using code B20, Human immunodeficiency virus (HIV) disease, per ICD-10-CM Official Guidelines for Coding and Reporting, Guideline I.C.1.a.1 (CMS 2022a). Patients with an HIV-related illness should be coded to category B20, which includes AIDS, AIDS-like syndrome, AIDS- related complex, and symptomatic HIV infection. B20, Human immunodeficiency virus, is the first-listed diagnosis code when a patient is seen for an HIV-related condition, unless the reason for admission is hemolytic-uremic syndrome associated with HIV disease. Any HIV-related conditions should be listed as additional diagnosis codes (CMS 2022a; Schraffenberger and Palkie 2022, 130–133). Question 9 5 out of 5 points The CMS-HHC model indicates the cost of treating the individual relative to the average beneficiary through a measure identified as the _____. Selected Answer: Risk score Answers: Case mix Risk score Major diagnostic category Resource-based relative value Response Feedback: The CMS-HCC model is used to create a risk score for each beneficiary (Casto and White 2021, 60). Question 10 5 out of 5 points What is the best reference tool for ICD-10-CM and ICD-10-PCS coding advice? Selected Answer:

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AHA's Coding Clinic for ICD-10-CM/PCS Answers: CMS Inpatient Prospective Payment System (IPPS) ICD-10-CM and ICD-10-PCS Coding Guidelines AHA's Coding Clinic for ICD-10-CM/PCS National Correct Coding Initiative (NCCI) Response Feedback: AHA's Coding Clinic for ICD-10-CM/PCS is a quarterly publication of the Central Office on ICD-10-CM/PCS, which allows coding professionals to submit a request for coding advice through the coding publication. AHA's Coding Clinic is the only official publication for ICD-10-CM and ICD-10-PCS coding guidelines and advice provided by the four Cooperating Parties (Smith 2021, 8, 41). Question 11 5 out of 5 points What is the name of the organization that develops the billing form that hospitals are required to use? Selected Answer: National Uniform Billing Committee (NUBC) Answers: American Academy of Billing Forms (AABF) National Uniform Billing Committee (NUBC) National Uniform Claims Committee (NUCC) American Billing and Claims Academy (ABCA) Response The National Uniform Billing Committee (NUBC) was

Feedback: established with the goal of developing an acceptable, uniform bill that would consolidate the numerous billing forms hospitals were required to use (Smith 2021, 15). Question 12 5 out of 5 points What is the basic formula for calculating each MS-DRG hospital payment? Selected Answer: Hospital payment = MS-DRG relative weight × hospital base rate Answers: Hospital payment = MS-DRG relative weight × hospital base rate Hospital payment = MS-DRG relative weight × hospital base rate – 1 Hospital payment = MS-DRG relative weight / hospital base rate + 1 Hospital payment = MS-DRG relative weight / hospital base rate Response Feedback: For any given patient in a MS-DRG, the hospital knows, in advance, the amount of reimbursement it will receive from Medicare. It is the responsibility of the hospital to ensure that its resource use is in line with the payment (Casto and White 2021, 210–211). Question 13 5 out of 5 points An electrolyte panel (80051) in the Laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of _____. Selected Answer: Unbundlin

g Answers: Optimizing Unbundlin g Sequencin g Classifying Response Feedback: Unbundling occurs when a panel code exists, and the individual tests are reported rather than the panel code (Smith 2021, 69, 199). Question 14 5 out of 5 points The maximum number of ambulatory payment classifications (APCs) that may be reported per outpatient encounter is _____. Selected Answer: No maximum number Answers: One Six Ten No maximum number Response Feedback: The number of APCs reportable per encounter is unlimited (Casto and White 2021, 170). Question 15 5 out of 5 points In the Laboratory section of CPT, if a group of tests overlaps two or more

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panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coding professional do with the remaining test codes that are not part of a panel? Selected Answer: Report the remaining tests using individual test codes. Answers: Report the remaining tests using individual test codes. Do not report the remaining individual test codes. Report only those test codes that are part of a panel. Do not report a test code more than once regardless of whether the test was performed twice. Response Feedback: It is inappropriate to assign additional panel codes when all tests in the panel are not performed. Reporting individual lab test codes is appropriate when all tests in a panel have not been provided (Smith 2021, 214–215). Question 16 5 out of 5 points On October 1, 2012, the Affordable Care Act established which of the following, requiring CMS to reduce payments to IPPS hospitals with excess admissions? Selected Answer: Hospital Readmissions Reduction Program Answers: Hospital-acquired conditions (HACs) MS-DRGs Hospital Readmissions Reduction Program RUG-III Response Feedback: One section of the Affordable Care Act established the Hospital Readmissions Reduction Program, requiring CMS to reduce payments to the IPPS hospitals for discharges

beginning October 1, 2012 (Casto and White 2021, 58, 60). Question 17 5 out of 5 points A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? Selected Answer: Monies paid to the healthcare provider cannot exceed charges. Answers: The patient receives any monies paid by the insurance companies over and above the charges. Monies paid to the healthcare provider cannot exceed charges. The decision on which company is primary is based on remittance advice. The patient should not have a Medicare supplement. Response Feedback: The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Casto and White 2021, 51–58). Question 18 5 out of 5 points In fiscal year 2008, Medicare revamped the inpatient payment system to incorporate three severity levels. The grouping is known as _____. Selected Answer: MS-DRGs Answers: AP-DRGs RBRVS MS-DRGs

APR- DRGs Response Feedback: Medicare revamped the DRG system to incorporate severity of illness into the MS-DRG payment system in fiscal year 2008 (Casto and White 2021, 75). Question 19 5 out of 5 points Assignment of benefits is a contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services and the beneficiary for the _____, and to accept the Medicare payment as payment in full. Selected Answer: Coinsurance or deductible Answers: Coinsurance or deductible Deductible only Coinsurance only Balance of charges Response Feedback: When a physician accepts assignment of benefits, the physician can only collect any applicable deductible or coinsurance from the patient (Casto and White 2021, 125, 243). Question 20 5 out of 5 points CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of service greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set? Selected Answer: HCPCS/CPT

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codes Answers: ICD-10-PCS codes HCPCS/CPT codes ICD-10-CM codes LOINC Response Feedback: CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system that pays providers based on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2022a, I-5–I-6).

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