RHIA Domain 4 Exam Questions
with Complete Solutions
Medicare administrative contractors - Answer-Multistate, regional, contractors
responsible for administering both Medicare Part A & Part B claims
Quality Improvement organization - Answer-Reviews inpatient hospital claims to prevent
improper payment through DRG upcoming (Medicare)
Outpatient code editor - Answer-A software program linked to the correct coding
initiative that applies a set of logical rules to determine whether various combinations of
codes are correct and appropriately represent the services provided; used for
ambulatory claims
What is a grouper? - Answer-Computer software programs that assigns appropriate
MS-DRG according to the information provided for each episode of care
Retrospective payment systems - Answer-The exact amount of the payment is
determined after the service has been delivered
Prospective payment system - Answer-The exact amount of the payment is determined
before the service is delivered
Omnibus budget reconciliation act - Answer-Mandates that CMS develop a prospective
system for hospital based outpatient services provided to Medicare beneficiaries
Fee for service reimbursement - Answer-Payments are issued to healthcare providers
based on the charges assigned to each of he separate services that were performed for
the patient
Traditional fee for service reimbursement - Answer-Third party payers or patients issue
payments to healthcare providers after healthcare services have been provided
Managed fee for service reimbursement - Answer-Third party payers or patients issue
payments to healthcare providers after healthcare services have been provided except
managed care plans to control costs of managing the use of healthcare services by
members
APG - Answer-Medicaid outpatient services, payment methodology
APC - Answer-Medicare outpatient services, payment methodology
, RUG - Answer-Skilled nursing facility, Medicare
Episode of care reimbursement - Answer-Issue lump sum payments to providers to
compensate them for all the healthcare services delivered to a patient for a specific
illness or over a specific period of time
Capitation - Answer-A specified amount of money paid to a health plan or doctor. Based
on per person premiums or membership fees rather than on itemized per procedure/per
service charges
Global payments - Answer-Lump sum payments were distributed among the physicians
who performed the procedure/interpreted the results and the facility that provided
equipment, supplies, and technical support required
Medical home - Answer-Model or philosophy of primary care that is patient centered,
comprehensive, team based, coordinated, accessible, and focused on quality and
safety
Principal diagnosis - Answer-The condition that, after study, is determined to have
caused the admission of the patient to the hospital for care
Complication - Answer-A secondary condition that arises during hospitalization; can
increase the LOS
Present on Admission - Answer-A condition present at the time the Oder for inpatient
admission occurs
Resource based relative value scale system - Answer-The way Medicare determines
how much it will pay physicians is based on the resource costs needed to provide a
Medicare covered service. the RBRVS is calculated using three components; physician
work, practice expense, professional insurance
Medicare fee schedule - Answer-A feature of the resource based relative value system
that includes a complete list of the payments Medicare makes to physicians and other
providers
What is the standard increment for the aging of accounts? - Answer-30 days
How often must the home health agency's assessment and care plan must be updated?
- Answer-At least every 60 days or based on the severity of the patients condition
Participating providers - Answer-Accept Medicare and always take the assignment.
Taking assignment means that the provider accepts medicares approved amount for
health care services as full payment. These providers are required to submit a bill (file a
claim) to Medicare for the care they receive. Medicare will process the bill and pay your
with Complete Solutions
Medicare administrative contractors - Answer-Multistate, regional, contractors
responsible for administering both Medicare Part A & Part B claims
Quality Improvement organization - Answer-Reviews inpatient hospital claims to prevent
improper payment through DRG upcoming (Medicare)
Outpatient code editor - Answer-A software program linked to the correct coding
initiative that applies a set of logical rules to determine whether various combinations of
codes are correct and appropriately represent the services provided; used for
ambulatory claims
What is a grouper? - Answer-Computer software programs that assigns appropriate
MS-DRG according to the information provided for each episode of care
Retrospective payment systems - Answer-The exact amount of the payment is
determined after the service has been delivered
Prospective payment system - Answer-The exact amount of the payment is determined
before the service is delivered
Omnibus budget reconciliation act - Answer-Mandates that CMS develop a prospective
system for hospital based outpatient services provided to Medicare beneficiaries
Fee for service reimbursement - Answer-Payments are issued to healthcare providers
based on the charges assigned to each of he separate services that were performed for
the patient
Traditional fee for service reimbursement - Answer-Third party payers or patients issue
payments to healthcare providers after healthcare services have been provided
Managed fee for service reimbursement - Answer-Third party payers or patients issue
payments to healthcare providers after healthcare services have been provided except
managed care plans to control costs of managing the use of healthcare services by
members
APG - Answer-Medicaid outpatient services, payment methodology
APC - Answer-Medicare outpatient services, payment methodology
, RUG - Answer-Skilled nursing facility, Medicare
Episode of care reimbursement - Answer-Issue lump sum payments to providers to
compensate them for all the healthcare services delivered to a patient for a specific
illness or over a specific period of time
Capitation - Answer-A specified amount of money paid to a health plan or doctor. Based
on per person premiums or membership fees rather than on itemized per procedure/per
service charges
Global payments - Answer-Lump sum payments were distributed among the physicians
who performed the procedure/interpreted the results and the facility that provided
equipment, supplies, and technical support required
Medical home - Answer-Model or philosophy of primary care that is patient centered,
comprehensive, team based, coordinated, accessible, and focused on quality and
safety
Principal diagnosis - Answer-The condition that, after study, is determined to have
caused the admission of the patient to the hospital for care
Complication - Answer-A secondary condition that arises during hospitalization; can
increase the LOS
Present on Admission - Answer-A condition present at the time the Oder for inpatient
admission occurs
Resource based relative value scale system - Answer-The way Medicare determines
how much it will pay physicians is based on the resource costs needed to provide a
Medicare covered service. the RBRVS is calculated using three components; physician
work, practice expense, professional insurance
Medicare fee schedule - Answer-A feature of the resource based relative value system
that includes a complete list of the payments Medicare makes to physicians and other
providers
What is the standard increment for the aging of accounts? - Answer-30 days
How often must the home health agency's assessment and care plan must be updated?
- Answer-At least every 60 days or based on the severity of the patients condition
Participating providers - Answer-Accept Medicare and always take the assignment.
Taking assignment means that the provider accepts medicares approved amount for
health care services as full payment. These providers are required to submit a bill (file a
claim) to Medicare for the care they receive. Medicare will process the bill and pay your
