Exam (elaborations)
CHAPTER 17 HOSPITAL BILLING QUESTIONS WITH 100% CORRECT ANSWERS
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CHAPTER 17 HOSPITAL BILLING QUESTIONS WITH 100% CORRECT ANSWERS
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CHAPTER 17 HOSPITAL BILLINGQUESTIONS WITH 100% CORRECT
ANSWERS
admission nnreview nn- nnAnswer nnA nnreview nnfor nnappropriateness nnand nnnecessity nnof
nnadmissions.
ambulatory nnpayment nnclassifications nn- nnAnswer nnAPCs, nnA nnsystem nnof nnoutpatient
nnhospital nnreimbursement nnbased nnon nnprocedures nnrather nnthan nndiagnoses.
appropriateness nnevaluation nnprotocols nn- nnAnswer nnNineteen nncriteria nnfor
nnadmission nnunder nnthe nnprospective nnpayment nnsystem, nnseparated nninto nntwo
nncategories: nnseverity nnand nnintensity nnof nnillness. nnTo nnallow nna nnpatient
nnadmission nnto nnan nnacute nncare nnfacility, nnone nncriterion nnfrom nneach nncategory
nnmust nnbe nnmet.
benefit nnsummary nnsheets nn- nnAnswer nnDocuments nnpublished nnby nnhealth
nninsurance nncompanies nnthat nnprovide nnguidelines nnon nnmedical nncodes,
nnreimbursement nnschedules, nnand nnother nndata nnfor nncompletion nnof nnaccurate
nnmedical nnclaim nnforms.
capitation nn- nnAnswer nnSystem nnof nnpayment nnused nnby nnmanaged nncare nnplans nnin
nnwhich nnphysicians nnand nnhospitals nnare nnpaid nna nnfixed, nnper nncapita nnamount nnfor
nneach nnpatient nnenrolled nnover nna nnstated nnperiod nnregardless nnof nnthe nntype nnand
nnnumber nnof nnservices nnprovided; nnreimbursement nnto nnthe nnhospital nnon nna nnper-
member/per-month nnbasis nnto nncover nncosts nnfor nnthe nnmembers nnof nnthe nnplan.
case nnrate nn- nnAnswer nnAn nnaveraging nnafter nna nnflat nnrate nnis nngiven nnto nncertain
nncategories nnof nnprocedures.
charge nndescription nnmaster nn- nnAnswer nnA nncomputer nnprogram nnthat nnis nnlinked
nnto nnvarious nnhospital nndepartments nnand nnincludes nnprocedure nncodes, nnprocedure
nndescriptions, nnservice nndescriptions, nnfees, nnand nnrevenue nncodes; nnAKA: nncharge
nnmaster nnor nnprocedure nncode nndictionary.
charges nn- nnAnswer nnThe nndollar nnamount nna nnhospital nnbills nnan nnoutlier nncase nnon
nnthe nnbasis nnof nnthe nnitemized nnbill.
, clinical nnoutliers nn- nnAnswer nnCases nnthat nncannot nnadequately nnbe nnassigned nnto
nnan nnappropriate nnDRG, nnowing nnto nnunique nncombinations nnof nndiagnoses nnand
nnsurgeries, nnrare nnconditions, nnor nnother nnunique nnclinical nnreasons. nnSuch nncases
nnare nngrouped nntogether nninto nnclinical nnontlier nnDRGs nnand nntherefore nnconsidered
nnoutliers.
code nnsequence nn- nnAnswer nnThe nncorrect nnorder nnof nndiagnostic nncodes nn(1,2,3,4)
nnwhen nnsubmitting nnan nninsurance nnclaim nnthat nnaffects nnmaximum nnreimbursement.
nnOther nnfactors nnaffecting nnmaximum nnreimbursement nnare nnaccurate nndiagnostic
nncoed nnselection nnand nnlinking nnthe nnproper nnservice nnor nnprocedures nnprovided nnto
nnthe nnpatient.
comorbidity nn- nnAnswer nnAn nnongoing nncondition nnthat nnexists nnalong nnwith nnthe
nncondition nnfor nnwhich nnthe nnpatient nnis nnreceiving nntreatment; nnin nnregard nnto
nnDRGs, nna nnpreexisting nncondition nnthat, nnbecause nnof nnits nnpresence nnwith nna
nncertain nnprincipal nndiagnosis, nnwill nncause nnan nnincrease nnin nnlength nnof nnstay nnby
nnat nnleast nn1 nnday nnin nnapproximately nn75% nnof nncases. nnAKA nnsubstantial
nncomorbidity
cost nnoutlier nn- nnAnswer nnA nntypical nncase nnthat nnhas nnan nnextraordinarily nnhigh
nncost nnwhen nncompared nnwith nnmost nndischarges nnclassified nnto nnthe nnsame
nndiagnostic nncost nngroup nn(DRG).
cost nnoutlier nnreview nn- nnAnswer nnA nnreview nnby nna nnprofessional nnreview
nnorganization nn(PRO) nnfor nnthe nnnecessity nnof nna nnpatient's nnhospital nnadmission
nnand nnto nndetermine nnwhether nnall nnservices nnrendered nnwere nnmedically
nnnecessary. nnCost nnoutlier nncases nnare nnrecognized nnonly nnif nnthe nncase nnis nnnot
nneligible nnfor nnday nnoutlier nnstatus.
day nnoutlier nnreview nn- nnAnswer nnA nnreview nnof nnpotential nnday nnoutliers nn(short nnor
nnunusually nnlong nnlength nnof nnhospital nnstay) nnto nndetermine nnthe nnnecessity nnof
nnadmission nnand nnnumber nnof nndays nnbefore nnthe nnday nnoutlier nnthreshold nnis
nnreached, nnas nnwell nnas nnthe nnnumber nnof nndays nnbeyond nnthe nnthreshold. nnThe
nnprofessional nnreview nnorganization nndetermines nnthe nncertification nnof nnadditional
nndays.
diagnosis-related nngroups nn- nnAnswer nnA nnpatient nnclassification nnsystem nnthat
nncategorizes nnpatients nnwho nnare nnmedically nnrelated nnwith nnrespect nnof nndiagnosis
nnand nntreatment nnand nnstatistically nnsimilar nnin nnlength nnof nnhospital nnstay.
nnMedicare nnhospital nninsurance nnpayments nnare nnbased nnon nnfixed nndollar
nnamounts nnfor nna nnprincipal nndiagnosis nnas nnlisted nnin nnDRGs.
DRG nncreep nn- nnAnswer nnCoding nnthat nnis nninappropriately nnaltered nnto nnobtain nna
nnhigher nnpayment nnrate; nnalso nnknown nnas nncoding nncreep, nndiagnostic nncreep, nnor
nnupcoding.
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