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CCS EXAM - Medical Billing and Reimbursement System Exam Questions with Answers
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CCS EXAM - Medical Billing and ReimbursementSystem Exam Questions with Answers
A computer software program that assigns appropriate MS-DRGs according
to the information provided for each episode of care is called a(n) - -grouper
-A patient with Medicare is seen in the physician's office.The total charge for
this office visit is $250.00.The patient has previously paid his deductible
under Medicare Part B.The PAR Medicare fee schedule amount for this
service is $200.00.The non-PAR Medicare fee schedule amount for this
service is $190.00.
If this physician is a nonparticipating physician who does NOT accept
assignment for this claim, the total amount the physician will receive is - -
$190
-Ambulatory patient classifications (APC) - -a prospective payment system
for hospital outpatient services provided to Medicare and Medicaid
beneficiaries
-Capitation - -System of payment used by managed care plans in which
physicians and hospitals are paid a fixed, per capita amount for each patient
enrolled over a stated period regardless of the type and number of services
provided; reimbursement to the hospital on a per-member/per-month basis
to cover costs for the members of the plan.
-Claim Forms and Processes for Submission - -UB-04: the paper claim form
used by hospitals
HIPAA X12N 837I: electronic claims form of the UB-04
CMS-1500: the paper claim form used by outpatient facilities and physicians
HIPAA X12N 837P: electronic claims form of the CMS-1500
CMS-1491: the paper claim form used by ambulance companies
-Code used to identify the procedure, service, or treatment - -HCPCS/CPT
code
-Commercial insurance plans usually reimburse health care providers under
some type of __________ payment system, whereas the federal Medicare
program uses some type of _________ payment system. - -retrospective,
prospective
-Diagnosis-related groups (DRG) - -A classification system that establishes
pretreatment diagnosis billing categories
, -Explanation of benefits (EOB) - -readmittance advice sent to the
policyholder
-Home Health Agencies (HHAs) utilize a data entry software system called -
-HAVEN (Home Assessment Validation and Entry)
-ICD-10-PCS procedure codes are used on which of the following forms to
report services provided to a patient? - -UB-04
-Medicare physician fee schedule (MPFS) - -A national price list for physician
services established by Medicare
-Non-PAR limiting charge - -for a non-participating physician who does not
accept assignment, the limiting charge is 15% over the non-PAR allowed
amount
-Payment calculations - -Resource-based reimbursement value system
(RBRVS)
Usual, customary, and reasonable (UCR)
Capitation
Fee-for-service (FFS)
Episodic care
Case-mix index (CMI)
Resource utilization groups (RUG)
Ambulatory patient classifications (APC)
-Payment Systems - -IPPS: inpatient prospective payment system
OPPS: outpatient prospective payment system
-Remittance advice (RA) - -an explanation of benefits transmitted
electronically by a payer to a provider
-Resource utilization groups (RUG) - -a case-mix-adjusted system based on
Minimum Data Set assessments in skilled nursing facilities (SNF)
-Review policies that describe the circumstances of coverage for various
types of medical treatment - -local coverage determinations and national
coverage determinations
-Terminally ill patients with life expectancies of ______ may opt to receive
hospice services. - -6 months are less
-The computer-to-computer transfer of data between providers and third-
party payers in a data format agreed upon by both parties is called - -
electronic data interchange (EDI)
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