Reimbursement Methodology AHIMA
The financial manager of the physician group practice explained that the healthcare insurance company
would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that
Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks.
The payment covered *All The Services That Mrs. Zale Incurred During The Period*. What method of
reimbursement was the physician group practice receiving? correct answersEpisode-of-care
The notice from the healthcare insurance plan used the abbreviation "PMPM." How should the
insurance analyst interpret this abbreviation? correct answersPer member per month
The ICD-10-CM/PCS Coordination and Maintenance Committee is composed of representatives from
__________ and __________ correct answersNCHS and CMS
In which type of reimbursement methodology do healthcare insurance companies reimburse providers
after the costs have been incurred? correct answersRetrospective payment
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan was contracted with
the health plan to serve 300 members, of which he provided services to 100. He received $4,500 from
the health plan. What method is the health plan using to reimburse Dr. Tan? correct answersCapitated
rate
In which type of healthcare payment method does the healthcare plan pay for each service that a
provider renders? correct answersFee-for-service reimbursement
All of the following are discounted fee-for-service healthcare payment methods except:
CRG
CPR 10
RBRVS
UCR correct answersCRG
,CPT Category III codes represent: correct answersEmerging technologies
In which type of reimbursement methodology does the health insurance company have the greatest
degree of risk? correct answersRetrospective
____was created for reporting procedures and services performed by physicians in clinical practice?
correct answersCPT
The coding system that is used for reporting diagnoses for hospital inpatients is known as __________.
correct answersICD-10-CM
The Health Insurance Portability and Accountability Act (HIPPA) was enacted in __________. correct
answers1996
_________maintains the International Classification of Diseases (ICD) correct answersthe World Health
Organization (WHO)
HCPCS Level II codes begin with correct answersan alpha character followed by four numbers (A1234)
The official publication for CPT® coding issues and guidance is called the: correct answersCPT Assistant
by the AMA
In the IPPS, ____________ is the term for each hospital's unique standardized amount based on its costs
per Medicare discharge correct answers"base payment rate"
Patients with all the following conditions are appropriate for LTCHs except _______,
ventilator-dependent emphysema
sequelae of head trauma
Chronic tuberculosis
Acute myocardial infarction correct answersacute myocardial infarctions
, The MS-DRG payment includes reimbursement for all of the following inpatient services except _______
Skilled nursing facility
Long-term care hospital
Inpatient rehabilitation hospital
Home health agency correct answersSkilled nursing facility SNF
_______provides the underpinning of the Home Health PPS correct answersOASIS
___is the classification system used to case-mix adjust the SNF per-diem rates. correct answersRefined
RUG-III
_____stands for major complication/comorbidity correct answersMCC
_______is the average of the sum of the relative weights of all patients treated during a specified time
period? correct answersCase mix index
The fiscal year for MS-DRGs is______ correct answersOctober through September.
the software that assigns inpatient diagnosis related groups. correct answersGrouper
To meet the definition of an IRF, facilities must have an inpatient population with at least a specified
percentage of patients with certain conditions. Which of the following conditions is counted in the
definition?Chronic myelogenous leukemia
Acute myocardial infarction
Cancer
Brain injury correct answersBrain injury
The financial manager of the physician group practice explained that the healthcare insurance company
would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that
Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks.
The payment covered *All The Services That Mrs. Zale Incurred During The Period*. What method of
reimbursement was the physician group practice receiving? correct answersEpisode-of-care
The notice from the healthcare insurance plan used the abbreviation "PMPM." How should the
insurance analyst interpret this abbreviation? correct answersPer member per month
The ICD-10-CM/PCS Coordination and Maintenance Committee is composed of representatives from
__________ and __________ correct answersNCHS and CMS
In which type of reimbursement methodology do healthcare insurance companies reimburse providers
after the costs have been incurred? correct answersRetrospective payment
The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan was contracted with
the health plan to serve 300 members, of which he provided services to 100. He received $4,500 from
the health plan. What method is the health plan using to reimburse Dr. Tan? correct answersCapitated
rate
In which type of healthcare payment method does the healthcare plan pay for each service that a
provider renders? correct answersFee-for-service reimbursement
All of the following are discounted fee-for-service healthcare payment methods except:
CRG
CPR 10
RBRVS
UCR correct answersCRG
,CPT Category III codes represent: correct answersEmerging technologies
In which type of reimbursement methodology does the health insurance company have the greatest
degree of risk? correct answersRetrospective
____was created for reporting procedures and services performed by physicians in clinical practice?
correct answersCPT
The coding system that is used for reporting diagnoses for hospital inpatients is known as __________.
correct answersICD-10-CM
The Health Insurance Portability and Accountability Act (HIPPA) was enacted in __________. correct
answers1996
_________maintains the International Classification of Diseases (ICD) correct answersthe World Health
Organization (WHO)
HCPCS Level II codes begin with correct answersan alpha character followed by four numbers (A1234)
The official publication for CPT® coding issues and guidance is called the: correct answersCPT Assistant
by the AMA
In the IPPS, ____________ is the term for each hospital's unique standardized amount based on its costs
per Medicare discharge correct answers"base payment rate"
Patients with all the following conditions are appropriate for LTCHs except _______,
ventilator-dependent emphysema
sequelae of head trauma
Chronic tuberculosis
Acute myocardial infarction correct answersacute myocardial infarctions
, The MS-DRG payment includes reimbursement for all of the following inpatient services except _______
Skilled nursing facility
Long-term care hospital
Inpatient rehabilitation hospital
Home health agency correct answersSkilled nursing facility SNF
_______provides the underpinning of the Home Health PPS correct answersOASIS
___is the classification system used to case-mix adjust the SNF per-diem rates. correct answersRefined
RUG-III
_____stands for major complication/comorbidity correct answersMCC
_______is the average of the sum of the relative weights of all patients treated during a specified time
period? correct answersCase mix index
The fiscal year for MS-DRGs is______ correct answersOctober through September.
the software that assigns inpatient diagnosis related groups. correct answersGrouper
To meet the definition of an IRF, facilities must have an inpatient population with at least a specified
percentage of patients with certain conditions. Which of the following conditions is counted in the
definition?Chronic myelogenous leukemia
Acute myocardial infarction
Cancer
Brain injury correct answersBrain injury
