What payment methodology is used to reimburse inpatient rehabilitation groups? - ANSWERSCase-mix groups
Response Feedback:
Inpatient rehabilitation hospitals are reimbursed under Case-Mix Groups (CMGs)
What payment methodology is used by Medicare to reimburse inpatient acute care hospitals? - ...
CIC - CH 12 - Review Exam Questions &
Answers
What payment methodology is used to reimburse inpatient rehabilitation groups? -
ANSWERSCase-mix groups
Response Feedback:
Inpatient rehabilitation hospitals are reimbursed under Case-Mix Groups (CMGs)
What payment methodology is used by Medicare to reimburse inpatient acute care
hospitals? - ANSWERSMS-DRGs
Response Feedback:
Inpatient acute care hospitals are reimbursed under MS-DRGs
A condition code is defined as: - ANSWERSA two-digit code entered on the claim form
to indicate that a condition applies to the bill that affects processing and payment of the
claim
Condition codes are reported on the UB-04 to describe any conditions or events that
apply to the billing period for Medicare claims. Condition codes are mandatory when
filing claims when the ABN is signed or when the item or service is statutorily not
covered, and/or the patient demands the facility file the claim.
Medicare statutory denials include: - ANSWERSI, II, III. IV
The following are examples in which Medicare payment is denied based on statutory
provisions.
Routine physicals and most tests for screening
Most vaccinations
Routine eye care, most eyeglasses and examinations
Hearing aids and hearing examinations
Cosmetic surgery
Orthopedic shoes and foot supports (orthotics)
Dental care and dentures (in most cases)
Routine foot care and flat foot care
Services under a physician's private contract
Services paid under a government entity that is not Medicare
Healthcare received outside the United States not covered by Medicare
Services by immediate relatives
Services required as a result of war
Services for which there is no legal obligation to pay
Home health services furnished under a plan of care, if the agency does not submit the
claim
Items or services excluded under the Assisted Suicide Funding Restriction Act of 1997
, Items or services furnished in a competitive acquisition area by any entity that does not
have a contract with the Department of Health and Human Services (HHS) (except in a
case of urgent need)
Physicians' services performed by a physician assistant (PA), midwife, psychologist, or
nurse anesthetist, when furnished as an inpatient, unless furnished under arrangement
with the hospital
Items and services furnished to an individual who is a resident of a skilled nursing
facility (SNF) or a part of a facility that includes a SNF, unless they are furnished under
arrangements by a SNF
Services of an assistant at surgery without prior approval from a peer review
organization
Outpatient occupational and physical therapy services furnished incident-to a
physician's service
CMS-HCC applies to: - ANSWERSMedicare Advantage
CMS hierarchical condition category risk adjustment model provides adjusted payments
based on a patient's diseases and demographic factors. If a coder does not include all
pertinent diagnoses and co-morbidities, the provider may lose out on additional
reimbursement for which he/she is entitled.
What payment methodology is used to reimburse skilled nursing facilities? -
ANSWERSPatient Driven Payment Models
Response Feedback:
Skilled nursing facilities are reimbursed under Patient Driven Payment Models (PDPM).
Medicare nonparticipating providers: - ANSWERSAre required to accept the allowed
amount determined by Medicare; however, they can bill the remainder of the limiting
charge to the patient.
Response Feedback:
For Medicare services, even if a provider is non-participating, there are limits set on
what can be charged for each CPT® code, referred to as a limiting charge. When
Medicare pays the non-participating provider, the provider can bill the difference
between the Medicare payment and the limiting charge amount to the patient.
How many MDCs are there? - ANSWERS25
Response Feedback:
Each MS-DRG is assigned to one of 25 MDCs.
When does the Final Rule for IPPS go into effect? - ANSWERSOctober 1
Response Feedback:
Annual changes to MS-DRGs are included in the Federal Register; the proposed rule is
released around midsummer and goes into effect Oct. 1.
Medicare provides: - ANSWERSPart A, Part B, Part C and Part D.
Response Feedback:
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