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Ch. 1 - Reimbursement, HIPAA, and Compliance

MAST 1510 Medical Billing and Coding

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Audrey Meyer

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Cards in this guide (46)
If a QIO provider renders a covered service that costs $100 and bills Medicare for the service and Medicare allowed $58, the provider would bill this amount to the patient:

$0

Identify this acronym:OIG

Office of the Inspector General

Identify this acronym:RBRVS

Outpatient Resource - Based Relative Value Scale

A(n) (Blank) (three words), usually an insurance co., handles the daily operations for Medicare, including paper work, claims, and payments.

Medicare Administrative Contractors

A(n) (Blank) assignment is when a provider does not bill the patient for the difference between the service cost and Medicare allowed.

accepting

A medical coder's responsibility is to code accurately and (Blank).

completely

The physician fee schedule is updated each April 15 and is composed of:
  1. Relative Value Units (RVUs)
    2) Geographic adjustment factor to adjust for regional variations in the cost of operating a health care facility
    3) A National Conversion Factor
The amount determined by multiplying the RVU weight by the geographic index and the conversion factor is called (Blank) (two words) amount.

fee schedule

The (Blank) (two words) is a national dollar amount that applied to all services paid on the basis of the MFS.

conversion factor

For endoscopic procedures, Medicare allows the full value of the highest valued endoscopy, plus the difference between the next highest endoscopy and the (Blank) endoscopy.

highest

Identify the Medicare part with this coverage: "Automatic Coverage"

Part A

Ch.1, pg.5:
"Beneficiaries are automatically eligible for Part A..."

Identify the Medicare part with this coverage: "Hospice Care"

Part A

Identify this acronym:QIO

Quality Improvement Organizations

The conversion factor (CF) is a national dollar amount that is applied to all services paid on the basis of the (Blank).

Medicare Fee Schedule (MFS)

Select the three types of persons eligible for Medicare:
  1. those with disability benefits
    2) those with permanent kidney failure
    3) those 65 and over
Under the RBRVS, the unit value is termed (Blank) Value Unit.

Relative

What are the three items that the Medicare beneficiaries are responsible for paying before Medicare will began to pay for services
  1. deductibles
    2) premiums
    3) coinsurance
Identify this acronym:MAAC

Maximum Actual Allowable Charge

Medicare Part B pays for:

Physician services & durable Medical equipment

Medicare Part A pays for:

hospital/facility care

The Medicare program was established in:

1965

(Blank) is the largest third-party payer in the U.S.:

Medicare

The (Blank) is the fastest growing segment of the population.

Elderly

Which group does the Medicare program NOT cover

prisoners

Medicare Part (Blank) is a prescription drug benefit.

D

Identify this acronym:CMS

Centers for Medicare and Medicaid services

Medicare sets the payment level for assistant surgeons at a percentage of the "fee schedule" amount for the (Blank) surgical service.

global

Select the three components of the relative value unit.
  1. malpractice
    2) work
    3) overhead
A major charge took place in Medicare in (Blank) with the enactment of the Omnibus Budget Reconciliation Act. (OBRA)

1989

Medicare pays for what percentage of covered charges

80%

If a surgeon performs more than one procedure on the same patient on the same day, and discounts were made on all subsequent procedures, Medicare would pay what percentage for the first, second, third, fourth, and fifth procedures

1st - 100%

2nd - 50%
3rd - 50%
4th - 50%
5th - 50%

Nationally, unit values have been assigned for each service by Medicare (CPT and HCPCS) and determined on the basis of the resources necessary for the physician's performance of the service. (T/F)

TRUE

The Federal Register is the official publication for all "Presidential Documents", "Rules & Regulations", "Proposed Rules" & "Notices". (T/F)

TRUE

Identify this acronym:RVU

Relative Value Unit

Identify the Medicare part with this coverage: "Prescription Drug"

Part D

What edition of the Federal Register would outpatient facilities be especially interested in

November & December

Identify the Medicare part with this coverage: "Physician visits"

Part B

Who handles the day-to-day operation of the Medicare program for the CMS

MACs (Medicare Administrative Contractors)

Fraud is an intentional or misrepresentation that an individual knows to be false or does not believe to be true and makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person. (T/F)

TRUE

(a)Blank) are activities involving the transfer of healthcare information and (b)Blank) means the movement of electronic data between two entities and the technology that supports the transfer.

(a) Transactions

(b) transmission

Who is the largest third-party payer in the nation

Government

Identify this acronym:DHHS

Department of Health and Human Services

In the role as a medical coder, it is your responsibility to ensure that you code (Blank) and completely to optimize reimbursement for services provided.

accurately

Kickbacks from patients "areβ€œ allowed under certain circumstances according to Medicare guidelines. (T/F)

FALSE

Natioanally, unit values have been assigned for each service by Medicare (CPT and HCPCS) and determined on the basis of the resources necessary for the physicians performance of the service. (T/F)

TRUE

Which of the following is NOT a stated goal of the Physician Payment Reform

Increase Medicare expenditures.

Ch.1, pg.11: "because they decrease."

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