Final Study Guide

Question 1

How many MS-DRGs per inpatient admission and how many APCs per patient encounter?

Answer 1

MS-DRGs- only 1 MS-DRG allowed

APCs- Can have multiple

Question 2

Performance Improvement

Answer 2

Compares a facility’s current performance with itself

Think of the I in improvement as it “I” in myself

Question 3

Performance acheivement

Answer 3

Compare a facility’s performance with others

Question 4

Facililty PE

Answer 4

Will be less because the hospital handles the overhead

Question 5

Non-facility PE

Answer 5

Will be more because the org/physician may need to take on more overhead on their own

Question 6

Base Rate Payment is used to calculate which system’s reimbursement rate?

Answer 6

IPPS

Question 7

Coversion Factor is used to calculate which system’s reimbursement rates?

Answer 7

OPPS

Question 8

What is the formula to calculate an OPPS payment?

Answer 8

Wage-adjusted CF x APC RW

Question 9

What are the IPPS Provisions?

Answer 9

1. High-cost outliers
2. New medical services and tech
3. Transfers

Question 10

What are the OPPS Provisions?

Answer 10

1. Interrupted Costs (reported w/ modifers)
2. High-cost outliers
3. Cancer Hospital Adjustments
4. Rural Hospital Adjustment
5. Pass through payment policies (goes through different systems)

Think of HIRCP

Question 11

What are pass-through payments?

Answer 11

These are exceptions to the MPPS. They get passed through to other other payment mechanisms. They do occur to both IPPS and OPPS

Question 12

What is the first step toward establishing a Value-Based Purchasing (VBP) Program (Quality Reporting Program)?

Answer 12

Developing quality measures. These measures help to determine an org’s performance over time

Question 13

What are the provisions in a RBRVS/MPFS payment system?

Answer 13

1. Clinician type (PAR vs non-PAR)
2. Special Circumstances (exs: bilateral procedure, mult. procedures, physicians assisting in surgery)
3. Underserved areas

Think of CSU

Question 14

Differentiate between PAR and nonPAR.

Answer 14

PAR: Physicians who participate in medicare. MAC reimburses physician
non-PAR (accepts assignment): opts out of Medicare, but Medicare assignment reduced by 5%. MAC Reimburses phys
non-PAR (does not accept assignment): opts out of medicare with 5% reduction but can collect 115% of non-PAR MPFS amt. MAC does not reimburse phys

Question 15

What kind of work can entry-level coders get?

Answer 15

can be given ED or outpatient cases

Question 16

What kind of work can experienced (mid-level) coders expect to get?

Answer 16

more exposure to inpatient coding

Question 17

What kind of work can expert coders expect to get?

Answer 17

inpatient Medicare coding

Question 18

What is the coding position progression?

Answer 18

1. coder trainee
2. outpatient coder
3. inpatient coder
4. coding specialist
5. lead coder
6. coding supervisor
7. clinical data analyst

Question 19

What 3 elements are considered in coding performance assesment?

Answer 19

1. Productivity
2. Accuracy
3. Query appropriateness

Question 20

Which entity creates an Annual Work Plan, so Healthcare Providers and Facilities will know the area of focus for the upcoming year.

Answer 20

OIG

Question 21

CMI (KPI)

Answer 21

Case-mix index of org/facility. Measures the effectiveness of coding management

Question 22

RBRVS measures ____.

Answer 22

Resources

Question 23

MPFS is ____.

Answer 23

the reimbursement methodology platform

Question 24

Is the RBRVS/MPFS a prospective payment system?

Answer 24

No. It is a fee schedule, hence the “FS” in MPFS.

Question 25

# T or F Physicians can up their reimbursement by providing more services under the MPFS/RBRVS.

Answer 25

True

Question 26

How do we calculate a facility MPFS payment?

Answer 26

Multiple all the RVUs by the GPCIs. Add up all the sums, and that is the answer

Question 27

How do we calculate a nonfacility MPFS payment?

Answer 27

multiply all rvus with gpcis. Add up all products up to get the sum. Multiply the sum by the CF and that is your answer

Question 28

How do we calculate an IPPS payment?

Answer 28

RW x Base rate

Question 29

Denial Rate (KPI)

Answer 29

Measures that ability to comply w/ documentation, coding, and billing requirements

Question 30

Clean Claim Rate (KPI)

Answer 30

Measure that assesses the ability to comply with billing edits

Question 31

DNFB (KPI)

Answer 31

Measure of the health of the claims generation process (MEASURED IN DAYS OR DOLLARS)

Question 32

PEPPER Metrics ( KPI)

Answer 32

Metric used to identify billing patterns different from majority of other providers in the nation

Question 33

CC/MCC Capture rate

Answer 33

Metric used to identify coding of cc/mcc secondary diagnosis code issues

Question 34

What are the main functions of CDI?

Answer 34

1. record review 2. query for clarification 3. physician education

Question 35

Fraud vs. Abuse?

Answer 35

Fraud: done on purpose abuse: unaware of action

Question 36

what are 3 examples of common forms of abuse/fraud?

Answer 36

upcoding/unbundling, billing unnecessary medical services, charging excessivly for services/supplies

Question 37

What are the seven elements the OIGlisted as what should be included in a compliance plan?

Answer 37

1. written policies/procedures 2. Designation of complaince officer 3. education/training 4. communication 5. auditing/monitoring 6. disciplinary action 7. corrective action

Question 38

CERT Program

Answer 38

measures improper payments for traditional Medicare (Parts A,B, D)

Question 39

PEPPER report

Answer 39

provides stats for discharges that are vulnerable to improper payments

Question 40

MAC vs. RAC

Answer 40

MAC: A/B medicare claims- PREVENTS improper payments RAC: Medicare parts A,b,c,d claims and medicaid claims- PREVENTS AND CORRECTS improper payments

Question 41

SMRC

Answer 41

A/B claims, medicaid claimes DMEPOS claims. lower improper payment rates

Question 42

CMI formula

Answer 42

CMI= sum of MS-DRG weights/ # of discharges Ex: ((15 x 5.5419)+(55 x 2.9297)+(78 x 2.2257))/ 15+55+78 = 2.8234