1. You're an outpatient coder in Dr. Smith's office. When you code procedures, you're probably using _______ codes.
A. ICD-10-CM
B. ICD-9-CM
C. HCPCS
D. CPT ANSWER
2. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
What is the hospital's reimbursement for this patient under the PPS?
A. $3,028.26
B. $6,687
C. $4,500
D. $10,360 ANSWER
3. Which of the following would be the best to use to help plan home health care outcomes and assessments?
A. RAVEN
B. OASIS
C. MAC ANSWER
D. HAVEN
4. A health care plan wants to measure their quality and performance. They could use
A. HAVEN.
B. HEDIS. ANSWER
C. MSDRG.
D. RAVEN.
5. Dr. M is receiving reimbursement based on actual charges after the patient has been treated. She's being reimbursed on a (I DON’T KNOW THIS ONE).
A. prospective payment system.
B. usual, customary, and reasonable charges system.
C. retrospective, fee-for-service payment system.
D. indemnity system.
6. Mr. B is an 82-year-old retired railroad worker who is having a mole removed at his physician's office.
The physician's office is probably billing which of the following?
A. Medicare Part D
B. Medicare Part C
C. Medicare Part B
D. Medicare Part A ANSWER
7. New Medicare payments systems and implementation of SCHIP both came out of the (I DON’T KNOW THIS ONE.)
A. Balanced Budget Act.
B. health maintenance organization.
C. Federal Act 33-2.
D. retrospective payment system.
8. Which of the following may lead to claim denials or improper service reimbursement?
A. Updated ICD-9-CM codes
B. Inaccurate physician documentation ANSWER
C. HCPCS codes on outpatient surgeries
D. Reporting of multiple APGs
9. You're switching jobs on Monday. Which one of the following acts was developed, in part, to ensure that you have ongoing insurance coverage during the change?
A. HIPAA ANSWER
B. HP2010
C. OCIIO
D. BBA
10. Before she can receive insurance benefits, Sally must pay the first $500 out of her own finances. The $500 is called a/an
A. co-pay. ANSWER
B. co-insurance.
C. deductible.
D. indemnity.
11. You're grandmother has a question about her Medicare reimbursement, but it's 10:30 P.M. What organization will answer her questions at this time of night?
A. HCPCS
B. CMS
C. OIG ANSWER
D. SCHIP
12. When a physician is billing under the RBRVS system, he or she is using
A. HCPCS/CPT codes. ANSWER
B. APCs.
C. MS-DRGs.
D. ICD-9 procedure codes.
13. Dr. Smith's medical office group and the hospital in which he's affiliated are both examples of
A. suppliers.
B. resources.
C. payers.
D. providers. ANSWER
14. Which of the following was created to allow coverage for options that aren't covered under Medicare A or B?
A. Medigap ANSWER
B. Medicare Part D
C. Medicare+Choice
D. Medicare Part C
15. If you're in an 80-20 policy, it means
A. you pay 80% of the expenses and the insurer pays 20%.
B. the insured pays 80% of the expenses and you pay 20%.
C. the insurer pays 80% of the expenses and you pay 20%. ANSWER
D. you pay 80% of the expenses and the insured pays 20%.
16. Dr. S. is working within a reimbursement system where the insurance is billed after all the treatment has been given to the patients. The main reason that he orders more tests, exams, and procedures under this system is
A. because no one has to pay for it.
B. to increase resource utilization ANSWER.
C. fear of being sued.
D. to make a profit.
17. It's January 2, 2011, and you're a hospital coder who just assigned three diagnosis codes to a patient's record. You probably used _______ codes.
A. HCPCS
B. CPT
C. ICD-10-CM
D. ICD-9-CM ANSWER
18. Mrs. F is a 72-year-old retired school teacher who is hospitalized for pneumonia. Which of the End of exam following is most likely covering her inpatient hospital stay? (I DON’T KNOW THIS ONE.)
A. Medicare Part D
B. Medicare Part B
C. Medicare Part C
D. Medicare Part A
19. Paul Patient is trying to get new insurance, but he fears he'll be denied due to his cancer diagnosis and ongoing treatment. Which of the following was put in place to help patients like Paul avoid insurance denial due to their current conditions?
A. Healthy People 2010
B. Social Security Title XVIII ANSWER
C. Affordable Care Act
D. Balanced Budget Act
20. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0.
The coding system grouped the information into MS-DRG 178 (RW: 1.4860).
The hospital has a base rate of $4,500.
Which of the following is the principal diagnosis? (I DON’T KNOW THIS ONE.)
A. 482.
B. 178
C. 428.22
D. 428.0
The answer to number 7 is the Balanced Budget Act. I'm sure you've figured that out already but I'm not sure if fellow readers with the same question are able to read other responses.
The answer to number 18 is Medicare Part A. Part A covers hospitals. Part B covers medical. Part C was implemented so that those with part a and part b could have more options. Part D is for prescription drug plans.
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You're switching jobs on Monday. Which act was developed, in part, to ensure that you have ongoing insurance coverage during the change?
5. If a physician is charging for a mole removal procedure based on what other physicians generally charge for this procedure, the physician is probably using
A. UCR.
B. PPS.
C. ABG.
D. DRG.
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1. When coding procedures as an outpatient coder, you are probably using CPT codes (Answer: D).
2. The hospital's reimbursement for this patient under the PPS (Prospective Payment System) is $3,028.26 (Answer: A). To calculate the reimbursement, you need to multiply the MS-DRG relative weight (1.4860) by the base rate ($4,500). The result is $6,729. However, if the hospital is reimbursed based on actual charges, the reimbursement will be reduced to $3,028.26.
3. The best tool to use to help plan home health care outcomes and assessments is OASIS (Outcome and Assessment Information Set) (Answer: B). OASIS is a standardized data collection tool that helps assess patients' status and measure outcomes.
4. To measure quality and performance, a healthcare plan could use HEDIS (Healthcare Effectiveness Data and Information Set) (Answer: B). HEDIS is a set of performance measures used by health plans to evaluate healthcare quality.
5. If Dr. M is receiving reimbursement based on actual charges after the patient has been treated, she is being reimbursed on a retrospective, fee-for-service payment system (Answer: C). In this payment system, the provider bills for services after they have been provided, and reimbursement is based on the actual charges.
6. The physician's office is probably billing Medicare Part B for the mole removal of Mr. B, an 82-year-old retired railroad worker (Answer: C). Medicare Part B covers outpatient services, including physician services.
7. The new Medicare payment systems and implementation of SCHIP (State Children's Health Insurance Program) both came out of the Balanced Budget Act (Answer: A).
8. Inaccurate physician documentation may lead to claim denials or improper service reimbursement (Answer: B). Accurate and detailed physician documentation is essential for correct coding and billing.
9. The act that was developed, in part, to ensure ongoing insurance coverage during job changes is HIPAA (Health Insurance Portability and Accountability Act) (Answer: A). HIPAA includes provisions that protect individuals' access to healthcare coverage when transitioning between jobs.
10. The $500 that Sally must pay before receiving insurance benefits is called a deductible (Answer: C). A deductible is the amount an individual must pay out of pocket before the insurance coverage starts.
11. If your grandmother has a question about her Medicare reimbursement at 10:30 P.M., the organization that will answer her questions is the OIG (Office of Inspector General) (Answer: C). The OIG is responsible for investigating fraud, waste, and abuse in federal healthcare programs, including Medicare.
12. When a physician is billing under the RBRVS (Relative Value-Based Resource Utilization System) system, they are using HCPCS/CPT codes (Answer: A). RBRVS is a reimbursement system that assigns relative values to medical services based on the resources required to provide them.
13. Dr. Smith's medical office group and the hospital in which he's affiliated are both examples of providers (Answer: D). Providers are individuals or organizations that deliver healthcare services.
14. Medigap was created to allow coverage for options that aren't covered under Medicare A or B (Answer: A). Medigap plans are supplemental insurance policies sold by private insurance companies to fill gaps in Original Medicare coverage.
15. In an 80-20 policy, the insurer pays 80% of the expenses, and you pay 20% (Answer: C). This type of insurance policy is commonly known as coinsurance.
16. When working within a reimbursement system where the insurance is billed after all treatment has been given to the patients, physicians may order more tests, exams, and procedures to increase resource utilization (Answer: B). This behavior can increase the overall cost of healthcare.
17. It's January 2, 2011, and as a hospital coder, you probably used ICD-9-CM codes when assigning three diagnosis codes to a patient's record (Answer: D). ICD-9-CM was the coding system used before the transition to ICD-10-CM.
18. Medicare Part A is most likely covering the inpatient hospital stay of Mrs. F, a 72-year-old retired school teacher (Answer: D). Medicare Part A covers inpatient hospital stays and related services.
19. The Balanced Budget Act (BBA) was put in place to help patients like Paul avoid insurance denial due to their current conditions (Answer: D).
20. In the given scenario, the principal diagnosis is not specified. To determine the principal diagnosis, additional information is needed.