Podcast
Questions and Answers
Which form is utilized by hospitals for paper claims?
Which form is utilized by hospitals for paper claims?
What is an electronic version of the remittance advice that is sent to the provider?
What is an electronic version of the remittance advice that is sent to the provider?
What is the predetermined fixed amount paid by the individual at each healthcare encounter?
What is the predetermined fixed amount paid by the individual at each healthcare encounter?
Which payment system used by Medicare is based on the Medicare Severity-Diagnosis Related Group (MS-DRG) classification system?
Which payment system used by Medicare is based on the Medicare Severity-Diagnosis Related Group (MS-DRG) classification system?
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How does the outpatient prospective payment system (OPPS) reimburse hospitals for the care they provide to Medicare beneficiaries?
How does the outpatient prospective payment system (OPPS) reimburse hospitals for the care they provide to Medicare beneficiaries?
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What is the resource-based reimbursement value system (RBRVS) based on?
What is the resource-based reimbursement value system (RBRVS) based on?
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Which payment model is used in the healthcare industry where providers are paid a set amount for each patient they see?
Which payment model is used in the healthcare industry where providers are paid a set amount for each patient they see?
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Which payment model is used in the healthcare industry where providers are paid for each service rendered, such as an office visit or a lab test?
Which payment model is used in the healthcare industry where providers are paid for each service rendered, such as an office visit or a lab test?
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What is the purpose of the Medicare Physician Fee Schedule (MPFS)?
What is the purpose of the Medicare Physician Fee Schedule (MPFS)?
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What is the purpose of the Geographic Practice Cost Indices (GPCIs) in Medicare payment calculations?
What is the purpose of the Geographic Practice Cost Indices (GPCIs) in Medicare payment calculations?
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Which of the following terms refers to medical conditions and unrelated co-existing conditions that complicate patient care during a hospital stay?
Which of the following terms refers to medical conditions and unrelated co-existing conditions that complicate patient care during a hospital stay?
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What do complications and co-morbidities (CC) refer to?
What do complications and co-morbidities (CC) refer to?
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What are hospital-acquired conditions (HAC)?
What are hospital-acquired conditions (HAC)?
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What does Non-PAR limiting charge apply to?
What does Non-PAR limiting charge apply to?
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Study Notes
Healthcare Claims and Reimbursements
- Hospitals utilize the UB-04 form for paper claims submission.
- The electronic version of remittance advice sent to providers is known as the 835 transaction.
Patient Payment Responsibility
- A predetermined fixed amount paid by individuals at each healthcare encounter is called a copayment.
Medicare Payment Systems
- The Medicare Severity-Diagnosis Related Group (MS-DRG) classification system is the basis for the Inpatient Prospective Payment System (IPPS).
- The Outpatient Prospective Payment System (OPPS) reimburses hospitals using a predetermined fee schedule based on the Ambulatory Payment Classifications (APCs).
- The Resource-Based Relative Value Scale (RBRVS) is based on the costs associated with the resources utilized in providing care, including time, skill, and overhead.
Payment Models
- Capitation is a healthcare payment model where providers receive a set amount for each patient they see, regardless of visits or services rendered.
- Fee-for-service is a model where providers are reimbursed for each individual service rendered, such as office visits or lab tests.
Medicare Fee Schedule and Indices
- The Medicare Physician Fee Schedule (MPFS) establishes payment rates for services provided by physicians and other healthcare professionals.
- Geographic Practice Cost Indices (GPCIs) adjust payment rates based on geographic variations in the cost of delivering healthcare services.
Medical Conditions in Hospital Care
- Complications and comorbidities (CC) refer to medical conditions and unrelated co-existing conditions that complicate patient care during a hospital stay.
- Hospital-acquired conditions (HAC) are specific conditions that patients acquire during their hospital stay, rather than upon admission.
- Non-Participating Providers (Non-PAR) limiting charge applies to the maximum amount a non-participating provider can charge Medicare patients above the fee set by Medicare.
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Description
Test your knowledge on payment adjustments and code combinations with this quiz. Learn about the NCCI Procedure to Procedure (PTP) edits and how they can impact correct payment. Explore factors such as NCCI, MC, CC, HACS, and Non-PAR limiting charges. Challenge yourself on understanding major complications and co-morbidities (MCC) in medical coding.
