Grand Valley State University HIM 364/ HIM364: Reimbursement and Revenue Cycle Data Analysis Challenge | Complete updated 100% questions and answers.

HIM 364 Reimbursement and Revenue Cycle Data Analysis Challenge Total Points: 25 (1 point for each question) Instructions: Use the following table to answer questions 1-3. EXAMPLE OF A CHARGE DESCRIPTION MASTER (CDM) FILE LAYOUT Charge Code Item Description Dept # HCPCS Code Charge Revenu e Code Activity Medicar Date e Medicai d 4968310 5 CT scan; head; w/o contrast .00 0351 1/1/201 7 4968310 6 CT scan; head; with contract .00 0351 1/1/201 7 1. This information is included on the 837I electronic claim form (or UB-04 printed claim form) to represent the cost center (e.g., lab, radiology, cardiology, respiratory, etc.) for the department in which the item is provided. It is used for Medicare billing. a. HCPCS code b. Revenue code c. Charge code d. Department number 2. This information is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can be available for various financial classes. a. HCPCS code b. Revenue code c. Department number d. Charge code 3. This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. a. Department number b. HCPCS code c. Item Description d. Revenue codeUse the following case scenario to answer questions 4-8. A patient with Medicare is seen in the physician’s office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare fee schedule amount for this service is $200.00. The nonPAR Medicare fee schedule amount for this service is $190.00 4. The patient is financially liable for the coinsurance amount, which is a. 80% b. 100% c. 20% d. 15% 5. If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is a. $200.00 b. $250.00 c. $218.50 d. $190.00 6. If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is a. $250.00 b. $200.00 c. $218.50 d. $190.00 7. If this physician is a participating physician who accepts assignment for this claim, the total amount of the patient’s financial liability (out-of-pocket expense) is a. $200.00 b. $40.00 c. $160.00 d. $30.00 8. If this physician is a non-participating physician who does NOT accept assignment for this claim, the total amount of the patient’s financial liability (out-of-pocket expense) is a. $66.50 b. $38.00 c. $190.00 d. $152.00Use these data to calculate answers to questions 9 and 10. Venice Bay Health Center collected the data displayed below concerning its four highest volume MS-DRGs. MS-DRG A MS-DRG B MS-DRG C MS-DRG D RW Volume RW Volume RW Volume RW Volume 2....2432 386 9. The MS-DRG that generated the most revenue for Venice Bay Health Center is a. MS-DRG A b. MS-DRG B c. MS-DRG C d. MS-DRG D 10. CMS has increased the weight for MS-DRG A by 14%, increased the weight for MSDRG B by 20%, and decreased the weight for MS-DRG D by 10%. Given these new weights, which MS-DRG generated the most revenue for Venice Bay Health Center? a. MS-DRG A b. MS-DRG B c. MS-DRG C d. MS-DRG DUse the following table to answer questions 11-14. Happy Hospital’s TOP 10 MS-DRGs MSDRG MS-DRG Description Patient Volume CMS RW 470 Major joint replacement or reattachment of lower extremity w/o MCC 2,750 2.0544 392 Esophagitis, gastroenteritis & misc. digestive disorders w/o MCC 2,200 0.7594 194 Simple pneumonia & pleurisy w CC 1,150 0.9333 247 Percutaneous cardiovascular procedure with 2 drugeluting stents w/o MCC 900 2.1158 293 Heart failure & shock w/o MCC 850 0.6737 313 Chest pain 650 0.7025 292 Heart failure & shock w CC 550 0.9589 690 Kidney & urinary tract infections w/o MCC 400 0.7946 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.7266 871 Septicemia w/o MV 96+ hours w MCC 250 1.8231 11. The case-mix index for the top 10 MS-DRGs above is a. 1.164 b. 1.285 c. 0.782 d. 1.097 12. Which individual MS-DRG has the highest reimbursement? a. 247 b. 470 c. 871 d. 293 13. Based on this patient volume, during the time period, the MS-DRG that brings in the highest “total” reimbursement to the hospital is a. 470 b. 247 c. 392 d. 871 14. The inpatient CCR is .412. Based on this patient volume during the time period, the MSDRG that brings in the highest total profit to the hospital is a. 470 b. 247 c. 392 d. It cannot be determined from this informationUse the following scenario to answer questions 15- 17. An analyst at Happy Hospital wishes to use the CMI for a set of MS-DRGs to determine if a documentation improvement program is having an impact. 15. Calculate the CMI for the three MS-DRGs to establish a baseline. MSDRG MS-DRG Description RW Volume 163 Major chest procedures w MCC 4.9507 36 164 Major chest procedures w CC 2.5786 52 165 Major chest procedures w/o CC/MCC 1.8506 100 a. 4.9864 b. 2.6456 c. 1.7651 d. 2.6446 The analyst is examining the CMI trend for the past four quarters as shown in the following graph. Q1 Q2 Q3 Q3 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 CMI CMI 16. Which of the following statement is FALSE. a. The CMI has increased over the past year. b. The volume for MS-DRG 165 has increased drastically over the past year. c. The volume for MS-DRGs 163 and 164 have increased over the past year.d. The CDI program appears to have impacted the CMI for this MS-DRG set (family). The analyst gathers peer data to compare their CMI for this MS-DRG set to other hospitals and their state. Q1 Q2 Q3 Q4 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 CMI Trend Happy Hopsital Sunshine Hospital State 17. Which of the following actions should the analyst consider recommending to the Revenue Cycle Team at Happy Hospital? a. Review of CDI team physician queries to ensure AHIMA practice guidelines for CDI program are being followed b. Review of coding to ensure principal diagnosis is correctly assigned c. Review of CDM to ensure OR charges are correct d. No action needs to be taken because the CMI continues to increaseReview the following graph and answer question18. Set 1 Set 2 Set 3 Set 4 50 60 70 MS-DRG Set Under Review with MCC with CC without CC/MCC 18. Based on the graph above what type of review should the coding manager conduct to ensure coding compliance at her facility? a. Focused review for MS-DRG Set 4 b. Random sample review for past 6 months c. Focused review of cases with MCC d. Focused review of cases without CC/MCCReview the following chart to answer questions 19 and 20. RAC Review Results for Inpatient Accounts Medical Necessity No Documentation Incorrect Coding DMEPOS 19. To improve Medical Necessity errors at this facility the coding manager should a. Demand that his coders memorize the NCDs and LCDs b. Work with the Utilization Management to review the admission screening software used at the facility c. Work with the CDI team to improve the reporting of secondary diagnoses at the facility d. Work with patient accounts to correct the inpatient bills and re-submit 20. To improve No Documentation errors at this facility the coding manager should a. Request to audit physician documentation b. Work with the CDI team to improve the reporting of secondary diagnoses at the facility c. Work with release of information unit to ensure that complete records are submitted to the RAC by the designated due date d. Implement more coding education sessionsUse the following table to answer questions 21-23. Table 1 – Happy Hospital Inpatient Coding Audit Results (Sample) Audit # DRG Final DRG Coder Issue1 Issue2 1 055 054 C Missed MCC 2 167 168 D Documentation does not support CC code 3 256 255 A Missed MCC Documentation does not support CC code 4 539 539 A Missed secondary diagnosis code 5 639 639 A None 6 623 623 B None 7 870 871 D Incorrect procedure code 8 853 855 C Documentation does not support MCC code Missed secondary diagnosis 9 639 638 B Missed CC code 21. Table 1 provides a sample of the results for Happy Hospital’s recent inpatient coding review. Which method of calculating errors should be utilized by the coding manager at Happy Hospital for this data set? Challenge Question a. Record-over-Record b. Record-over-Code c. Code-over-Code d. Code-over-Record 22. For Audit record #3 what is the result of the coding error(s)? a. Happy Hospital must pay back money to CMS because documentation did not support a CC code that was reported. b. Happy Hospital will re-bill the claim so that CMS can reimburse Happy Hospital at a higher rate. c. Happy Hospital takes no action with the claim because the over reporting of the CC and under reporting of the MCC cancel each other out. d. Happy Hospital takes no action because this is a retrospective review and it is just to obtain coding quality rates. 23. What tool would the coding manager use to show the fiscal impact of the coding audit?a. Coding productivity analysis b. Service mix index, before and after audit c. Case mix index, before and after audit d. SOI and ROM scores, before and after audit 24. During the monthly Revenue Cycle Meeting the committee discussed the increase in returned claims for OCE edit #48. Which of the following actions would help the CDM Coordinator identify the root cause of these incorrect claims? OCE Edit #48 – Revenue center requires HCPCS code; Action – Claim returned to provider, provider may resubmit the claim once the errors are corrected. a. E-mail the Coding Manager and ask her why the coders are missing codes. b. Run a data report to identify which charge code(s) is activating this edit. c. Ask the Radiology Manager to check the radiology portion of the CDM for missing revenue codes. d. Hire an external consultant to perform a random sample of hard coded claims. 25. Which of the following is the definition of revenue cycle management? a. The regularly repeating set of events that produces revenue or income b. The method by which patients are grouped together based on a set of characteristics c. The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization d. Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.