Medical Billing and Reimbursement
ACTUAL QUESTIONS AND CORRECT
ANSWERS
The case-mix management system that utilizes information from the Minimum Data Set
(MDS) in long-term care settings is called
a. Resource Utilization Groups (RUGs).
b. Ambulatory Patient Classifications (APCs).
c. Medicare Severity Diagnosis Related Groups (MS-DRGs).
d. Resource Based Relative Value System (RBRVS). - CORRECT ANSWERS✅✅a.
Resource Utilization Groups (RUGs).
The prospective payment system used to reimburse home health agencies for patients with
Medicare utilizes data from
a. UHDDS (Uniform Hospital Discharge Data Set).
b. UACDS (Uniform Ambulatory Core Data Set).
c. MDS (Minimum Data Set).
d. OASIS (Outcome and Assessment Information Set). - CORRECT ANSWERS✅✅d.
OASIS (Outcome and Assessment Information Set).
3.
________ indicates that the claim is suspended in the billing system awaiting late charges,
diagnoses/procedure codes that are soft coded by the coders, and/or insurance verification.
a. Bill drop
b. Concurrent review
c. Bill hold
d. Accounts receivables - CORRECT ANSWERS✅✅c. Bill hold
,All of the following items are "packaged" under the Medicare outpatient prospective payment
system, EXCEPT for
a. anesthesia.
b. medical visits.
c. recovery room.
d. medical supplies. - CORRECT ANSWERS✅✅b. medical visits.
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned
relative value units. These three components are
a. conversion factor, CMS weight, and hospital-specific rate.
b. physician work, practice expense, and malpractice insurance expense.
c. geographic index, wage index, and cost of living index.
d. fee-for-service, per diem payment, and capitation. - CORRECT ANSWERS✅✅b.
physician work, practice expense, and malpractice insurance expense.
The prospective payment system used to reimburse hospitals for Medicare hospital
outpatients is called
a. MS-DRGs.
b. APCs.
c. APGs.
d. RBRVS - CORRECT ANSWERS✅✅b. APCs.
A patient was seen by Dr. Zachary. The charge for the office visit was $125. The Medicare
beneficiary had already met his deductible. The Medicare fee schedule amount is $100. Dr.
Zachary does not accept assignment. The office manager will apply a practice termed as
"balance billing," which means that the patient is
a. financially liable for only the deductible.
b. not financially liable for any amount.
c. financially liable for the Medicare fee schedule amount.
,d. financially liable for charges in excess of the Medicare fee schedule, up to a limit. -
CORRECT ANSWERS✅✅d. financially liable for charges in excess of the Medicare fee
schedule, up to a limit.
The prospective payment system based on resource utilization groups (RUGs) is used for
a. skilled nursing facilities
b. intermediate care facilities
c. freestanding ambulatory surgery centers
d. hospital-based outpatients - CORRECT ANSWERS✅✅a. skilled nursing facilities
The ________ is a statement sent to the provider to explain payments made by third-party
payers.
a. acknowledgment notice
b. attestation statement
c. remittance advice
d. advance beneficiary notice - CORRECT ANSWERS✅✅c. remittance advice
How many major diagnostic categories are there in the MS-DRG system?
a. 25
b. 80
c. 100
d. 2,000 - CORRECT ANSWERS✅✅a. 25
The computer-to-computer transfer of data between providers and third-party payers in a data
format agreed upon by both parties is called
a. health data exchange (HDE).
b. health information exchange (HIE).
, c. HIPPA (Health Insurance Portability and Accountability Act).
d. electronic data interchange (EDI). - CORRECT ANSWERS✅✅d. electronic data
interchange (EDI).
A computer software program that assigns appropriate MS-DRGs according to the
information provided for each episode of care is called a(n)
a. scrubber.
b. grouper.
c. encoder.
d. case-mix analyzer. - CORRECT ANSWERS✅✅b. grouper.
The standard claim form used by hospitals to request reimbursement for inpatient and
outpatient procedures performed or services provided is called the
a. CMS-1600.
b. CMS-1491.
c. UB-04.
d. CMS-1500. - CORRECT ANSWERS✅✅c. UB-04.
Under ASCs, when multiple procedures are performed during the same surgical session, a
payment reduction is applied. The procedure in the highest level group is reimbursed at
________ and all remaining procedures are reimbursed at ________.
a. 100%, 75%
b. 100%, 25%
c. 50%, 25%
d. 100%, 50% - CORRECT ANSWERS✅✅d. 100%, 50%
The ________ refers to a statement sent to the patient to show how much the provider billed,
how much Medicare reimbursed the provider, and what the patient must pay the provider.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
The case-mix management system that utilizes information from the Minimum Data Set
(MDS) in long-term care settings is called
a. Resource Utilization Groups (RUGs).
b. Ambulatory Patient Classifications (APCs).
c. Medicare Severity Diagnosis Related Groups (MS-DRGs).
d. Resource Based Relative Value System (RBRVS). - CORRECT ANSWERS✅✅a.
Resource Utilization Groups (RUGs).
The prospective payment system used to reimburse home health agencies for patients with
Medicare utilizes data from
a. UHDDS (Uniform Hospital Discharge Data Set).
b. UACDS (Uniform Ambulatory Core Data Set).
c. MDS (Minimum Data Set).
d. OASIS (Outcome and Assessment Information Set). - CORRECT ANSWERS✅✅d.
OASIS (Outcome and Assessment Information Set).
3.
________ indicates that the claim is suspended in the billing system awaiting late charges,
diagnoses/procedure codes that are soft coded by the coders, and/or insurance verification.
a. Bill drop
b. Concurrent review
c. Bill hold
d. Accounts receivables - CORRECT ANSWERS✅✅c. Bill hold
,All of the following items are "packaged" under the Medicare outpatient prospective payment
system, EXCEPT for
a. anesthesia.
b. medical visits.
c. recovery room.
d. medical supplies. - CORRECT ANSWERS✅✅b. medical visits.
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned
relative value units. These three components are
a. conversion factor, CMS weight, and hospital-specific rate.
b. physician work, practice expense, and malpractice insurance expense.
c. geographic index, wage index, and cost of living index.
d. fee-for-service, per diem payment, and capitation. - CORRECT ANSWERS✅✅b.
physician work, practice expense, and malpractice insurance expense.
The prospective payment system used to reimburse hospitals for Medicare hospital
outpatients is called
a. MS-DRGs.
b. APCs.
c. APGs.
d. RBRVS - CORRECT ANSWERS✅✅b. APCs.
A patient was seen by Dr. Zachary. The charge for the office visit was $125. The Medicare
beneficiary had already met his deductible. The Medicare fee schedule amount is $100. Dr.
Zachary does not accept assignment. The office manager will apply a practice termed as
"balance billing," which means that the patient is
a. financially liable for only the deductible.
b. not financially liable for any amount.
c. financially liable for the Medicare fee schedule amount.
,d. financially liable for charges in excess of the Medicare fee schedule, up to a limit. -
CORRECT ANSWERS✅✅d. financially liable for charges in excess of the Medicare fee
schedule, up to a limit.
The prospective payment system based on resource utilization groups (RUGs) is used for
a. skilled nursing facilities
b. intermediate care facilities
c. freestanding ambulatory surgery centers
d. hospital-based outpatients - CORRECT ANSWERS✅✅a. skilled nursing facilities
The ________ is a statement sent to the provider to explain payments made by third-party
payers.
a. acknowledgment notice
b. attestation statement
c. remittance advice
d. advance beneficiary notice - CORRECT ANSWERS✅✅c. remittance advice
How many major diagnostic categories are there in the MS-DRG system?
a. 25
b. 80
c. 100
d. 2,000 - CORRECT ANSWERS✅✅a. 25
The computer-to-computer transfer of data between providers and third-party payers in a data
format agreed upon by both parties is called
a. health data exchange (HDE).
b. health information exchange (HIE).
, c. HIPPA (Health Insurance Portability and Accountability Act).
d. electronic data interchange (EDI). - CORRECT ANSWERS✅✅d. electronic data
interchange (EDI).
A computer software program that assigns appropriate MS-DRGs according to the
information provided for each episode of care is called a(n)
a. scrubber.
b. grouper.
c. encoder.
d. case-mix analyzer. - CORRECT ANSWERS✅✅b. grouper.
The standard claim form used by hospitals to request reimbursement for inpatient and
outpatient procedures performed or services provided is called the
a. CMS-1600.
b. CMS-1491.
c. UB-04.
d. CMS-1500. - CORRECT ANSWERS✅✅c. UB-04.
Under ASCs, when multiple procedures are performed during the same surgical session, a
payment reduction is applied. The procedure in the highest level group is reimbursed at
________ and all remaining procedures are reimbursed at ________.
a. 100%, 75%
b. 100%, 25%
c. 50%, 25%
d. 100%, 50% - CORRECT ANSWERS✅✅d. 100%, 50%
The ________ refers to a statement sent to the patient to show how much the provider billed,
how much Medicare reimbursed the provider, and what the patient must pay the provider.
