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CPB > 9&10 > Flashcards

9&10 Flashcards

Billing and A/R collection concepts

1
Q

How are cost based fee schedules developed?

A

By determining the total cost of all the procedures the physician will perform (including all maintenance, insurance, equipment and labor)

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2
Q

In the chargemaster, what is the four-digit code that reports the location or type of service is known as?

A

Revenue code

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3
Q

To submit claims data through EDI, what format must claim’s data be changed to?

A

Flat files format

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4
Q

What are the requirements to be classified as an inpatient?

A

Must be ordered by a physician with an anticipated stay of at least 48 hours (two midnights).

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5
Q

What does A/R stand for?

A

Accounts receivable

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6
Q

What does APC stand for?

A

Ambulatory payment classification

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7
Q

What does CDM stand for?

A

Charge description master or chargemaster. It is a list of prices for all services and supplies and such at a healthcare facility.

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8
Q

What does GPCI stand for?

A

Geographic practice cost index

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9
Q

What does MS-DRG stand for?

A

Medicare severity - diagnosis related groups

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10
Q

What does RA stand for and what is it?

A

Remittance advice. Insurance payers send it to providers after adjudication is complete.

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11
Q

What does RVU stand for?

A

Relative value unit

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12
Q

What is a contractual adjustment?

A

The amount the provider agrees to accept as a participating provider with the insurance carrier.

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13
Q

What is an EOB and who is it sent to?

A

Explanation of benefits, it is sent to the patient at the same time the RA is sent to the physician.

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14
Q

What is the difference between a fee schedule and a payment schedule?

A

A fee schedule is set by the physician, a payment schedule is set by Medicare or insurers.

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15
Q

What is the difference between IPPS and OPPS?

A

IPPS is inpatient prospective payment system and OPPS is outpatient prospective payment system.

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16
Q

What is the difference between MS-DRG and APC?

A

MS-DRG is used with IPPS (inpatient) and APC is used with OPPS (outpatient).

17
Q

What is the electronic file format used for EDI?

A

ANSI ASC X12

18
Q

What is the timeframe to meet the timely filing deadline?

A

It varies by payer.

19
Q

What will happen if there is failure to post a contractual adjustment to a patient’s account?

A

It will leave a balance on the patients account that should not be there.

20
Q

When a claim is returned to the provider, at the clearinghouse level, what is it considered to be?

A

Rejected. Clearinghouses only reject and send back to the physician or acknowledge and send to the payer.

21
Q

Who is required to obtain prior authorization for a service or procedure?

A

The physician performing the procedure or service

CPB (5 decks)

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