chapter 2 self review.docx

Textbook Review Questions Self-Review 2.1 1. What is the difference between hospital inpatient care and hospital-based ambulatory care? Inpatient short-term acute care is the type of care generally associated with hospitals. Patients who are in need of around-the- clock acute care are admitted as hospital inpatients upon the order of a physician. Hospital-based ambulatory care can involve outpatient surgical care, clinic care, or emergency room care. 2. When a patient is admitted for observation services, the physician must determine whether the patient meets inpatient criteria within what timeframe? 24 Hours 3. What does PHP stand for, and how does it differ from inpatient care? PHP stands for a partial hospitalization program, in which the patient may receive a variety of services such as individual or group therapy; occupational therapy; diagnostic services; services of social workers, psychiatric nurses, and other staff; along with other types of services on an outpatient basis. 4. Name and discuss three types of patients.

( 1) Hospital inpatients are acutely ill individuals who are treated in an area of the hospital where patients generally stay overnight. (2) A hospital outpatient is a patient who is evaluated or treated at a hospital facility but is not admitted as an inpatient. (3) Long-term acute care hospital patients are admitted to a long- term care hospital (LTCH) and are generally more acutely ill than patients in other long-term care settings. 5. What is a hospitalist, and what is the advantage to the patient when a hospital has one? A hospitalist is a physician who provides comprehensive care to hospitalized patients but who ordinarily does not see patients outside of the hospital setting. The advantage to the patient is that the hospitalist is a specialist in dealing with conditions that require hospitalization and is not distracted by

the duties of seeing patients in the clinic setting. Self-Review 2.2 1. What is the difference between licensure and accreditation? Hospitals must be licensed by the state in which they are located. Hospitals voluntarily seek accreditation to demonstrate to their patients, to their communities, to insurers, to managed care organizations, and to others that their organizations are providing quality care. 2. What federal requirements must an organization meet to receive Medicare payments? Conditions of Participation 3. What three accrediting organizations are “deemed” to be in compliance with the federal Conditions of Participation? The Joint Commission, the AOA's Healthcare Facilities Accreditation Program (HFAP), and DNV Healthcare's NIAHO program Self-Review 2.3 1. True or False? A medical history and physical examination must be recorded in the medical record within 12 hours after a procedure is performed.

2. True or False? When emergency, urgent, or immediate care is provided, the time and means of arrival also must be documented in the medical record. 3. True or False? The Code of Federal Regulations contains the basic rules that regulate Medicare payments to teaching physicians. Self-Review 2.4 1. Payment policies developed by A/B MACs help educate health care providers on how to submit accurate claims for reimbursement. These payment policies are called? Payment policies developed by A/B MACs help educate health care providers on how to submit accurate claims for reimbursement. These payment policies are called ______.Local Coverage Determinations (LCDs) or Local Medical Review Policies (LMRPs) 2. What does MS-DRGs stand for? Medicare severity-diagnosis-related groups 3. What is the 72-hour rule? What are pass-through payments? When a hospital provides services to a Medicare patient as an outpatient within 72 hours of a related inpatient admission, charges for those outpatient services must not be billed separately. What are pass-through payments? Pass-through payments are additional payments to cover the costs of innovative medical devices, drugs, and biologicals. 4. In what ways are LTC-DRGs similar and different from inpatient DRGs? LTC-DRGs differ from inpatient DRGs in relative weights and in their associated lengths of stay.

LTC-DRGs also are similar to inpatient DRGs in that they are based on the patient's principal diagnosis, additional diagnoses, procedures performed during the stay, age, sex, and discharge status. Self-Review 2.5 5. True or False? Revenue codes are reported on the UB-04 to indicate the general nature of the service provided, such as pharmacy, room and board, or intensive care. 6. What is the purpose of CCI edits? The purpose of the CCI (Correct Coding Initiative) edits is to prevent improper payment when incorrect code combinations are reported1. The CCI edits are a set of rules based on clinical and coding guidelines that identify code combinations that should not be used together2. The CCI was implemented by the Centers of Medicare and Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate payments for Part B provider claims3 The purpose of the CCI edits is to prohibit unbundling of procedures, a practice that results in excessive payment to the provider when multiple codes are reported

instead of a combination code. 7. What piece of legislation included a Medicare and Medicaid incentive program for health care providers who demonstrate the ability to “meaningfully use” EHRs? The Medicare and Medicaid incentive program for health care providers who demonstrate the ability to “meaningfully use” EHRs was included in the American Recovery and Reinvestment Act of 2009 (ARRA) 1. The program was developed to encourage eligible professionals (EPs) and eligible hospitals and critical access hospitals (CAHs) to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified electronic health record technology (CEHRT) 2. The program was later renamed to Promoting Interoperability Program2. It includes the HITECH Act, which outlines the requirements for the EHR Incentive Program, designed to incent Medicare and Medicaid eligible hospitals (EHs), Critical Access Hospitals (CAHs) and eligible professionals (EPs) to electronically collect, store, transmit, and use health care information in a meaningful, secure, and

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