1. How much can a physician in St. Louis bill Medicare for an office visit for a new patient with a detailed history and physical and low-complexity medical decision making (assuming the patient has met any deductible for the year)? Assume a conversion factor of $34.0682
2. In which city would a physician receive the highest reimbursement for a TURP?
3. In which city would a physician receive the lowest reimbursement for a colonoscopy with biopsy?

4. Calculate the expected payment for an incision and drainage of a pilonidal cyst in each of the cities listed. Conversion Factor: $34.0682

2. Jane Doe is an 83-year-old patient who only has Medicare Part A insurance. Using the following information, calculate the patients financial responsibility for each hospitalization and answer the questions regarding her listed hospitalizations:

Table W7.4

DATE ADMITTED	DATE DISCHARGED	PATIENTS FINANCIAL RESPONSIBILITY
01/01	01/13	$1,024
03/20	03/30	$1,024
07/04	11/02	$24,576 ($1,024 + 7,680 + 15,872)
12/01	12/05	$2,560

1. How many benefit periods were used during this calendar year?
2. Were any lifetime reserve days used during this period of time? If so, how many?
3. If lifetime reserve days were used, how many does the patient have left to be used at a later date?
4. How many times was the patient required to pay a hospital deductible during this time period?

3. Following the last hospital admission, Jane was transferred to a skilled nursing facility (SNF) and remained there for continued treatment for 22 days.
   1. How much was Jane required to pay for her SNF care for days 1-20?

2. How much was she required to pay for the remainder of her SNF stay?

4. After Janes discharge from the skilled facility, she received home healthcare as prescribed by her physician for 14 days. During this time period, she met all of Medicares medical necessity criteria for her care. How much was Jane required to pay for her home healthcare?

Review Quiz

Instructions: Choose the most appropriate answer for the following questions.

1. Which of the following types of plans reimburses patients up to a specified amount?
   1. Health insurance
   2. Coinsurance
   3. Indemnity
   4. Major medical plan

2. What is the maximum number of days that Medicare will cover skilled nursing facility inpatient care?

a. 21

b. 30

c. 60

d. 100

3. Under what circumstances is hospital insurance included under Medicare?
   1. Only for those who pay a monthly premium
   2. For those who do not receive Social Security
   3. For beneficiaries enrolled in Medicare Part A
   4. For beneficiaries enrolled in Medicare Part B

4. On which criterion is Medicaid eligibility based?
   1. Income
   2. Whether a person is Medicare eligible
   3. Age
   4. Health status

5. Which term is used for retrospective reimbursement charges submitted by a provider for each service rendered?
   1. Fee-for-service
   2. Deductible
   3. Actuarial
   4. Prospective

6. Which of the following programs is funded by the federal government to provide medical care to people who receive public assistance?
   1. CHAMPUS
   2. Medicare
   3. Medicaid
   4. Medigap

7. Which of the following reimbursement methods pays providers according to charges that are calculated before the healthcare services are rendered?
   1. Fee-for-service reimbursement
   2. Prospective payment
   3. Retrospective payment
   4. Resource-based payment

8. Which of the following payment methods reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness?
   1. Managed fee-for-service
   2. Capitation
   3. Episode-of-care
   4. Point of service

9. Which of the following classification systems uses resident assessment data to assign residents to one of 53 groups, with each assessment applying to specific days within a resident's stay?
   1. MS-DRGs
   2. APCs
   3. RUGs
   4. HH PPS

10. What is the statement sent by a third-party payer to the patient to explain services provided, amount billed and payments made by the health plan?
    1. Fee schedule
    2. Remittance advice
    3. Explanation of benefits
    4. Electronic remittance advice

11. What is the list of healthcare services/procedures and charges called?
    1. Explanation of benefits
    2. Fee schedule
    3. Table of allowances
    4. a and c

12. Medicare Part B covers all of the following items except .
    1. Physicians services
    2. Durable medical equipment
    3. Custodial care
    4. Clinical laboratory services

13. Which of the following healthcare programs provides services to active-duty members of the military and their qualified family members?
    1. Medicare
    2. TRICARE
    3. Medicaid
    4. Workers compensation

14. A healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services is referred to as a(n) .
    1. Integrated delivery system (IDS)
    2. Preferred provider organization (PPO)
    3. Point-of-service plan (POS)
    4. Exclusive provider organization (EPO)

15. A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is referred to as a(n) .
    1. Case mix analyzer
    2. Encoder
    3. Severity of illness program
    4. Grouper

16. IRVEN is used by CMS to collect data on patients.
    1. Home health
    2. Inpatient rehabilitation
    3. Inpatient psychiatric
    4. Skilled nursing

17. A policy on interrupted stays is part of the _ prospective payment system.
    1. Home health
    2. RBRVS
    3. Outpatient
    4. Inpatient psychiatric

18. A(n) notifies a patient that the services being recommended may not be considered necessary or reasonable by Medicare.
    1. Medicare summary notice
    2. Explanation of benefits
    3. Advance beneficiary notice (ABN)
    4. Remittance advice

19. The classification of a patient into one of 153 HHRGs is based on data.
    1. MDS Version 2.0
    2. FIM
    3. OASIS
    4. UHDDS

20. Data on the geometric length of stay for various long-term care DRGs is used in determining adjustments.
    1. High cost outlier
    2. Short stay outlier
    3. Interrupted stay
    4. Area wage index

21. Which information found on the chargemaster describes a classification of a product or service provided to the patient?
    1. CPT/HCPCS code
    2. Revenue code
    3. Ledger number
    4. Activity code

Instructions: For items 2225, match the following terms with their definitions.

1. Condition established after study to be the reason for hospitalization
2. Categories of patients treated
3. Co-existing condition
4. Condition arising during hospitalization

22. case mix

23. principal diagnosis

24. complication

25. comorbidity