C812 Healthcare Reimbursement
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Free C812 Healthcare Reimbursement Questions
1. If a nurse on a unit receives a verbal order from a physician but is unsure about the medication dosage, what should the nurse do to ensure compliance with hospital policy and patient safety?
- Administer the medication as ordered without questioning
- Contact the physician for clarification before proceeding
- Ask a unit secretary to confirm the dosage
- Document the order in the patient's chart and administer the medication
Explanation
When a nurse receives a verbal order but is uncertain about any part of it—especially the medication dosage—the correct and safest action is to verify the order with the prescribing physician before proceeding. This step is critical to ensure patient safety, avoid medication errors, and comply with hospital policy and professional standards. Verbal orders carry a higher risk of miscommunication, so confirming accuracy with the physician helps maintain the integrity of care and prevents potential harm to the patient.
2. What is the term used to describe the practice of coding a diagnosis or procedure in a way that results in a higher reimbursement rate than warranted?
- Downcoding
- Upcoding
- Crosswalking
- Bundling
Explanation
Upcoding refers to the unethical and illegal practice of assigning codes for diagnoses or procedures that result in a higher level of reimbursement than what was actually justified by the patient’s medical record. This practice misrepresents the actual services provided and can lead to overpayment by insurance companies or government programs like Medicare and Medicaid. Upcoding is considered a form of healthcare fraud and can result in severe penalties, including fines and exclusion from participation in federal healthcare programs.
3. Which type of acute-care documentation is primarily the responsibility of the attending physician?
- Consultation report
- Discharge summary
- Laboratory report
- Pathology report
Explanation
The discharge summary is the primary responsibility of the attending physician. This document provides a comprehensive overview of the patient’s hospital stay, including the reason for admission, key findings, treatments provided, response to therapy, and instructions for follow-up care. It serves as a legal and clinical record summarizing the patient’s care episode and ensures continuity of care after discharge. In contrast, consultation reports are prepared by consulting specialists, and laboratory or pathology reports are generated by respective departments.
4. Broad classifications of diagnoses in the DRG system are called
- Diagnostic cost groups
- Diagnosis-related groups
- Major diagnostic categories
- Appropriate evaluation protocols
Explanation
In the Diagnosis-Related Group (DRG) system, broad classifications of diagnoses are referred to as Major Diagnostic Categories (MDCs). These categories are organized based on body systems or specific medical conditions and form the foundation for grouping individual DRGs. Each MDC includes diagnoses that relate to a single organ system or disease process, which helps standardize hospital payments under the Inpatient Prospective Payment System (IPPS). By grouping similar clinical cases, MDCs ensure that reimbursement accurately reflects the resources needed to treat patients with similar conditions.
5. If a healthcare provider submits a claim to Medicare that contains coding errors, what potential consequences could arise from this situation?
- The claim will be automatically approved without review.
- The provider may face penalties and delayed reimbursement.
- The provider will receive a bonus for timely submission.
- The claim will be forwarded to the Department of Justice for criminal investigation.
Explanation
When a healthcare provider submits a claim to Medicare with coding errors, it can result in claim denials, payment delays, or potential penalties depending on the nature of the error. Coding inaccuracies affect reimbursement accuracy and can raise compliance concerns if they occur repeatedly or appear intentional. In most cases, the provider must correct the claim and resubmit it, causing delayed payments. If errors suggest fraud or abuse, further investigation could occur, but routine mistakes typically lead only to administrative issues and financial penalties.
6. If a hospital is facing a high rate of claim denials due to coding errors, which of the following strategies should they implement to improve their reimbursement process?
- Increase the number of concurrent reviews conducted by the medical staff.
- Eliminate the use of local coverage determinations in coding.
- Develop a training program focused on accurate coding practices and medical necessity documentation.
- Reduce the number of appeals submitted to payers.
Explanation
When hospitals experience frequent claim denials caused by coding errors, the most effective solution is to improve coder education and documentation accuracy. Developing a comprehensive training program focused on accurate coding practices, medical necessity documentation, and compliance with payer rules helps ensure that claims are coded correctly before submission. This proactive approach minimizes denials, speeds up reimbursement, and maintains compliance with healthcare regulations. Simply reducing appeals or ignoring local coverage determinations would worsen the problem rather than resolve it.
7. Explain the difference between a complication and a comorbidity in the context of hospital care.
- A complication is a new problem that arises during hospitalization, while a comorbidity is a pre-existing condition.
- A complication is a pre-existing condition, while a comorbidity is a new problem that arises during hospitalization.
- Both terms refer to new problems arising during hospitalization.
- Both terms refer to pre-existing conditions affecting treatment.
Explanation
In hospital care, complications and comorbidities are both secondary conditions but differ in timing and origin. A complication refers to a new condition that develops during hospitalization as a result of medical treatment or the underlying disease. A comorbidity, on the other hand, is a pre-existing condition that the patient already had upon admission and that can affect the course of treatment, recovery, and hospital resource use. Proper identification of these conditions is critical for accurate coding and reimbursement under systems like MS-DRG.
8. Which of the following groups is covered by the Medicare program in addition to those age 65 and older and permanently disabled individuals?
- Individuals with end-stage renal disease
- Individuals with chronic illnesses
- Individuals with low income
- Individuals with mental health disorders
Explanation
In addition to individuals aged 65 and older and those with permanent disabilities, Medicare also covers individuals diagnosed with end-stage renal disease (ESRD)—a severe, chronic kidney condition requiring dialysis or transplantation. This provision was established to ensure that patients with life-threatening kidney failure receive essential medical treatment, regardless of age. This distinguishes Medicare coverage from Medicaid, which primarily assists individuals with low income.
9. Which of the following is NOT typically included in a coding compliance plan?
- Physician query process
- Correct use of encoder software
- Coding diagnoses supported by medical record documentation
- Tracking length of stay
Explanation
A coding compliance plan is designed to ensure that medical coding practices adhere to regulatory guidelines, promote accuracy, and reduce the risk of billing errors or fraud. It typically includes policies such as the physician query process, proper use of encoder software, and ensuring that coded diagnoses and procedures are supported by medical record documentation. However, tracking a patient’s length of stay pertains more to case management and utilization review rather than coding compliance. Therefore, it is not a standard component of a coding compliance plan.
10. Which entity is responsible for overseeing the reporting of breaches in healthcare privacy?
- The Federal Trade Commission
- The Office of Civil Rights in the Department of Health and Human Services
- The Centers for Medicare & Medicaid Services
- The National Institutes of Health
Explanation
The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is the entity responsible for enforcing the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules. This includes overseeing and investigating reports of breaches in healthcare privacy, such as unauthorized access, use, or disclosure of protected health information (PHI). The OCR ensures that covered entities and business associates comply with federal regulations designed to protect patient confidentiality and may impose penalties or corrective actions when violations occur.
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