CDIP Regulatory and Payer Requirements 2 — Questions and Answers
Question 1: Which federal program requires hospitals to submit claims using ICD-10-CM/PCS codes under the Inpatient Prospective Payment System (IPPS)?
- Medicaid only
- Medicare Part A (Correct answer)
- TRICARE only
- Medicare Part B
Correct answer: Medicare Part A
Medicare Part A covers inpatient hospital stays and uses IPPS, which requires ICD-10-CM/PCS coding for payment under DRGs.
Question 2: Under IPPS, what term describes the process of grouping inpatient cases into payment categories based on principal diagnosis, procedures, and other factors?
- APC assignment
- DRG grouping (Correct answer)
- RBRVS calculation
- HCPCS coding
Correct answer: DRG grouping
Diagnosis-Related Group (DRG) grouping classifies inpatient cases into payment categories under IPPS for Medicare reimbursement.
Question 3: CMS's Two-Midnight Rule primarily affects which type of patient status determination?
- Emergency department classification
- Outpatient observation status
- Inpatient admission criteria (Correct answer)
- SNF level of care
Correct answer: Inpatient admission criteria
The Two-Midnight Rule establishes that inpatient admission is appropriate when the physician expects the patient to require hospital care spanning at least two midnights.
Question 4: Which organization publishes the Official Guidelines for Coding and Reporting that CDI professionals must follow for ICD-10-CM/PCS?
- AHA and CMS jointly (Correct answer)
- AHIMA alone
- AMA only
- The Joint Commission
Correct answer: AHA and CMS jointly
The Official Guidelines for Coding and Reporting are published cooperatively by the AHA, AHIMA, CMS, and NCHS (the four cooperating parties).
Question 5: A Medicare Advantage plan (Part C) differs from traditional Medicare primarily in that it:
- Uses only CPT codes for payment
- Is administered by private insurers approved by CMS (Correct answer)
- Covers only outpatient services
- Does not require ICD-10 coding
Correct answer: Is administered by private insurers approved by CMS
Medicare Advantage plans are offered by private insurance companies approved by CMS to provide Medicare benefits, often with additional coverage options.
Question 6: Under the False Claims Act, what is the minimum per-claim civil penalty a hospital faces for knowingly submitting a false Medicare claim?
- $500
- $5,000
- $13,000 (adjusted for inflation) (Correct answer)
- $100,000
Correct answer: $13,000 (adjusted for inflation)
The False Claims Act imposes civil penalties per false claim, currently adjusted to approximately $13,000–$26,000 per violation under inflation adjustments.
Question 7: Which type of Medicare review contractor conducts post-payment reviews of inpatient claims to identify improper payments and potential fraud?
- MAC (Medicare Administrative Contractor)
- RAC (Recovery Audit Contractor) (Correct answer)
- ZPIC (Zone Program Integrity Contractor)
- QIO (Quality Improvement Organization)
Correct answer: RAC (Recovery Audit Contractor)
Recovery Audit Contractors (RACs) conduct post-payment reviews to identify overpayments and underpayments in Medicare claims.
CDIP Regulatory and Payer Requirements 2
Which federal program requires hospitals to submit claims using ICD-10-CM/PCS codes under the Inpatient Prospective Payment System (IPPS)?