Regulatory and Payer Requirements Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory and Payer Requirements flashcards as text
Which federal program requires hospitals to submit claims using ICD-10-CM/PCS codes under the Inpatient Prospective Payment System (IPPS)?
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.
Under IPPS, what term describes the process of grouping inpatient cases into payment categories based on principal diagnosis, procedures, and other factors?
Answer: DRG grouping
Diagnosis-Related Group (DRG) grouping classifies inpatient cases into payment categories under IPPS for Medicare reimbursement.
CMS's Two-Midnight Rule primarily affects which type of patient status determination?
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.
Which organization publishes the Official Guidelines for Coding and Reporting that CDI professionals must follow for ICD-10-CM/PCS?
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).
A Medicare Advantage plan (Part C) differs from traditional Medicare primarily in that it:
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.
Under the False Claims Act, what is the minimum per-claim civil penalty a hospital faces for knowingly submitting a false Medicare claim?
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.
Which type of Medicare review contractor conducts post-payment reviews of inpatient claims to identify improper payments and potential fraud?
Answer: RAC (Recovery Audit Contractor)
Recovery Audit Contractors (RACs) conduct post-payment reviews to identify overpayments and underpayments in Medicare claims.