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
The Hierarchical Condition Category (HCC) risk adjustment model is primarily used by which Medicare payment program?
Answer: Medicare Advantage (Part C)
HCC risk adjustment is used by Medicare Advantage to adjust capitation payments to plans based on the predicted health costs of enrolled members.
Which condition is classified as a Hospital-Acquired Condition (HAC) under CMS policy that can result in reduced payment when not documented as present on admission?
Answer: Catheter-associated urinary tract infection (CAUTI)
CAUTI is one of CMS's designated HACs; if not present on admission, the hospital may not receive additional payment for treating this complication.
The Present on Admission (POA) indicator is required for all diagnoses on inpatient claims. Which POA indicator code means the condition was present at the time of inpatient admission?
Answer: Y
POA indicator 'Y' (Yes) means the condition was present at the time of inpatient admission.
Under the Affordable Care Act's Value-Based Purchasing (VBP) program, hospital payments are adjusted based on:
Answer: Performance on quality and patient experience measures
Hospital VBP adjusts Medicare payments up or down based on hospitals' performance on quality, safety, and patient experience measures.
Which Medicare claim type is used for outpatient hospital services, including emergency department visits and clinic visits?
Answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) form is used by institutional providers, including hospitals billing for outpatient services under OPPS.
Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare patients for designated health services to entities in which the physician has a financial relationship unless:
Answer: A valid exception applies
Stark Law prohibitions can be avoided only if the arrangement meets one of the specific statutory or regulatory exceptions defined in the law.
The Outpatient Prospective Payment System (OPPS) uses which classification system to group outpatient services for payment?
Answer: Ambulatory Payment Classifications (APCs)
OPPS pays for outpatient hospital services using Ambulatory Payment Classifications (APCs), which group similar services with similar costs.