CDIP Regulatory and Payer Requirements 3 — Questions and Answers
Question 1: The Hierarchical Condition Category (HCC) risk adjustment model is primarily used by which Medicare payment program?
- IPPS for inpatient hospitals
- Medicare Advantage (Part C) (Correct answer)
- Medicare Part D pharmacy
- Outpatient PPS (OPPS)
Correct 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.
Question 2: 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?
- Community-acquired pneumonia
- Catheter-associated urinary tract infection (CAUTI) (Correct answer)
- Chronic obstructive pulmonary disease exacerbation
- Sepsis due to prior outpatient infection
Correct 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.
Question 3: 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?
- N
- U
- W
- Y (Correct answer)
Correct answer: Y
POA indicator 'Y' (Yes) means the condition was present at the time of inpatient admission.
Question 4: Under the Affordable Care Act's Value-Based Purchasing (VBP) program, hospital payments are adjusted based on:
- Volume of services provided
- Performance on quality and patient experience measures (Correct answer)
- Number of Medicare Advantage enrollees
- Total charity care provided
Correct 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.
Question 5: Which Medicare claim type is used for outpatient hospital services, including emergency department visits and clinic visits?
- UB-04 (CMS-1450) (Correct answer)
- CMS-1500
- 837I transaction
- ANSI X12 837P
Correct answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) form is used by institutional providers, including hospitals billing for outpatient services under OPPS.
Question 6: 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:
- The service is medically necessary
- A valid exception applies (Correct answer)
- The patient provides written consent
- The referral is documented in the medical record
Correct 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.
Question 7: The Outpatient Prospective Payment System (OPPS) uses which classification system to group outpatient services for payment?
- Diagnosis-Related Groups (DRGs)
- Ambulatory Payment Classifications (APCs) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Episode Payment Models (EPMs)
Correct answer: Ambulatory Payment Classifications (APCs)
OPPS pays for outpatient hospital services using Ambulatory Payment Classifications (APCs), which group similar services with similar costs.
CDIP Regulatory and Payer Requirements 3
The Hierarchical Condition Category (HCC) risk adjustment model is primarily used by which Medicare payment program?