Health Information Management Technology 4th Ed By Sayles -Test Bank A+

Health Information Management Technology 4th Ed By Sayles -Test Bank A+

Health Information Management Technology 4th Ed By Sayles -Test Bank A+

Health Information Management Technology 4th Ed By Sayles -Test Bank A+

This is a comprehensive chapter on reimbursement methodologies. The instructor may use all of the content or select portions that apply to specific healthcare settings.

Depending upon the philosophy of the instructional program, the first part of the chapter on reimbursement history and reimbursement system types can be presented as either a global overview or a more in depth lesson. For most HIT programs the purpose and use of this section is to give students a general understanding of the evolution of reimbursement and how we have gotten to the complex place we are today.

The section on healthcare reimbursement methodologies is an important one for all HIT students. Students should develop a clear understanding of and be able to distinguish among the various methodologies.

The section on claims processing and knowledge of various government forms for reimbursement is an essential one, particularly for those programs preparing individuals for coding positions.

The section on reimbursement support processes is an essential one, particularly in relation to managing fee and chargemasters and addressing issues of documentation and quality coding.

Chapter Outline

Learning Objectives

Key Terms


Theory into Practice

History of Healthcare Reimbursement in the United States

Pre-Medicare/Medicaid Campaigns for National Health Insurance

Medicare/Medicaid Programs

Cost Management

Development of Prepaid Health

Blue Cross/Blue Shield

Group Health Insurance

Major Medical Insurance

Health Insurance Coverage

Healthcare Reimbursement Systems

Commercial Insurance

Private Health Insurance Plans

Employer-Based Self-Insurance Plans

Not-for-Profit and For-Profit Healthcare Plans

Blue Cross and Blue Shield Plans

Government-Sponsored Healthcare Programs


Medicare Part A

Medicare Part B

Services Not Covered by Part A or Part B

Part C Medicare Advantage (MA Plans)

Part D Medicare Prescription Drug Plan, Improvement and Modernization Act

Out-of-Pocket Expenses and Medigap Insurance


Medicaid Eligibility Criteria

Medicaid Services

Medicaid–Medicare Relationship

State Children’s Health Insurance Program


Veterans Health Administration


Indian Health Service

Workers’ Compensation

Federal Workers’ Compensation Funds

State Workers’ Compensation Funds

Managed Care


Managed Care Quality Initiatives

Health Maintenance Organizations

Group Model HMOs

Independent Practice Associations

Network Models HMOs

Staff Model HMOs

Preferred Provider Organizations

Point-of-Service Plans

Exclusive Provider Organizations

Integrated Delivery Systems

Group Practices without Walls

Integrated Provider Organizations

Management Service Organizations

Medical Foundations

Physician-Hospital Organizations

Healthcare Reimbursement Methodologies

Fee-for-Service Reimbursement Methodologies

Traditional Fee-for-Service Reimbursement

Managed Fee-for-Service Reimbursement

Episode-of-Care Reimbursement Methodologies


Global Payment

Global Surgery Payments

Prospective Payment

Medicare Prospective Payment Systems

Medicare Acute Inpatient Prospective Payment System (IPPS)

Diagnosis-Related Groups (DRGs)

MS-DRG Assignment

Case-Mix Index All Patient DRG

Hospital-Acquired Conditions and Present on Admission Indicator Reporting

Resource-Based Relative Value Scale (RBRVS) System

Skilled Nursing Facility Prospective Payment System

Resource Utilization Groups

Resident Assessment Validation and Entry

Consolidated Billing Provision

Outpatient Prospective Payment System

Ambulatory Payment Classification Groups (APCs)

Payment Status Indicators

Ambulatory Surgery Center Prospective Payment Systems (ASC PPS)

Home Health Prospective Payment System (HH PPS)

OASIS-C and Home Assessment Validation and Entry (HAVEN)

Home Health Resource Groups

Low Utilization and Outlier Payments

Ambulance Fee Schedule

Inpatient Rehabilitation Facility (IRF) Prospective Payment System

Patient Assessment Instrument

CMG Relative Weight

Long-Term Care Hospitals (LTCH) Prospective Payment System



Inpatient Psychiatric Facilities (IPFs) Prospective Payment System


Processing of Reimbursement Claims

Coordination of Benefits

Submission of Claims

Explanation of Benefits and Medicare Summary Notice Remittance Advice

Medicare Administrative Contractors

National Correct Coding Initiative (NCCI)

Physician Query Process

Electronic Data Interchange

Reimbursement Support Processes

Management of Fee Schedules

Management of the Chargemaster

Maintenance of the Chargemaster

Management of the Revenue Cycle

Revenue Cycle Management Committee

Management of Documentation and Coding Quality

Coding and Corporate Compliance

History of Fraud and Abuse and Corporate Compliance in Healthcare

Elements of Corporate Compliance

Relationship between Coding Practice and Corporate Compliance

OIG Workplan

The HIM Compliance Program

Code of Conduct

Policies and Procedures

Education and Training


Internal Audits

Corrective Action


Recovery Audit Contractor Program

Real-World Case



Learning Objectives

  • Understand the historical development of healthcare reimbursement in the United States
  • Describe current reimbursement processes, forms, and support practices for healthcare reimbursement
  • Differentiate between commercial health insurance and employer-based self-insurance
  • Describe the purpose and basic benefits of the following government-sponsored health programs: Medicare Part A, Medicare Part B, Medicare Advantage, Medicaid, CHAMPVA, TRICARE, HIS, TANF, PACE, SCHIP, workers’ compensation, and FECA
  • Understand the concept of managed care and to provide examples of different types of managed care organizations
  • Identify and differentiate between the different types of fee-for-service reimbursement methods
  • Describe the various Medicare prospective payment systems
  • Understand the purpose of the fee schedules, chargemasters, and auditing procedures that support the reimbursement process
  • Support accurate billing through chargemaster, claims management, and bill reconciliation processes
  • Outline the revenue cycle processes
  • Describe the elements of a compliance program
  • Explain the relationship between coding practice and corporate compliance

Key Terms

Accept assignment

Accounts receivable

Administrative services only (ASO)


Advance Beneficiary Notice of

Noncoverage (ABN)

All patient DRGs

All patient refined DRGs (APR-DRGs)

Ambulatory payment classification (APC) system

Ambulatory surgery center (ASC)


Balance billing

Balanced Budget Refinement Act of 1999


Blue Cross and Blue Shield (BC/BS)

BC/BS Federal Employee Program (FEP)

Bundled payments


Case-mix group

Case-mix group (CMG) relative weights

Case-mix index

Categorically needy eligibility groups


Centers for Medicare and Medicaid

Services (CMS)


Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS)

Civilian Health and Medical Program-

Veterans Affairs (CHAMPVA)






Compliance program guidance


Coordination of benefits (COB) transaction

Cost outlier

Cost outlier adjustment

Current Procedural Terminology (CPT)

Department of Health and Human Services (HHS)

Diagnosis-related groups (DRGs)

Discharge planning


DRG grouper

Employer-based self-insurance

Episode-of-care (EOC) reimbursement

Exclusive provider organization (EPO)

Explanation of Benefits (EOB)

External reviews (audits)

Federal Employees’ Compensation Act


Fee schedule

Fee-for-service basis

Fraud and abuse

Geographic practice cost index (GPCI)

Global payment

Global surgery payment

Group health insurance

Group model HMO

Group practice without walls (GPWW)


Health maintenance organization (HMO)

Health Plan Effectiveness Data and

Information Set (HEDIS)

Healthcare Common Procedure Coding

System (HCPCS)

Healthcare provider

Home Assessment Validation and Entry (HAVEN)

Home health agency (HHA)

Home health prospective payment system

Home health resource group (HHRG)


Hospital-acquired conditions (HAC)

Hospitalization insurance (HI) (Medicare Part A)

Indemnity plans

Independent practice association (IPA)

Indian Health Service (IHS)

Inpatient psychiatric facility (IPF)

Inpatient rehabilitation facility (IRF)

Inpatient Rehabilitation Validation and

Entry (IRVEN)



Integrated delivery system (IDS)

Integrated provider organization (IPO)

Long-term care hospital (LTCH)

Low-utilization payment adjustment (LUPA)

Major diagnostic category (MDC)

Major medical insurance

Managed care

Management service organization (MSO)


Medical foundation

Medically needy option (Medicaid)


Medicare administrative contractor (MAC)

Medicare Advantage

Medicare carrier

Medicare fee schedule (MFS)

Medicare severity diagnosis-related groups


Medicare Summary Notice (MSN)


Minimum Data Set 3.0 (MDS)

National Committee for Quality Assurance (NCQA)

National conversion factor (CF)

National Correct Coding Initiative (NCCI)

National Uniform Billing Committee (NUBC)

Network model HMO

Network provider

Nonparticipating providers

Omnibus Budget Reconciliation Act (OBRA)

Outcomes and Assessment Information Set (OASIS)

Out-of-pocket expenses

Outpatient code editor (OCE)

Outpatient prospective payment system (OPPS)


Partial hospitalization

Patient Protection and Affordable Care Act

Payer of last resort (Medicaid)

Payment status indicator (PSI)

Per member per month (PMPM)

Per patient per month (PPPM)

Physician-hospital organization (PHO)

Point-of-service (POS) plan



Preferred provider organization (PPO)


Present on admission (POA)

Primary care physician (PCP)

Principal diagnosis

Principal procedure

Professional component (PC)

Programs of All-Inclusive Care for the Elderly (PACE)

Prospective payment system (PPS)

Public assistance

Relative value unit (RVU)

Remittance advice (RA)

Resident assessment instrument (RAI)

Resident Assessment Validation and Entry (RAVEN)

Resource Utilization Groups, Version IV


Resource-based relative value scale (RBRVS)

Respite care

Retrospective payment system

Recovery audit contractor (RAC)

Revenue codes

Skilled nursing facility prospective

payment system


Social Security Act

Staff model HMO

State Children’s Health Insurance Program (SCHIP)

State workers’ compensation insurance funds

Supplemental medical insurance (SMI)

(Medicare Part B)

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Technical component (TC)

Temporary Assistance for Needy Families (TANF)

Third-party payer

Traditional fee-for-service reimbursement




TRICARE Standard

UB-04 (CMS-1450)



Usual, customary, and reasonable (UCR)


Veterans Health Administration

Voluntary Disclosure Program

Workers’ compensation


Learning Simulation

One of the best types of learning activities is one where the student participates in a learning simulation. Simulations that can be developed include having the student function as a supervisor of reimbursement and perform the following tasks:

  • Following set procedures (developed by the instructor), perform an internal coding audit for coding compliance
  • Following set procedures (developed by the instructor) perform an audit on a snapshot of a chargemaster or fee schedules for various types of healthcare delivery sites

Exercise and Discussion

Given appropriate health records and other documentation have students complete various reimbursement forms for government and private pay. Compare completed forms of all students afterwards in a discussion session. Have a discussion of the complexity of completing such forms and what types of policies, procedures, and audit mechanisms must be in place to ensure quality documentation.

Theory into Practice and Real-World Case

Use the Theory into Practice section and/or the Real-World Case to initiate student discussion of the material in the chapter. The questions in the Check Your Understanding sections located throughout the chapter also can be used to stimulate class discussion.

Guest Speakers

  • Invite a coding supervisor to speak to the class about managing coding functions in a healthcare facility.
  • Invite a director of health information to speak to the class and to share information about reimbursement and about accounts receivable management and other techniques used to monitor coding processes to ensure facility reimbursement.


Use the enclosed PowerPoint slides as a lecture guide.

Class Discussion

  • Have individual students present information from their facility coding interviews (see Projects) to the class. Their varied experiences can stimulate a discussion of similarities and differences in various types of hospitals or other care settings.
  • Alternatively, divide the class into groups made up of students who visited different facilities for the interview. Select a topic for each group such as the process of coding, ensuring coding quality and coding compliance programs, staffing a coding service and setting productivity standards, use of encoders, or reimbursement systems. Have each group prepare a presentation addressing the similarities and differences its members observed relative to their topic. Ask each group to research published information on their topic and to incorporate this information into their presentation.
  • Give students sample billing forms for government and private payers (including CMS-1450 and CMS-1500) and, using sample patient records, have them enter billing data on the forms. Discuss the difficulty in finding data elements and discuss the types of policies, procedures, and audit mechanisms that must be in place to ensure quality documentation.

Literature Review/Additional Readings

  • There are many articles pertaining to issues of coding and reimbursement. Students can access readings via the university/college library or by using the FORE HIM Body of Knowledge available at
  • Have the students read and be prepared to discuss the following (available at
    • Youmans, K. 2004. An HIM spin on the revenue cycle. Journal of AHIMA 75(3):32–36.
    • Campbell, T. 2003. Opportunities for HIM in revenue cycle management. Journal of AHIMA 74(10):62–63.
    • Practice Briefs:
      1. Rhodes, H. 1999. Practice brief: The care and management of charge masters. Journal of AHIMA 70(7):supplement 2.
      2. Prophet, S. 2001. Practice brief: Developing a physician query process. Journal of AHIMA 72(9):88I–M.
    • Students may also consult the following books as extra resources.
    • Schraffenberger, L. 2011. Effective Management of Coding Services, 4th ed. Chapter 7: The Charge Description Master. Chicago: AHIMA Press.
    • Bowman, S. 2008.Health Information Management Compliance: Guidelines for Preventing Fraud and Abuse, 4th ed. Chicago: AHIMA Press.


The facility coding interview project detailed as follows may be done individually, in pairs, or in small groups.

Have the students visit a healthcare facility and interview a coding supervisor or director of health information services about the process of coding, productivity standards, quality assurance of coding, reimbursement systems, and management issues. The interview guide below provides sample questions to ask in the interview. Students should choose one of the following types of facilities. Make sure that each type of facility is visited by a group.

(a) Hospitals (inpatient and outpatient functions)

(b) Physician’s office

(c) Ambulatory surgery center

(d) Skilled nursing facility

(e) Long-term care hospital

(f) Inpatient rehabilitation hospital

(g) Inpatient psychiatric hospital

(h) Home health agency

Make an appointment to interview the director of the department or a coding supervisor. The interview should take approximately one hour. Be sure to send a thank-you letter to the person you interview.

The information from your interview should be compiled into a three- to four-page report that can be presented in both verbal and written format. Summarize all the information you learned during the interview, and answer the following questions:

  1. What are your reactions to the interview?
  2. Was the interview educational? Was anything surprising or particularly interesting?
  3. Did this experience help you to integrate classroom information?

Use the data from the interviews as you continue the discussion of coding issues, especially as they relate to the quality of data.

Following are suggested items of information students should try to obtain. This list is intended for guidance only; it is by no means an exhaustive list of questions.

Facility Data

  • Name, title, and credentials of the person interviewed
  • Name and type of facility
  • Number of beds
  • Number of outpatient visits per year (if applicable)
  • Director of the HIM department
  • Coding supervisor

Data Regarding the Coding Function

  • How many coders does the facility employ? How many are full-time and how many part-time?
  • What are the credentials of the coders? RHIAs? RHITs? CCSs? CCAs? CCS-Ps? Other? None?
  • If some of the coders are noncredentialed, how did they obtain coding training?
  • On-the-job training
  • Formal in-service program at the hospital
  • AHIMA Coding In-Service Training Program
  • Other (specify)
  • Do coders regularly attend continuing education workshops on coding issues? If so, what types of workshops do they attend?
  • State HIM association workshops
  • AHIMA workshops
  • AHA teleconferences (Is the hospital a teleconference site?)
  • Local HIM association workshops
  • Other (specify)
  • Does the facility use outside coding services/contractors for coding? If so, what is the name of the company? Does the facility use this service to perform all coding, only backlog coding, or only overload?
  • Has the facility used coding/reimbursement consultants to help optimize coding and MS-DRG assignment? If so, which company? Was the facility satisfied with the service?
  • Does the department have an automated encoder? If so, what type of encoder do they use?
  • Is a MS-DRG grouper part of the encoding system?
  • Is the department satisfied with the encoder? What advantages and disadvantages does this system have? How does the department feel about the system’s accuracy, consistency, ease of use, and ease in training? Does the department get adequate support from the vendor?
  • If possible, get samples of input and output screens from the encoding product.

The Coding Process

  • What is the average time lapse between discharge and coding?
  • Are Medicare records handled differently from non-Medicare discharges?
  • If there are two or more coders, how are records divided among coders?
  • Do coders have other responsibilities in the department, such as abstracting, quantitative analysis, or MS-DRG assignment?
  • Are there current backlogs in coding?

Monitoring the Coding Function

  • Is coding productivity monitored? Does the department have coding-related standards? If so, what standards do they set for quantity, quality, and timeliness?
  • Are coders rewarded for meeting or exceeding the standards? Are they disciplined if they consistently do not meet the standards?
  • Does the facility have a compliance plan in place to address issues of fraud and abuse? Does it address coding guidelines?
  • Is coding done using only the face sheet, or are other reports used?
  • Is the record coded if the face sheet and/or summary are not completed?
  • Do coders contact physicians for information and clarification, or is contact made only by the supervisor?
  • Is the medical staff generally cooperative in providing adequate documentation for coding?
  • Are incentives used to persuade the physicians to complete their records?
  • Is concurrent coding done in the facility? If so, is it effective in getting the record coded in a timely way? Are there quality or accuracy problems?

Staffing the Coding Area

  • Has coder turnover been a problem in this department?
  • How many positions opened up in the coding area last year?
  • Is it difficult to fill coding positions?
  • Are there current shortages?
  • How does the department recruit coders? Is there an adequate supply in the area?
  • What is the average salary for a coder? (Ask the interviewee if he or she is willing to share this information with you. Salaries are sensitive information, and the interviewee may not be willing to give exact figures.)
  • Are candidates for coding positions tested during their interview? Are coders selected on the basis of a coding test?

Producing the Disease/Diagnosis and Operative Index

  • What system is used to capture coded data to produce monthly/annual diagnosis and operative indexes? Are data entered directly into a computer system or abstracted on a paper abstract?
  • Is the abstract system or database a commercial system or an in-house system? Is it linked to the grouper?
  • Are monthly and/or annual indexes produced, or is information retrieved as needed?
  • What types of routine reports are produced? Who reviews them?
  • What types of special reports are produced?
  • If possible, obtain samples of the input document(s) and routine reports.


Real-World Case Discussion Questions

  1. Why is revenue cycle management important?

Delays in the revenue cycle management will delay payment to the healthcare facility. This delay can result in cash flow problems that can jeopardize the financial stability of the healthcare facility.

  1. What is the role of the HIM professional in revenue cycle management?

The HIM professional can be involved at a number of points throughout the revenue cycle. The points include, but not limited to admission, coding, billing, and chargemaster maintenance.

  1. Why would the hospital spend the time creating the flowchart of the claim process?

Using a flowchart to diagram the revenue cycle is a very useful tool as it can identify problems and delays in the process. Once problems are identified, then steps can be taken to solve the problems and therefore improve the efficiency of the revenue cycle.

Application Exercises

Exercise 1

Jane Doe is an 83-year-old patient who only has Medicare Part A insurance. After reviewing the following information, answer the questions regarding her listed hospitalizations.



07/0411/02$21,888 ($912 + 6,840 + 14, 136)

  1. How many benefit periods were used during this calendar year?


  1. Were any lifetime reserve days used during this period of time? If so, how many? ____36_____

  1. If lifetime reserve days were used, how many does the patient have left to be used at a later date?


  1. How many times was the patient required to pay a hospital deductible during this time period?


  1. Following this last hospital admission, Jane was transferred to a skilled nursing facility (SNF) and remained there for continued treatment for 22 days.
  2. How much was Jane required to pay for her SNF care for days 1–20?


  1. How much was she required to pay for the remainder of her SNF stay?


  1. After Jane’s discharge from the skilled facility, she received home health care as prescribed by her physician for 14 days. During this time period, she met all Medicare’s medical necessity criteria for her care. How much did the patient have to pay for her home health care?


Exercise 2

Under the new outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. For each case that follows, determine whether the patient will pay the coinsurance or copayment amount.

  1. Mr. Smith was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. Mr. Smith has already paid his annual Medicare Part B deductible of $100.

Mr. Smith would pay the copayment amount because it is less than the coinsurance amount.

  1. Mr. Jones and Mrs. Day live in the same area of the country. They are having the same outpatient procedure done, but at different hospitals. Mr. Jones’s hospital charges $250 for the procedure, but Mrs. Day’s hospital charges $150. The national median charge for this procedure is $225 (adjusted for wages in their area) with a fixed copayment of $54. Both patients have already paid their $100 yearly Medicare Part B deductible.

In both cases, the 20 percent coinsurance amount is the lesser of the charges, so Mr. Jones and Mrs. Day would pay the coinsurance amount.

Exercise 3

Alfred State Medical Center’s charges, payments, and adjustments from third-party payers for the month of July are represented in the table below.

  1. Calculate the percentage of charges, payments, and adjustments for each third-party payer and enter the percentages in the percentages columns of the table.


* Managed care capitated payment for period

  1. Based on the percentages calculated in the charges column, identify the payer the facility does the most business with and the payer it does the least business with.

Medicare; Tricare

  1. Based on the percentages calculated in the payment column, identify the payers that reimburse the facility the most and the least.

Medicare; Tricare

  1. Based on the percentages calculated in the adjustments column, identify the payers that proportionately reimburse the facility the most and the least.

Commercial; Medicaid

Exercise 4

Use the tables below to answer the following questions.

The national conversion factor for 2011 is $33.9764.

  1. How much can a physician in St. Louis bill Medicare for an office visit for a new patient with a detailed history and physical and low-complexity medical decision making (assuming the patient has met any deductible for the year)?

Conversion Factor: $33.9764

Billing 99203 in St. Louis

1.42 × 0.99163 = 1.408115

0.72 × 0.939923 = 0.676745

0.10 × 1.793 = 0.1793

Total = 2.264159 × $33.9764 = $76.93

  1. In which city would a physician receive the highest reimbursement for a TURP? Conversion factor: $33.9764

TURP (52601)

St. Louis

15.26 × .99163 = 15.13227

8.09 × .939923 = 7.603977

1.49 × 1.0594 = 1.578506

Total = 24.31476 × $33.9764= $826.13


15.26 × 1.0113 = 15.43244

8.09 × 0.99943 = 8.085389

1.49 × 0.82543311 =1.229895

Total = 24.74772 × $339764 = $840.84


15.26. × .98989 = 15.10572

8.09 × 0.932469= 7.543674

1.49 × 1.670886 = 1.229895

Total = 23.87929 × $3 = $811.33

The physician in Dallas has the highest reimbursement.

  1. In which city would a physician receive the lowest reimbursement for a colonoscopy with biopsy? Conversion Factor: $33.9764

Colonoscopy with biopsy (45380)

St. Louis

4.43 × 0.99163 = 4.385213

2.73 × 0.939923 = 2.54564

0.67 × 1.05944 = 1.119494

Total = 7.668735 × $33.9764 = $260.56


4.43 × 1.0113 = 4.480059

2.73 × 0.99943 = 2.728444

0.67 × 0.82543311 = 0.55304

Total = 7.761543 × $33.9764 = $263.71


4.43 × 0.98989 = 4.385213

2.73 × 0.932469 = 2.54564

0.67 × 1.670886 = 1.119494

Total = 8.050347 × $33.9764 = $273.5218

The city where physicians receive the lowest reimbursement is St. Louis.

  1. Calculate the expected payment for an incision and drainage of a pilonidal cyst in each of the cities listed. Conversion factor: $33.9764

Incision and Drainage (10080)

St. Louis

4.19 × 0.99163 = 4.15493

3.49 × 0.939923 = 3.280331

0.76 × 1.05944 = 0.805174

Total = 8.240435 × $33.9764 = $279.98


4.19 × 1.0113 = 4.237347

3.49 × 0.99943 = 3.488011

0.76 × 0.82543311 = 0.627329

Total = 8.352687 × $33.9764 = $283.79


4.19 × 0.98989 = 4.147639

3.49 × 0.932469 = 3.254317

0.76 × 1.269873 = 1.269873

Total = 8.671829 × $33.9764 = $294.64

Review Quiz

Instructions: Choose the most appropriate answer for the following questions.

  1. Which of the following plans reimburses patients up to a specified amount?
  2. Health insurance
  3. Coinsurance
  4. Indemnity
  5. Major medical plan

  1. Catastrophic coverage is categorized as part of which of the following?
  2. Major medical insurance
  3. Managed care insurance

c Special risk insurance

  1. Coinsurance

  1. The number of days Medicare will cover SNF inpatient care is limited to which of the following?
  2. 21
  3. 60
  4. 30
  5. 100

  1. Which of the following types of care is not covered by Medicare?
  2. Long-term nursing care
  3. Skilled nursing care
  4. Hospice care
  5. Home health care

  1. Which of the following covers prescribed preventive benefits and is subject to a deductible?
  2. Medicare Part A
  3. Medicare Part B
  4. Medicare Part D
  5. Medicare Prescription Drug, Improvement and Modernization Act

  1. Which of the following terms is used for the amount charged for a medical insurance policy?
  2. Fee schedule
  3. Premium
  4. Claim
  5. Deductible

  1. Upon which criterion is Medicaid eligibility-based?
  2. Income
  3. Whether a person is Medicare eligible
  4. Age
  5. Health status
  1. How many benefit periods are covered by hospital insurance during a Medicare beneficiary’s lifetime?
  2. One per year
  3. Based on a 90-day stay
  4. None
  5. Unlimited

  1. What term is used for retrospective reimbursement charges submitted by a provider for each service rendered?
  2. Fee-for-service
  3. Deductible
  4. Actuarial
  5. Prospective

  1. What is the name of the federally funded program that pays the medical bills of the spouses and dependents of persons on active duty in the uniformed services?
  5. Medigap

  1. What is the name of the program funded by the federal government to provide medical care to people on public assistance?
  3. Medicare
  4. Medicaid
  5. Medigap

  1. Some services are covered and paid by Medicare before Medicaid makes payments because Medicaid is considered which of the following?
  2. Qualified beneficiary
  3. Premium payer
  4. Payer of last resort
  5. Alternative payer

  1. Which of the following groups of healthcare providers contracts with an employer to provide healthcare services?
  2. Preferred provider organization
  3. Health maintenance organization
  4. Point-of-service provider
  5. Independent practice association

  1. Which of the following is a nonprofit organization that contracts with physicians, acquires assets, and manages the business side of medical practices?
  2. Management service
  3. Managed care organization
  4. Medical foundation
  5. Group practice
  1. Which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered?
  2. Fee-for-service reimbursement method
  3. Prospective payment method
  4. Retrospective payment method
  5. Resource-based payment method

  1. Which of the following payment methods reimburses healthcare providers in the form of lump sums for all healthcare services delivered to a patient for a specific illness?
  2. Managed fee-for-service
  3. Capitation
  4. Episode of care
  5. Point of service

  1. Which of the following apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?
  2. Global payments
  3. Professional payment
  4. Bundled payment
  5. Fee-for-service

  1. Which of the following is a state-licensed, Medicare-certified supplier of healthcare services to Medicare beneficiaries?
  2. Global surgery center
  3. Ambulatory surgery center
  4. Professional surgery center
  5. Technical surgery center

  1. Critique this statement: Medicare severity-diagnosis-related groups represent a prospective payment system implemented by CMS to reimburse hospitals a predetermined amount for inpatient stays.
  2. This is a true statement.
  3. This is not a true statement as MS-DRGs apply to ambulatory care.
  4. This is a false statement as MS-DRGs utilize bundled payments not
    predetermined payments.
  5. MS-DRGs are controlled by the CDC not CMS.

  1. Dr. Smith has received a single payment for preoperative care, performing surgery, and postoperative care for Ms. Jones’s cholecystectomy. This model of reimburse is called:
  2. Global surgery payment
  3. Bundled payment
  4. Fee-for-service
  5. Capitation

Instructions for questions 21–24. Match the terms with their definitions.

  1. Condition established after study to be the reason for hospitalization
  2. Categories of patients treated
  3. Coexisting condition
  4. Condition arising during hospitalization

  1. _b_ Case mix
  2. _a_ Principal diagnosis
  3. _d_ Complication
  4. _c_ Comorbidity

Test Bank

with Key

Instructions: Choose the most appropriate answer for the following questions.

  1. Critique this statement: Skilled nursing facilities are no longer paid under a system based on reasonable cost but, rather, through per-diem prospective case-mix-adjusted payment rates.
  2. This is a true statement.
  3. This is a false statement as skilled nursing facilities are paid on a per visit rate.
  4. This is a false statement as skilled nursing facilities are paid based on a schedule.
  5. This is a false statement as skilled nursing facilities are paid based on charges.

2 Which of the following classification systems uses resident assessment data to assign residents to one of 44 groups, with each assessment applying to specific days within a resident’s stay?

  1. MS-DRG
  2. APC
  3. RUG
  4. HH PPS

  1. The ambulatory payment classification system is based on the categorization of which services?
  2. Inpatient care
  3. Home care
  4. Outpatient care
  5. Skilled care

  1. Which of the following terms can be defined as the combination of certain items (such as anesthesia, supplies, and drugs) for the purposes of reimbursement?
  2. Packaging
  3. Discounting
  4. Prospective payment
  5. Global surgery payment

  1. Which classification system is established for the prospective reimbursement of covered home care services to Medicare beneficiaries during a 60-day episode of care?
  2. OASIS
  3. HAVEN
  4. HHRGs
  5. HH PPS

Instructions for questions 6–10: In the following questions, answer “a” if the provider should submit a CMS-1500 to a third-party payer or “b” if the provider should submit a UB-92/UB-04 to a third-party payer.

  1. _a_ Physician who sees a patient in the office
  2. _b_ Hospital that treats a patient as a hospital


  1. _b_ Ambulance company that responds to a motor vehicle accident and transports the patient to the closest trauma center
  2. _a_ DMERC supplier that provides services to the patient
  3. _b_ Ambulatory surgery center that performs same-day

surgery on the patient

Instructions: Choose the most appropriate answer for the following questions.

  1. Which organizations enter into contracts with the CMS to process claims for Parts A & B professional physician services?
  2. Medicare administrative contractors
  3. Medicare fiscal intermediaries
  4. Quality improvement organizations
  5. Integrated provider organization

  1. Which term is used in reference to the transfer of health claims using electronic media?
  2. ANSI
  3. ASC X12
  4. EDI
  5. Optical scanning

  1. Which term is used in reference to the electronic transmission of information from a provider to a health plan to determine a patient’s eligibility for services?
  2. Claims transaction
  3. Coordination of benefits transaction
  4. Electronic data interchange
  5. Remittance advise

  1. Which of the following explains Medicare payments and denials?
  2. ERA
  3. HCC
  4. HIPAA
  5. Payment transaction

  1. Which of the following statements best describes the situation for a provider that agrees to accept assignment for Medicare services?
  2. Reimbursed at 15 percent above the allowed charge
  3. Paid according to the MFS plus 10 percent
  4. Prohibited from balance billing patients
  5. Referred to as a nonparticipating provider

  1. When did CMS implement the Correct Coding Initiative for physician claims?
  2. 1983
  3. 1990
  4. 1996
  5. 2000

  1. Our hospital wants to partner with local physicians so that we can be viewed as a single entity in negotiating managed care contracts. Which of the following model should we develop?
  2. MSO
  3. PHO
  4. Medical foundation
  5. ASO

Health Information Management Technology

An Applied Approach

Fourth Edition

Instructor’s Manual

Chapter 7

Health Information Functions

Lesson Plan

Background and Instructional Delivery

This chapter focuses on the functions required by the processing of paper records, hybrid records, and the electronic health record, including storage and retrieval, chart processing, monitoring of chart completion, transcription, release of information, and clinical coding.

Storage and maintenance of the health record is the most fundamental HIM function and affects all other functions. If records and information are not stored and maintained appropriately, then it is almost impossible to perform other tasks. This chapter discusses filing systems, storage systems, microfilming, remote storage, chart tracking, and quality monitoring of paper-based record systems. The HIM functions of hybrid and electronic health records systems are also discussed.

In addition to the typical HIM functions, other related functions that are sometimes performed by the HIM department are also discussed, including research and statistics, cancer and trauma registries, and birth certificates.

Figure 7.1 of the chapter provides a description of a fictional HIM department. This fictional department will help students to visualize how all the various services and functions of the HIM department are integrated.

Review the department organization with students and discuss the HIM functions. Students may have been exposed to other HIM departments through work, site visits or rotations. This is a good opportunity to discuss differences and similarities among organizational structures and functions of HIM departments.

Secondary uses of health data are also discussed in this chapter. Indexes and registers support functions for areas such as coding and research and statistics. This section covers the customary indexes and registers.

Patient registration is discussed as the starting point of the health record with the collection of demographic information, admitting diagnosis, and payment information. Points of registration are described for a large healthcare facility. Discussion of the need for coordination and consistency of registration activities should be emphasized with regard to data integrity, completeness, and accuracy. If possible, obtain registration forms from various points of patient registration and compare these for consistency. The interdepartmental relationships in regards to data integrity and health record content should be discussed.

The next section of the chapter covers the management of the health record content and processes. Joint Commission accreditation is discussed, with examples of the HIM monitoring activities that assist in determining compliance with Joint Commission standards. The instructor should discuss other examples of the HIM department’s involvement in the accreditation process.

Forms design and development are also covered. In most acute care facilities, the medical records committee serves as the forms committee.

Chapter Outline

Learning Objectives

Key Terms


Theory into Practice

HIM Functions and Services

Master Patient Index

Maintenance of Master Patient Index

Patient Identity in a Health Information Exchange Environment

Identification Systems

Identification Systems for Paper-Based Health Records

Serial Numbering System

Unit Numbering System

Serial-Unit Numbering System

Alphabetic Identification and Filing System

Identification Systems for Electronic Health Records

HIM Functions in a Paper-based Environment

Record Storage and Retrieval Functions

Filing Systems for Paper-based Health Records

Alphabetic Filing Systems

Numeric Filing Systems

Alphanumeric Filing Systems

Centralized Unit Filing Systems

Storage Systems for Paper-based Records

Filing Cabinets or Shelving Units

File Folders

Microfilm-Based Storage Systems

Off-Site Storage Systems

Imaged-Based Storage Systems

Retrieval and Tracking Systems for Paper-based Records

Retention and Destruction of Paper-based Records



Record Processing of Paper-based Records

Admission and Discharge Record Reconciliation for Paper-based Records

Record Assembly Function for Paper-based Records

Deficiency Analysis for Paper-based Records

Monitoring Completion of Paper-based Records

Authorization and Access Control for Paper-based Records

Forms Design, Development and Control for Paper-based Records

Forms Design and Development
Clinical forms Committee

Forms Control, Tracking, and Management

Quality Control Functions in Paper-based Systems

Storage and Retrieval

Record Processing

HIM Functions in a Hybrid Environment

Record Storage, Retrieval, and Retention of Hybrid Records

Use of Electronic Document Management Systems

Workflow Using an EDMS

Record Retention

Handling Corrections

Search, Retrieval and Manipulation

Authorization and Access Control for Hybrid Records

Quality Control Functions for Hybrid Records

Quality in Record Processing

Reconciliation in the Hybrid Records

Issues and Challenges with Hybrid Records

HIM Functions in an Electronic Environment

Transition Functions to an EHR

Record Filing and Tracking of EHRs

Record Processing of EHRs

Version Control of EHRs

Management of Free Text in EHRs

Management and Integration of Digital Dictation, Transcription and Voice Recognition

Reconciliation Processes for EHRs

Managing Other Electronic Documentation


Voice Mail

Handling Materials from Other Facilities

Search, Retrieval and Manipulation Functions of EHRs

Access Control for EHRs





Handling Amendments and Corrections in EHRs

Purge and Destruction of EHRs

Quality Control Functions for EHRs

Medical Transcription

Management of Medical Transcription

Quality Control

Release of Information (ROI)

ROI Quality Control

Legal Health Record

Tracking and Report of Disclosures

Clinical Coding

Quality Control in Clinical Coding

Revenue Cycle Management

Other HIM Functions

Data Reporting and Interpretation

Maintenance of Indexes and Registries

Disease and Operation Indexes

Physician Index


Birth Certificates

HIM Interdepartmental Relationships

Patient Registration

Billing Department

Patient Care Departments

Information Systems

Participation on Medical Staff and Organizational Committee

Managing Documentation Requirements

Virtual HIM

Accreditation and Licensing Documentation Requirements

Monitoring of Accreditation, Licensure, and Standards Requirements

Management and Supervisory Processes

Policy and Procedure Development

Future Direction in Health Information Management Technology

Real-World Case



Learning Objectives

  • Identify typical health information management functions
  • Explain the purpose and techniques used for the maintenance of the master patient index in paper-based and electronic environments
  • Identify operational techniques for managing traditional HIM functions in paper-based, hybrid, and electronic record environments
  • Discuss techniques used in the processing, storage, retrieval, and maintenance of health records in paper-based, hybrid and electronic environments
  • Explain the use of quality control techniques used for paper-based, hybrid, and electronic health records and for supporting services such as medical transcription, release of information, and coding functions
  • Discuss the concept of the legal health record and how it is applied
  • Describe practices for authorization and access control of health records in paper-based, hybrid, and electronic formats
  • Recognize the interrelationship between the HIM department and other key departments within the healthcare organization
  • Describe the purpose, development, and maintenance of registries and indexes such as the master patient index, disease index, and operation indexes
  • Discuss the functions and responsibilities of common HIM support services, including cancer and trauma registries, birth certificate completion, and statistical and research services
  • Explain the relationship of accreditation, licensing, and standards requirements to HIM functions and how compliance with these is monitored
  • Describe techniques used in the management of the HIM department, such as policy and procedure development and the budgeting process

Key Terms


Access control

Alphabetic filing system

Alphanumeric filing system

APC grouper



Back-end speech recognition

Certificate of destruction

Clinical coding

Computer-assisted coding (CAC)

Concurrent review


Deemed status

Deficiency slip

Delinquent record


Digital dictation

Duplicate medical record number


Enterprise master person/patient index


Free-text data

Front-end speech recognition

Health information exchange (HIE)

Health record number

Hybrid record


Joint Commission

Legal health record

Master patient index (MPI)

Medical transcription

Middle-digit filing system

MS-DRG grouper

Natural language processing (NLP)


Numeric filing system

Operation index




Patient account number



Purged records

Quantitative analysis


Record completion

Record processing

Record reconciliation


Release of information (ROI)





Retrospective review

Serial numbering system

Serial-unit numbering system


Storage and retrieval

Straight numeric filing system

Terminal-digit filing system


Unit numbering system

Version control

Virtual HIM

Voice recognition technology


Site Visit

  1. Have students perform tasks in clinical coding, medical transcription, storage and retrieval, chart completion, or release of information, or shadow an employee performing one of these tasks. Students may then write a procedure for the task they performed or observed. The students can use the format for the procedure as shown in the sample procedure in figure 8.22 of the textbook.

  1. During clinical rotations or a site visit to an acute care facility, have students gather information using the question inventories below. These question inventories cover the release of information function, chart completion process, and storage and retrieval functions. Questions can be modified as necessary to accommodate information at non-acute facilities. After the questions are answered, have the students compare and contrast their site observations/experiences with classroom and textbook discussions.

Question Inventory: Storage and Retrieval

Note: Some questions for this activity may be covered in other chapters of the textbook.

Numbering System

  1. What type of numbering system(s) is used by this facility? Describe.

Storage (Filing) System

  1. What type of health record storage system is used (for both paper-based, hybrid, and electronic systems)? Briefly describe the system(s). What are the advantages and disadvantages of the system(s)?

  1. How does the facility define an active chart? What is considered the legal health record?

  1. Is a centralized unit filing system used? Explain.

  1. How long are records retained?

  1. Is microfilm or off-site storage used? If so, describe the process.

Record Control

  1. Describe methods of record control (for example, outguides, policies for record requests, audit trails, passwords, and access monitors).

  1. Describe the chart tracking system used.

Filing Facilitators

  1. Describe methods used to facilitate the storage and retrieval process (for example, color-coded labels, terminal digit, purging, year label, bar coding, or header sheets).

  1. Is there adequate space for expansion? Consider the physical space for paper-based records and computer space for the EHR.

  1. For paper-based systems, estimate the current linear filing inches of the permanent record storage area. Describe how you determined this number.

  1. For the EHR, describe the level of computer storage needed to maintain the electronic health records.


  1. Name at least one aspect of forms design/control you would suggest changing, if you were responsible for forms control in this facility. For electronic or hybrid health records, name at least one aspect of screen design or navigation, you would suggest changing. Why?

Loose Report Filing

  1. Who is responsible for ensuring that loose reports are filed in the patient health record?

  1. Is there a backlog of loose filing? If so, estimate the amount of loose sheets needing to be filed. Describe how you determined this number.

  1. How long would you estimate it would take to file this backlog? How did you determine this time period?

Regulatory Requirements

  1. Which policies and procedures pertaining to the storage and retrieval function are based on standards established by regulatory agencies? What are the regulatory standards? What agency established these standards? Be specific.

Question Inventory: Chart Completion Process

  1. Is there an established chart order for the facility?

  1. What type of chart format (source-oriented, problem-oriented, or integrated) is used by this facility? Describe.

  1. What type of deficiencies are analyzed for chart completion? Is this type of analysis considered qualitative or quantitative and why?

  1. Describe how chart deficiencies are marked (for example, colored clips or tags, paper clips, or electronic tags).

  1. Is the assembly/analysis or the prepping/imaging process concurrent? If so, explain how this works.

  1. If there is an incomplete filing area, what type of filing system is used for this area? Is this type of filing system effective and efficient? Why or why not? Describe the filing system.

  1. Describe the chart deficiency database.

  1. Create a flow chart of the flow of the health record from discharge to permanent filing. (If you are in an outpatient setting, create a flow chart relevant to your setting.)


  1. At what point is the chart considered delinquent? Why was this timeframe selected? If this question is not applicable to your setting, explain why it is not.

  1. How are the physicians notified that they have records to complete?

  1. What are the consequences if a physician does not complete his/her incomplete or delinquent records? Explain.

  1. Are there quantity and/or quality standards established for the tasks related to assembly/analysis, prepping/scanning and quality review?

Regulatory Requirements

  1. Which policies and procedures pertaining to chart completion are based on standards established by regulatory agencies? What is the name of the agency and what are the regulatory standards? Be specific.

Question Inventory: Release of Information

General Release of Information

  1. What types of requests for information are received by the department or facility (for example, patient, attorneys, Bureau of Disability, or other healthcare providers)?

  1. How many written requests are received monthly?

  1. Is a copying service used? How many days a week is the copying service available?

  1. What is the average turnaround time for completing requests?

  1. What is the cost to the requester for record copies and/or form completion? Explain.

  1. Create a flow chart to show the process and logic of the release of information function for this facility.

  1. Describe the database or manual system used to track release of information.

Authorization Requirements

  1. What does the facility require in order for an authorization to be valid?

  1. When an authorization is found to be invalid, what steps are taken?

  1. What information is considered non-privileged by the facility?


  1. How are subpoenas handled at this facility? Be specific.

  1. Who accompanies the record to court? Describe a typical day at court when appearing with a medical record.

Regulatory Issues

  1. What legal principles, policies, regulations, and standards control the release of information and the request for information? Be specific. State how the facility meets these requirements.


  1. Numeric Filing Exercise: For this project students will use index cards labele
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