AAPC-CIC Certified Inpatient Coder - Set 4 - Part 2

Correct Answer: May still be appropriate inpatient treatment

Under the Medicare regulation, an unforeseen circumstance such as a beneficiary's death or transfer can shorten a stay below the physician's expectation of at least 2 midnights. The patient may still be considered appropriately treated as an inpatient. Option a is incorrect because inpatient admission orders cannot be standing orders under the guidance, and a standing order has no role in deciding how a shortened stay is paid. Option b is incorrect because the regulation names death as an unforeseen circumstance that does not defeat inpatient status; it contains no requirement to convert the stay to outpatient. Option c is incorrect because countersigning concerns authenticating orders given by others before discharge; it addresses who ordered the admission, not whether an unforeseen shortened stay stays inpatient.

Correct Answer: Direct graduate medical education activities

The costs of direct graduate medical education activities are listed under excluded costs, which the hospital outpatient prospective payment system does not cover. Recovery room use, observation services and intraocular lenses appear in the packaged costs list. Option a is incorrect because the regulation names it among items whose payment is packaged or conditionally packaged, which makes it a member of the set in the stem. Option b is incorrect because these are listed by the regulation as a packaged cost, falling under the supplies and devices that support the procedure. Option d is incorrect because appears in the regulation's list of packaged costs, so its payment is bundled with the associated procedure rather than made separately.

Correct Answer: Labor-related portion

Under the regulation on standardizing amounts, CMS determines the part of hospital outpatient costs that is labor-related. This share is known as the "labor-related portion" of hospital outpatient costs. Option b is incorrect because it is the cost measure CMS determines for services and procedures within each APC group, not the name for the labor share of costs. Option c is incorrect because it is determined for an APC group under subpart D alongside the copayment amount, so it describes a payment, not a share of costs. Option d is incorrect because CMS assigns it to each APC group to reflect relative geometric mean costs against all APC groups; it does not label a cost component.

Correct Answer: At least 2 years, but not more than 3 years

The limited period of payment rule states that CMS limits pass-through eligibility to a period of at least 2 years, but not more than 3 years, so the period has both a floor and a ceiling. Option a is incorrect because it overstates the range, since CMS caps the eligibility period at 3 years, and a 5-year ceiling is well beyond that cap. Option b is incorrect because the regulation does include an upper bound, because CMS limits eligibility to not more than 3 years, so the period is not open-ended. Option d is incorrect because it sets both limits too low; the regulation sets the minimum eligibility period at 2 years, so a 1-year floor does not match.

Correct Answer: In a budget neutral manner

The general rules for transitional pass-through payments state that CMS establishes the additional payments for certain innovative medical devices, drugs, and biologicals in a budget neutral manner. Option a is incorrect because the inpatient hospital deductible caps the copayment amount for a procedure in a year, which is a separate limit from pass-through payment rules. Option b is incorrect because the program payment percentage is a ratio used to work out the Medicare payment amount for each APC group, not a basis for pass-through payments. Option c is incorrect because a predetermined copayment is the beneficiary's share set for each APC group, not the way CMS establishes the additional pass-through payments.

Correct Answer: Reduce each additional payment pro rata

Under the uniform prospective reduction rule for transitional pass-through payments, when CMS estimates the total would exceed the applicable percentage of OPPS payments, it reduces, pro rata, each additional payment for that year. Option b is incorrect because the regulation keeps the additional payments in place and shrinks each one proportionally, with no step that halts payment for new items. Option c is incorrect because the regulation responds to the estimate by cutting payments so the applicable percentage is not exceeded, not by moving the limit upward. Option d is incorrect because incorporating estimated device costs into procedure APCs was a provision limited to the initial portion of the period the rules covered, not the response to an excess estimate.

Correct Answer: Blood deductible and coinsurance

The Part B scope of benefits regulation states the beneficiary is responsible for an annual deductible and a blood deductible and, once the annual deductible is met, coinsurance amounts specified for most services. Option a is incorrect because the inpatient hospital deductible is the ceiling on an outpatient procedure copayment, not a separate Part B amount owed alongside the annual deductible. Option b is incorrect because this is the share Medicare itself pays for an APC group, calculated as the lower of a ratio or 80 percent. Option c is incorrect because the regulation states Part B does not pay the full reasonable costs or charges, but it does not make the beneficiary liable for them in full.

Correct Answer: inpatient hospital deductible

Section 419.40(c) limits the OPPS copayment amount for a procedure in a year so that it cannot exceed the inpatient hospital deductible established under section 1813(b) of the Act for that year. Option a is incorrect because the regulation uses this rate as the denominator when comparing the unadjusted copayment amount, but it does not set the cap on a copayment. Option c is incorrect because this figure is the base from which the unadjusted copayment amount is calculated at 20 percent, which makes it a calculation input and not a limit. Option d is incorrect because it is the ratio used to work out Medicare's share of each APC group payment, not a ceiling applied to the beneficiary copayment amount.

Correct Answer: At the time of formal admission by the hospital pursuant to the order

Under the Medicare inpatient order guidance, inpatient status begins at the time of formal admission by the hospital pursuant to the order, including an initial or verbal order that is authenticated timely by authorized individuals. Option a is incorrect because emergency or clinic practitioners may order admission, but the guidance ties inpatient status to formal admission under the order, not to the start of emergency care. Option b is incorrect because meeting the two midnight benchmark does not, in itself, make a beneficiary an inpatient; formal admission pursuant to an order is what does. Option d is incorrect because a utilization review physician in that role lacks direct responsibility for the patient's care and is not considered knowledgeable enough to order admission.

Correct Answer: Hospital care crossing two midnights

The regulation states that an inpatient admission is generally appropriate for Part A payment when the admitting physician expects the patient to require hospital care that crosses two midnights. This is the two-midnight benchmark. Option a is incorrect because a stay not crossing two midnights falls under the separate limited-period provision, which relies on the admitting physician's clinical judgment rather than the general benchmark. Option b is incorrect because transfer appears only as an unforeseen circumstance that shortens a stay, not as the expectation that makes an admission appropriate. Option c is incorrect because the inpatient-only list is handled in a different paragraph of the regulation and is not the general benchmark for admission appropriateness.

Correct Answer: Authenticate the order promptly, prior to discharge

A verbal inpatient admission order must identify the ordering practitioner and be authenticated (countersigned) by that practitioner promptly and prior to discharge. The nurse's documentation at the time of receipt covers the recording step. Option b is incorrect because the inpatient admission order cannot be a standing order, so converting a verbal order into one would make it invalid. Option c is incorrect because the ordering practitioner communicates the verbal order directly to staff and need not separately record the order to admit. Option d is incorrect because the guidance allows staff without admitting authority under state law and by-laws to record a verbal order, so no such authorization is needed.

Correct Answer: Regional office oversight of contractor operations

Regional offices assure that contractors meet Federal requirements under their contracts. Analyzing contractor budgets and spending patterns to assure funds are economically and appropriately utilized is one of their listed oversight responsibilities within CMS. Option a is incorrect because State agencies certify to DHHS whether providers meet conditions of participation, which concerns facility eligibility rather than contractor spending. Option b is incorrect because an A/B MAC (A) audits provider records and pays providers; it is a contractor itself, not the body analyzing contractor budgets. Option c is incorrect because the Public Health Service administers professional health aspects, such as advising on health and safety standards, and is not assigned review of contractor budgets.

Correct Answer: Federal Hospital Insurance Trust Fund

Part A is financed through separate payroll contributions from employees, employers and self-employed persons. The proceeds go to the Federal Hospital Insurance Trust Fund, which is used only for hospital insurance benefits and administrative expenses. Option b is incorrect because prepaid capitation is how a risk-bearing entity is paid under an MA contract, which is not how payroll contributions for Part A are handled. Option c is incorrect because Medicaid is a separate program certified through State agencies, and Part A payroll contributions are not deposited into any State account. Option d is incorrect because it is the separate account that holds Part B premiums and Government contributions, and it pays only Part B benefits and administrative expenses.

Correct Answer: 100 days

The Medicare Benefit Policy Manual states that in each benefit period payment may be made for up to 100 days of posthospital extended care services in a SNF. Inpatient hospital days are limited separately. Option a is incorrect because the manual assigns this figure to inpatient hospital days in each benefit period, a separate benefit with its own day limit. Option b is incorrect because this is the life expectancy prognosis that makes an individual terminally ill for hospice election, so it measures eligibility rather than SNF days. Option c is incorrect because this figure describes the nonrenewable lifetime reserve days that supplement inpatient hospital benefits, not the SNF extended care limit.

Correct Answer: Payment may be made under Part B for the covered visits.

Part B may pay for a covered service when payment is not possible under Part A, for example when the beneficiary has no Part A entitlement. Supplementary medical insurance specifically covers home health visits unavailable under hospital insurance. Option a is incorrect because the Medicare manual states the prior inpatient stay requirement under Part A was eliminated, so a documented stay is not the condition that governs these visits. Option c is incorrect because the manual lists absence of Part A entitlement as a situation where visits are not available under hospital insurance, so coverage alone does not trigger Part A. Option d is incorrect because supplementary medical insurance is described as providing coverage for home health visits that hospital insurance does not make available, such as when no Part A entitlement exists.

Correct Answer: I and II

Under 42 CFR 422.4, a SNP is a coordinated care plan that exclusively enrolls special needs individuals, and every SNP must submit its model of care to CMS for NCQA evaluation and approval. Statements I and II are accurate. Option b is incorrect because statement III fails because a SNP exclusively enrolls special needs individuals as defined in the regulation, so mixing in other beneficiaries is not permitted. Option c is incorrect because statement IV misstates the rule, since a C-SNP may focus on one severe or disabling chronic condition or on a grouping of such conditions. Option d is incorrect because both statements are inaccurate: SNP enrollment is exclusive to special needs individuals, and a C-SNP is not confined to a single condition, so neither belongs in a correct combination.

Correct Answer: Not inpatient hospital services

Medicare does not cover private-duty nurses. A nurse restricted to one patient by arrangement is private-duty, even when the hospital advances the cost and supervises, so the services are not inpatient hospital services. Option a is incorrect because anesthetist coverage applies to a nurse anesthetist engaged by the hospital with billing by the hospital, which does not describe this case. Option b is incorrect because medical social services contribute meaningfully to treating the patient's condition, such as assessing social and emotional factors, and do not include one-to-one private nursing. Option d is incorrect because routine nursing furnished by the hospital is covered, but a nurse restricted to one patient by arrangement is a private-duty nurse, which is excluded.

Correct Answer: network

Under 42 CFR 422.4, a coordinated care plan includes a network of providers under contract or arrangement with the organization to deliver the benefit package approved by CMS. CMS also approves that network. Option a is incorrect because a gatekeeper is a utilization control mechanism, such as a referral requirement, that a coordinated care plan may include; it is not the defining group of contracted providers. Option c is incorrect because a subsidy relates to subsidy-eligible individuals in Part D and says nothing about how providers are organized within a coordinated care plan. Option d is incorrect because a formulary belongs to Part D, where drugs are grouped into cost sharing levels; it does not describe providers under contract with the organization.

Correct Answer: SNF arrangement with that entity for that service

Under 42 CFR 411.15(p), a service furnished to an SNF resident during a covered Part A stay by an outside entity is excluded unless the SNF has an arrangement with that entity to furnish that particular service. Option a is incorrect because that approval requirement belongs to the separate exclusion for assistants-at-surgery in cataract operations, not to services furnished to SNF residents by outside entities. Option b is incorrect because incident-to services are named among those subject to exclusion, so they fall within the rule instead of escaping it. Option c is incorrect because the exclusion applies regardless of whether services are furnished by, or under the supervision of, a physician or other health care professional.

Correct Answer: Applicable deductible and coinsurance amounts

For a covered stay, the limitations on charges to beneficiaries allow the hospital to charge the applicable deductible and coinsurance amounts, along with certain noncovered items and services. Charges for Medicare-paid services or cost shortfalls are prohibited. Option a is incorrect because a hospital may not charge a beneficiary for any service Medicare paid for, so billing again for those services would break the limitation on charges. Option c is incorrect because the regulation bars charging the beneficiary even when the hospital's costs are greater than the amount paid under the prospective payment systems. Option d is incorrect because withholding is a remedy CMS applies against the hospital when conditions are not met; it creates no charge the beneficiary owes.