AAPC-CIC Certified Inpatient Coder - Set 3 - Part 3

Correct Answer: Transportation services, including transport by ambulance

The regulation at 42 CFR 409.10 lists transportation services, including transport by ambulance, among the inpatient hospital services, alongside bed and board, nursing services, medical social services, and drugs, biologicals, supplies, appliances, and equipment. Option b is incorrect because this care, furnished by a hospital or critical access hospital with swing-bed approval, is named as excluded from inpatient hospital services. Option c is incorrect because nurse practitioner and clinical nurse specialist services are listed among the types of services that inpatient hospital services do not include. Option d is incorrect because the regulation places these services on its exclusion list, so they fall outside the definition of inpatient hospital services.

Correct Answer: Hospital services covered; physicians' medical services not covered

Hospital inpatient services are covered when hospitalization is required because of the severity of a noncovered dental procedure. Regardless of that coverage, physicians' medical services connected with noncovered dental services are not covered. Option a is incorrect because the dental exclusion has an exception for inpatient hospital services when hospitalization is required because of the severity of the dental procedures, so hospital services qualify. Option c is incorrect because physicians' medical services furnished in connection with noncovered dental services are not covered, regardless of whether the inpatient hospital services are covered. Option d is incorrect because this reverses the rule: hospitalization required by the severity of a noncovered dental procedure makes the inpatient services covered, while physician services remain excluded.

Correct Answer: It must represent a cost to the institution

Medicare requires three basic things for a covered hospital drug or biological: it represents a cost to the institution, meets the statutory definition, and its use is safe and effective and otherwise reasonable and necessary. Option a is incorrect because the QIO decides whether a drug is reasonable and necessary for an individual patient during review, but approval by the QIO is not one of the three basic requirements. Option b is incorrect because local medical review policy may or may not grant coverage for off-label uses, but it is not a basic requirement for every covered drug. Option c is incorrect because coverage can extend to uses beyond the labeling when the FDA has not specified the use as nonapproved, so labeling for every use is not required.

Correct Answer: Deluxe accommodations

The Medicare manual states the program pays the same amount for routine accommodations whether the room is private, semiprivate or ward, but adds that Medicare does not pay for deluxe accommodations in any case. Option b is incorrect because the manual places a private room that is medically necessary among the accommodations paid at the same amount as a semiprivate room. Option c is incorrect because a semiprivate room, whether 2-, 3-, or 4-bed, is expressly listed in the manual among accommodations paid at the same routine amount. Option d is incorrect because ward accommodations receive the same routine payment, provided they are consistent with program purposes, so they belong in the set the stem names.

Correct Answer: Payment of a different DRG

In PPS hospitals, when an appropriately admitted case includes a noncovered procedure, denied services may result in payment of a different DRG, one that excludes payment for the noncovered procedure. Option a is incorrect because limitation on liability applies only when the provider and beneficiary could not reasonably know services were unnecessary, which is a separate situation from a noncovered procedure. Option c is incorrect because outlier denial is a possible result in cases that become cost outliers, which is a different circumstance from a noncovered procedure being performed. Option d is incorrect because this outcome is described for non-PPS hospitals, or for care where the patient did not need hospitalization, not for an appropriately admitted PPS case.

Correct Answer: Quality Improvement Organization

Medicare law authorizes the Quality Improvement Organization for each hospital to judge, case by case, whether an inpatient admission was medically necessary. Its judgments are binding for purposes of Medicare coverage. Option b is incorrect because the Secretary appears in the guidance as the one who grants a swing bed agreement to a hospital, not as the admission reviewer. Option c is incorrect because the physician makes the admission decision, and the reviewing entity then judges that decision using only the medical evidence available to the physician at that time. Option d is incorrect because CMS is the agency that may withhold payment or terminate a provider agreement when a hospital fails to meet payment conditions, not the case-by-case reviewer.

Correct Answer: Differential between most prevalent private room rate and customary charge for room occupied

Medicare does not pay for deluxe accommodations, so a provider may charge a requesting beneficiary only the differential between the most prevalent private room rate at the time of admission and the customary charge for the room occupied. Option a is incorrect because the deluxe cap compares the most prevalent private room rate with the room occupied; semiprivate and ward rates are not part of that comparison. Option b is incorrect because this figure is the payment basis for ward accommodations furnished at the patient's request or for program purposes, not a limit on deluxe room charges. Option c is incorrect because Medicare rules set the ceiling at a differential, and Medicare pays the same amount for routine accommodations, so the whole customary charge is not the permitted amount.

Correct Answer: on an ongoing basis

Under the medical review requirements for admissions and quality review, a hospital must have an agreement with a QIO to review, on an ongoing basis, the medical necessity, reasonableness and appropriateness of admissions and discharges. Option b is incorrect because the regulation sets no denial trigger for this review; the agreement calls for continuing review rather than review that begins after a claim is denied. Option c is incorrect because the regulation names no quarterly schedule; it describes review that continues without a fixed periodic interval, so a quarterly cycle does not match it. Option d is incorrect because the review is a hospital obligation under its QIO agreement, not something started by a beneficiary asking for it.

Correct Answer: Inpatient care for which outlier payment is sought

The QIO agreement covers ongoing review of admissions and discharges and also of inpatient hospital care for which additional payment is sought under the outlier provisions, all required by the medical review requirements of the PPS conditions. Option a is incorrect because physician services meeting fee schedule requirements are excluded from inpatient hospital services, so they are not a listed category of ongoing QIO admission and quality review. Option b is incorrect because recordkeeping and cost reporting duties are set out in a separate reporting section for hospitals, not within the QIO medical review agreement. Option c is incorrect because the hospital may charge a customary differential for luxury services, and the guidance addresses that as a billing allowance, not an ongoing QIO review category.

Correct Answer: When neither provider nor beneficiary knew or reasonably could have known

Under limitation on liability, Medicare payment may be made when the provider and the beneficiary were not aware the services were not necessary and could not reasonably be expected to know this. Option b is incorrect because an admission that includes covered care is not denied at all, so a DRG change or outlier adjustment applies and limitation on liability is not needed. Option c is incorrect because patient-requested items in excess of covered services let the hospital charge the difference in customary charges, which is a separate provision from limitation on liability. Option d is incorrect because such procedures lead to denial of outlier payment in whole or in part, rather than to payment under limitation on liability.