QUESTION: 373

In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation, " EXCEPT

each service is paid based upon the actual charges.
the volume of services and their expense does not affect reimbursement.
capitation means paying a fixed amount per member per month.
captions involves a group of physicians or an individual physician.

Answer(s): A

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When billing for the admitting physician for a patient that is admitted to the hospital as an inpatient, one must use a CPT Evaluation and Management code based upon the level of care provided. These are the codes to be selected from for initial hospital care.99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components.
- a detailed or comprehensive history
- a detailed or comprehensive examination and
- medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components.
- a comprehensive history
- a comprehensive examination and
- medical decision making of moderate complexity
99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components.
- a comprehensive history
- a comprehensive examination and
- medical decision making of high complexity
The following statement is true.

This code can be used only once per hospitalization.
This code can be used by the admitting physician or consulting physician.
This code can be used for patients admitted to observation status.
This code can be used by the hospital to bill for facility services.

Answer(s): A

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QUESTION: 375

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS' Web Site.