Which is the extent of physiological decompensation or organ system loss of function?

Reimbursement Methodologies 9:30 MWLillian PearsonCh9 TermsRetrospective Reasonable Cost System – hospitals reported actual charges for inpatient care to payersafter discharge of the patient from the hospitalProspective Cost-Based Rates – established in advance, but are based on reported health care costs fromwhich a predetermined per diem rate is determinedProspective Price-Based Rates – associated with a particular category of patient, and rates areestablished by the payer prior to the provision of health care servicesCase Mix – describes a health care org’s patient population and is based on a number of characteristics,such as age, diagnosis, gender, resources consumed, risk factors, treatments received, and type of healthins.Payment System – healthcare systems that require services to be reimbursed according to apredetermined reimbursement methodologyAmbulance Fee Schedule – payment system for ambulance services provided to Medicare beneficiaries.Ambulatory Surgical Center (ASC) – state-licensed, Medicare-certified supplier of surgical health careservices that must accept assignment on Medicare claims.Ambulatory Surgical Center Payment Rates – fee to ASCs for facility services furnished in connection withperforming certain surgical proceduresClinical Laboratory Fee Schedule – data set based on local fee schedules for outpatient clinical diagnosticlab servicesDMEPOS fee schedule – medicare reimburses either 80% of the actual charge for the item or the feeschedule amount, whichever is lower.End-Stage Renal Disease (ESRD) Composite Payment Rate System – bundles ESRD drugs and related labtests with the composite rate payments, resulting in one reimbursement amount paid for ESRD servicesprovided to patients.Federally Qualified Health Centers (FQHCs) – safety net providers that primarily provide services typicallyfurnished in an outpatient clinic.Federally Qualified Health Centers Prospective Payment System (FQHC PPS) – includes an FQHC paymentcode on claims submitted for payment, and the are paid 80% of the lesser of charges based on FQHCpayment codes or the FQHC PPS rate

question

DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g., BlueCross BlueShield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.

answer

All-Patient diagnosis-related group (AP-DRG)

question

adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded original DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of physiological decompensation or organ system loss of function) and risk of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, and (4) extreme.

answer

All-Patient Refined diagnosis-related group (APR-DRG)

question

maximum fee a provider may charge.

question

payment system for ambulance services provided to Medicare beneficiaries. the balanced budget act of 1997 2002 was phased in over 5 years replacing a retrospedtive reasonable cost payment system.

answer

ambulance fee schedule

question

for OPPS, all services are paid according to ________ which group services according to similar clinical characteristics and in terms of resources required. Hospitals can be paid for more than one APC

answer

ambulatory payment classificaton

question

state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must accept assignment on Medicare claims.

answer

ambulatory surgical center (ASC)

question

predetermined amount for which ASC services are reimbursed, at 80 percent after adjustment for regional wage variations.

answer

ambulatory surgical center payment rate

question

billing beneficiaries for amounts not reimbursed by payers (not including copayments and coinsurance amounts); this practice is prohibited by Medicare regulations.

question

the types and categories of patients treated by a health care facility or provider.

question

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).

answer

charge description master (CDM) also called chargemaster

question

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).

question

process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.

answer

chargemaster maintenance

question

jointly shares the responsibility of updating and revising the chargemaster to ensure its accuracy and consists of representatives of a variety of departments, such as coding compliance financial services, health information management, information services, other departments, and physicians.

question

data set based on local fee schedules (for outpatient clinical diagnostic laboratory services).

answer

clinical laboratory fee schedule

question

a registered nurse licensed by the state in which services are provided, has a master's degree in a defined clinical area of nursing from an accredited educational institution, and is certified as a CNS by the American Nurses Credentialing Center.

answer

clinical nurse specialist (CNS)

question

communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS Internet-only program manual.

answer

CMS program transmittal

question

an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or cancelled, and new or revised manual instructions.

answer

CMS Quarterly Provider Update (QPU)

question

dollar multiplier that converts relative value units (RVUs) into payments.

question

clinical lab DMEPOS physician fee schedule skilled nursing facility ambulance fee schedule ambulatory surgica center payment rates

question

tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

question

each discahrge is catagorized into a ______ which is based on the patient's principal and secondary diagnosis. as well as procedures

answer

diagnosis related group

question

classifies mental health disorders and is based on ICD; published by the American Psychiatric Association.

answer

Diagnostic and Statistical Manual (DSM)

question

policy in which hospitals that treat a high percentage of low-income patients receive increased Medicare payments.

answer

disproportionate share hospital (DSH) adjustment

question

Medicare reimburses DMEPOS dealers according to either the actual charge or the amount calculated according to formulas that use average reasonable charges for items during a base period from 1986 to 1987, whichever is lower.

answer

durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) fee schedule

question

contributed to by an employer or employee pay-all plan; provides coverage to employees and dependents without regard to the enrollee's employment status (i.e., full-time, part-time, or retired).

answer

employer group health plan (EGHP)

question

bundles end-stage renal disease (ESRD) drugs and related laboratory tests with the composite rate payments, resulting in one reimbursement amount paid for ESRD services provided to patients; the rate is case-mix adjusted to provide a mechanism to account for differences in patients' utilization of health care resources (e.g., patient's age).

answer

End-Stage Renal Disease (ESRD) composite payment rate system

question

determines appropriate group (e.g., diagnosis-related group, home health resource group, and so on) to classify a patient after data about the patient is input.

question

Five-digit alphanumeric codes that represent case-mix groups about which payment determinations are made for the HH PPS.

answer

health insurance prospective payment system (HIPPS) code set

question

data entry software used to collect OASIS assessment data for transmission to state databases.

answer

Home Assessment Validation and Entry (HAVEN)

question

classifies patients into one of 80 groups, which range in severity level according to three domains: clinical, functional, and service utilization.

answer

home health resource group (HHRG)

question

Medicare regulation which permitted billing Medicare under the physician's billing number for ancillary personnel services when those services were incident to a service performed by a physician.

question

approved teaching hospitals receive increased Medicare payments, which are adjusted depending on the ratio of residents-to-beds (to calculate operating costs) and residents-to-average daily census (to calculate capital costs).

answer

indirect medical education (IME) adjustment

question

system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge.

answer

inpatient prospective payment system (IPPS)

question

implimentation of a per diem patient classification system that reflects differences in patient resources use and cost SCHIP balanced budget refinement act of 1999 replaced a resonable cost based system

answer

inpatient psychiatric facility prospective payment system (IPF PPS)

question

software used as the computerized data entry system by inpatient rehabilitation facilities to create a file in a standard format that can be electronically transmitted to a national database; data collected is used to assess the clinical characteristics of patients in rehabilitation hospitals and rehabilitation units in acute care hospitals, and provide agencies and facilities with a means to objectively measure and compare facility performance and quality; data also provides researchers with information to support the development of improved standards.

answer

Inpatient Rehabilitation Validation and Entry (IRVEN)

question

relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease.

answer

intensity of resources

question

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

answer

IPPS 3-day payment window

question

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

question

any patient with a diagnosis from one of ten CMS-determined DRGs, who is discharged to a post acute provider, is treated as a transfer case; this means hospitals are paid a graduated per diem rate for each day of the patient's stay, not to exceed the prospective payment DRG rate.

question

provided by an employer that has 100 or more employees or a multiemployer plan in which at least one employer has 100 or more full- or part-time employees.

answer

large group health plan (LGHP)

question

maximum fee a provider may charge. Non-Par doctors usually report only the _______ as their fee

question

classifies patients according to long-term (acute) care DRGs, which are based on patients' clinical characteristics and expected resource needs; replaced the reasonable cost-based payment system. BBRA of 1999 aurthorized implementation of per discharge DRG for cost reporting periods begining oct. 1 2002 (2008 medicare severity long term care diagnosis related groups were adopted for LTCH PPS

answer

long-term (acute) care hospital prospective payment system (LTCH PPS)

question

organizes diagnosis-related groups (DRGs) into mutually exclusive categories, which are loosely based on body systems (e.g., nervous system).

answer

major diagnostic category (MDC)

question

payment system that reimburses providers for services and procedures by classifying services according to relative value units (RVUs); also called resource-based relative value scale (RBRVS) system. 1992 - RBRVS)

answer

Medicare physician fee schedule (MPFS)

question

situations in which the Medicare program does not have primary responsibility for paying a beneficiary's medical expenses.

answer

Medicare Secondary Payer (MSP)

question

adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs; bases DRG relative weights on hospital costs and greatly expanded the number of DRGs; reevaluated complications/comorbidities (CC) list to assign all ICD-10-CM codes as non-CC status (conditions that should not be treated as CCs for specific clinical conditions), CC status, or major CC status; handles diagnoses closely associated with patient mortality differently depending on whether the patient lived or expired.

answer

Medicare severity diagnosis-related groups (MS-DRGs)

question

previously called an Explanation of Medicare Benefits or EOMB; notifies Medicare beneficiaries of actions taken on claims.

answer

Medicare Summary Notice (MSN)

question

standards of measurement, such as those used to evaluate an organization's revenue cycle to ensure financial viability.

question

has two or more years of advanced training, has passed a special exam, and often works as a primary care provider along with a physician.

answer

nurse practitioner (NP)

question

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

answer

Outcomes and Assessment Information Set (OASIS)

question

hospitals that treat unusually costly cases receive increased Medicare payments; the additional payment is designed to protect hospitals from large financial losses due to unusually expensive cases.

question

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

answer

outpatient encounter

question

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

question

classifies patients into IRF PPS (inpatient rehabilitation facility) groups based on clinical characteristics and expected resources needs

answer

patient assesment instrument

question

reimbursement method the federal government uses to compensate providers for patient care.

question

has two or more years of advanced training, has passed a special exam, works with a physician, and can do some of the same tasks as the doctor.

answer

physician assistant (PA)

question

IPPS Inpatienet psychiatric facility PPS home health hospital inpatient long term care pps

question

rates established in advance, but based on reported health care costs (charges) from which a prospective per diem rate is determined.

answer

prospective cost-based rates

question

rates associated with a particular category of patient (e.g., inpatients) and established by the payer (e.g., Medicare) prior to the provision of health care services.

answer

prospective price-based rates

question

payment components consisting of physician work, practice expense, and malpractice expense.

answer

relative value units (RVUs)

question

data entry system used to enter MDS data about SNF patients and transmit those assessments in CMS-standard format to individual state databases.

answer

Resident Assessment Validation and Entry (RAVEN)

question

distribution of financial resources among competing groups (e.g., hospital departments, state health care organizations).

answer

resource allocation

question

uses data analytics to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources, such as appropriately expending budgeted amounts as well as conserving resources and protecting assets while providing quality patient care.

answer

resource allocation monitoring

question

payment system that reimburses physicians practices expenses based on relative values for three components of each physicians services: physician work, practice expence, and malpractice insurance expense

answer

resource based relative value (RBRVS) system

question

reimbursement system in which hospitals report actual charges for inpatient care to payers after discharge of the patient from the hospital.

answer

retrospective reasonable cost system

question

a four-digit code that indicates location or type of service provided to an institutional patient; reported in FL 42 of UB-04.

question

assessment process that is conducted as a follow-up to revenue cycle monitoring so that areas of poor performance can be identified and corrected.

answer

revenue cycle auditing

question

process facilities and providers use to ensure financial viability.

answer

revenue cycle management

question

involves assessing the revenue cycle to ensure financial viability and stability using metrics (standards of measurement).

answer

revenue cycle monitoring

question

likelihood of dying.

answer

risk of mortality (ROM)

question

extent of physiological decompensation or organ system loss of function.

answer

severity of illness (SOI)

question

reduction of payment when office-based services are performed in a facility, such as a hospital or outpatient setting, because the doctor did not provide supplies, utilities, or the costs of running the facility.

answer

site of service differential

question

each cpt and hcpcs level ii code is assined a statis indicator as a payment indicator to identify how each code is paid (or not paid) under the OPPS S - significant procedures for which the multiple procedure payment does NOT apply T - service to which the multiple procedures payment reduction applies

answer

statis indicator (SI)

question

adjusts payments to account for geographic variations in hospitals' labor costs. add ons - such as pass-through payments that provide additional reimburcement to hospitals that use innovative biologicals, drugs, and technical devises, outlier payments for high cost services hold harmless payments for some hospitals and tranditional payments to limit loss under OPPS can increase payments

answer

HCFA (NOW CMS) IMPLEMENTED THE FIRST PROSPECTIVE PAYMENT SYSTEM (PPS) TO CONTROL THE COST OF HOSPITAL INPATIENT CARE TRUE ______ AN AMBULATORY SURGICAL VENTER IS A FEDERALLY LICENSED, MEDICARE CERTIFIED SUPPLIER OF SURGICAL HEALTH CARE SERVICES THAT MUST ACCEPT ASSIGNMENT OF MEDICAL CLAIMS FALSE ________ HOSPITAL INPATIENT DEPARTMENTS THAT PERFORM SURGERY ARE REIMBURSED UNDER OPPS, THE OUTPATIENT PAYMENT SYSTE, FALSE ______ THE MEDICARE DURABLE MEDICAL EQUIPMENT PROSTECTIC/ORTHOICS AND SUPLIERS (DMEPOS) FEE SCHEDULE WAS ESTABLISHED BY THE DEFICIT REDUCTION ACT OF 1984 TRUE ____ A VALID ICD-9 CM DIAGNOSIS CODE MUST BE REPORTED FOR EACH LINE ITEM ON ELECTRONICALLY-SUBMITTED CLAIMS TRUE ------ CPT CODES DIRECTLY AFFECT DRG'S ASSINGMENT FALSE ______ DRG'S ARE ORGANIZED INTO MUTUALLY EXCLUSIVE CATEFORIES CALLED MAJOR DIAGNOSTIC CATEGORIES (MDCS) TRUE ____ PAYING ACCORDING TO A COMPOSITE RATE IS A COMMON FORM OF MEDICARE PAYMENT, ALSO KNOWN AS UNBUNDLING. FALSE _____ A FACILITY CASE MIS IS A MEASURE OF THE TYPES OF PATIENTS TREATED,AND IT REFLECTS PATIENT UTILIZATION OF VARYING LEVELS OF HEALTH CARE RESOURCES TRUE ____ DECISION TREEE ARE USED BY CODERS AND BILLERS TO CALCULATE REIMBURSMENT FALSE ______ HOSPITALS THAT TREAT USUALLY COSTLY CASES AND RECIEVE INCREASED MEDICARE PAYMENTS ARE CALLED OUTLIERS TRUE _____ A MEDICARE ADMINSTRATIVE CONTACTOR IS A THIRD PARTY PAYER THAT CONTACTS WITH MEDICARE TO CARRY OUT THE OPERATIONAL FUNCTIONS OF THE MEDICARE PROGRAM TRUE ______ AN OUTPATIENT ENCOUNTER INCLUDES ALL OUTPATIENT PROCEDURES AND SERVIES PROVIDED DURING THE PATIENTS ENTIRE STAY FALSE ______ APC GROUPER SOFTWARE IS USED TO ASSIGN AN APC TO EACH CPT AND OR HCPC LEVEL II CODE REPORTED ON AN INPATIENT CLAIM, AS WEL AS TO REPORT ICD 9-CM DIAGNOSIS CODES AS APPROPRIATE FALSE ----- THE MEDICARE PHYSICIANS FEE SCHEDULE REIMBURES PROVIDERS ACCORDING TO PREDETERMINED RATES ASSIGNED TO SERVICES AND IS REVISED BY CMS EACH YEAR TRUE ____ WHAT DOES THE ACRONYM SOI STAND FOR SERVERITY OF ILLNESS ---- WHAT DOES THE ACRONYM ROM STAND FOR RICK OF MORTALITY _____ REIMBURSMENT ACCORDING TO ____ MEANS THAT HOPSITALS REPORTED ACTUAL CHARGES FOR INPATIENT CARE TO PAYERS AFTER DISCHARGE OF THE PATIENTS FROM THE HOSPITAL PAYMENT SYSTEM _____ WHICH OF THE FOLLOWING IS A FEDERAL HEALTH CARE PROGRAM ALL OF THE ABOVE ____ WHICH IS A PREDETERMINED REIMBURSEMENT METHODOLOGY PAYMENT SYSTEM ------- WHAT IS THE NAME OF THE PAYMENT SYSTEM FOR AMBULANCE SERVICES PROVIDED TO MEDICARE BENEFICIARIES AMBULANCE FEE SCHEDULE _____ WHICH OF THE FOLLWOING IS A LEVE OR AMBULANCE SERVICE ALL OF THE ABOVE ----- _____ IS A DATA SET BASED ON LOCAL FEE SCHEDULES FOR OUTPATIENT CLINICAL DIAGNOSTIC LABORATORY SERVICES CLINICAL LABORATORY FEE SCHEDULE ____ MEDICARE REIMBURSES LABORATY SERVICES ACCORDING TO ALL OF THE ABOVE ____ A FACILITIES_______ IS A MEASURE OF THE TYPES OF PATIENTS TREATED, AND IT REFLECTS PATIENT UTILIZATION OF CARYING LEVELS OF HEALTHER CARE RESOURCES CASE MIX ____ LONG TERM ACURE CARE HOPSITALS ARE DEFINED BY MEDICARE AS HAVING AN AVERAGE INPATIENT LENGTH STAY OF GREATER THEN 25 DAYS ___ THE ____ REIMBURSES PROVIDERS ACCORDING TO PREDETERMINED RATES ASSIGNED TO SERVICES AND IS REVISED BY CMS A YEAR MEDICARE PHTSICIAS SCHEDULE _____ MEDICARE IS ALWAYS A SECONDARY PAYER WHEN A MEDICARE BENEFICIARY ALSO HAS COVERAGE FROM WHICH OF THE FOLLOWING GROUPS ALL OF THE ABOVE ___ WHICH OF THE FOLLOWING INFORMATIN IS NECCESSARY TO CLACULATE THE AMOUNT OF MEDICARE SECONDARY BENIFITS PAYABLE ON A GIVEN CLAIM BOTH A AND C ___________ THE ____ IS A DOCUMENT THAT CONTAINS A COMPUTER GENERATED LIST OF PROCEDURES, SERVICES, AND SUPPLIES WITH CHARGES FOR EACH --- BOthh A & B

question

DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g., BlueCross BlueShield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.

answer

All-Patient diagnosis-related group (AP-DRG)

question

adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded original DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of physiological decompensation or organ system loss of function) and risk of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, and (4) extreme.

answer

All-Patient Refined diagnosis-related group (APR-DRG)

question

maximum fee a provider may charge.

question

payment system for ambulance services provided to Medicare beneficiaries. the balanced budget act of 1997 2002 was phased in over 5 years replacing a retrospedtive reasonable cost payment system.

answer

ambulance fee schedule

question

for OPPS, all services are paid according to ________ which group services according to similar clinical characteristics and in terms of resources required. Hospitals can be paid for more than one APC

answer

ambulatory payment classificaton

question

state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must accept assignment on Medicare claims.

answer

ambulatory surgical center (ASC)

question

predetermined amount for which ASC services are reimbursed, at 80 percent after adjustment for regional wage variations.

answer

ambulatory surgical center payment rate

question

billing beneficiaries for amounts not reimbursed by payers (not including copayments and coinsurance amounts); this practice is prohibited by Medicare regulations.

question

the types and categories of patients treated by a health care facility or provider.

question

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).

answer

charge description master (CDM) also called chargemaster

question

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).

question

process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.

answer

chargemaster maintenance

question

jointly shares the responsibility of updating and revising the chargemaster to ensure its accuracy and consists of representatives of a variety of departments, such as coding compliance financial services, health information management, information services, other departments, and physicians.

question

data set based on local fee schedules (for outpatient clinical diagnostic laboratory services).

answer

clinical laboratory fee schedule

question

a registered nurse licensed by the state in which services are provided, has a master's degree in a defined clinical area of nursing from an accredited educational institution, and is certified as a CNS by the American Nurses Credentialing Center.

answer

clinical nurse specialist (CNS)

question

communicate new or changed policies, and/or procedures that are being incorporated into a specific CMS Internet-only program manual.

answer

CMS program transmittal

question

an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or cancelled, and new or revised manual instructions.

answer

CMS Quarterly Provider Update (QPU)

question

dollar multiplier that converts relative value units (RVUs) into payments.

question

clinical lab DMEPOS physician fee schedule skilled nursing facility ambulance fee schedule ambulatory surgica center payment rates

question

tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.

question

each discahrge is catagorized into a ______ which is based on the patient's principal and secondary diagnosis. as well as procedures

answer

diagnosis related group

question

classifies mental health disorders and is based on ICD; published by the American Psychiatric Association.

answer

Diagnostic and Statistical Manual (DSM)

question

policy in which hospitals that treat a high percentage of low-income patients receive increased Medicare payments.

answer

disproportionate share hospital (DSH) adjustment

question

Medicare reimburses DMEPOS dealers according to either the actual charge or the amount calculated according to formulas that use average reasonable charges for items during a base period from 1986 to 1987, whichever is lower.

answer

durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) fee schedule

question

contributed to by an employer or employee pay-all plan; provides coverage to employees and dependents without regard to the enrollee's employment status (i.e., full-time, part-time, or retired).

answer

employer group health plan (EGHP)

question

bundles end-stage renal disease (ESRD) drugs and related laboratory tests with the composite rate payments, resulting in one reimbursement amount paid for ESRD services provided to patients; the rate is case-mix adjusted to provide a mechanism to account for differences in patients' utilization of health care resources (e.g., patient's age).

answer

End-Stage Renal Disease (ESRD) composite payment rate system

question

determines appropriate group (e.g., diagnosis-related group, home health resource group, and so on) to classify a patient after data about the patient is input.

question

Five-digit alphanumeric codes that represent case-mix groups about which payment determinations are made for the HH PPS.

answer

health insurance prospective payment system (HIPPS) code set

question

data entry software used to collect OASIS assessment data for transmission to state databases.

answer

Home Assessment Validation and Entry (HAVEN)

question

classifies patients into one of 80 groups, which range in severity level according to three domains: clinical, functional, and service utilization.

answer

home health resource group (HHRG)

question

Medicare regulation which permitted billing Medicare under the physician's billing number for ancillary personnel services when those services were incident to a service performed by a physician.

question

approved teaching hospitals receive increased Medicare payments, which are adjusted depending on the ratio of residents-to-beds (to calculate operating costs) and residents-to-average daily census (to calculate capital costs).

answer

indirect medical education (IME) adjustment

question

system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge.

answer

inpatient prospective payment system (IPPS)

question

implimentation of a per diem patient classification system that reflects differences in patient resources use and cost SCHIP balanced budget refinement act of 1999 replaced a resonable cost based system

answer

inpatient psychiatric facility prospective payment system (IPF PPS)

question

software used as the computerized data entry system by inpatient rehabilitation facilities to create a file in a standard format that can be electronically transmitted to a national database; data collected is used to assess the clinical characteristics of patients in rehabilitation hospitals and rehabilitation units in acute care hospitals, and provide agencies and facilities with a means to objectively measure and compare facility performance and quality; data also provides researchers with information to support the development of improved standards.

answer

Inpatient Rehabilitation Validation and Entry (IRVEN)

question

relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease.

answer

intensity of resources

question

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

answer

IPPS 3-day payment window

question

requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services when the inpatient principal diagnosis code (ICD-10-CM) exactly matches that for preadmission services.

question

any patient with a diagnosis from one of ten CMS-determined DRGs, who is discharged to a post acute provider, is treated as a transfer case; this means hospitals are paid a graduated per diem rate for each day of the patient's stay, not to exceed the prospective payment DRG rate.

question

provided by an employer that has 100 or more employees or a multiemployer plan in which at least one employer has 100 or more full- or part-time employees.

answer

large group health plan (LGHP)

question

maximum fee a provider may charge. Non-Par doctors usually report only the _______ as their fee

question

classifies patients according to long-term (acute) care DRGs, which are based on patients' clinical characteristics and expected resource needs; replaced the reasonable cost-based payment system. BBRA of 1999 aurthorized implementation of per discharge DRG for cost reporting periods begining oct. 1 2002 (2008 medicare severity long term care diagnosis related groups were adopted for LTCH PPS

answer

long-term (acute) care hospital prospective payment system (LTCH PPS)

question

organizes diagnosis-related groups (DRGs) into mutually exclusive categories, which are loosely based on body systems (e.g., nervous system).

answer

major diagnostic category (MDC)

question

payment system that reimburses providers for services and procedures by classifying services according to relative value units (RVUs); also called resource-based relative value scale (RBRVS) system. 1992 - RBRVS)

answer

Medicare physician fee schedule (MPFS)

question

situations in which the Medicare program does not have primary responsibility for paying a beneficiary's medical expenses.

answer

Medicare Secondary Payer (MSP)

question

adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs; bases DRG relative weights on hospital costs and greatly expanded the number of DRGs; reevaluated complications/comorbidities (CC) list to assign all ICD-10-CM codes as non-CC status (conditions that should not be treated as CCs for specific clinical conditions), CC status, or major CC status; handles diagnoses closely associated with patient mortality differently depending on whether the patient lived or expired.

answer

Medicare severity diagnosis-related groups (MS-DRGs)

question

previously called an Explanation of Medicare Benefits or EOMB; notifies Medicare beneficiaries of actions taken on claims.

answer

Medicare Summary Notice (MSN)

question

standards of measurement, such as those used to evaluate an organization's revenue cycle to ensure financial viability.

question

has two or more years of advanced training, has passed a special exam, and often works as a primary care provider along with a physician.

answer

nurse practitioner (NP)

question

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.

answer

Outcomes and Assessment Information Set (OASIS)

question

hospitals that treat unusually costly cases receive increased Medicare payments; the additional payment is designed to protect hospitals from large financial losses due to unusually expensive cases.

question

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

answer

outpatient encounter

question

includes all outpatient procedures and services (e.g., same-day surgery, x-rays, laboratory tests, and so on) provided during one day to the same patient.

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classifies patients into IRF PPS (inpatient rehabilitation facility) groups based on clinical characteristics and expected resources needs

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patient assesment instrument

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reimbursement method the federal government uses to compensate providers for patient care.

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has two or more years of advanced training, has passed a special exam, works with a physician, and can do some of the same tasks as the doctor.

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physician assistant (PA)

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IPPS Inpatienet psychiatric facility PPS home health hospital inpatient long term care pps

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rates established in advance, but based on reported health care costs (charges) from which a prospective per diem rate is determined.

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prospective cost-based rates

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rates associated with a particular category of patient (e.g., inpatients) and established by the payer (e.g., Medicare) prior to the provision of health care services.

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prospective price-based rates

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payment components consisting of physician work, practice expense, and malpractice expense.

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relative value units (RVUs)

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data entry system used to enter MDS data about SNF patients and transmit those assessments in CMS-standard format to individual state databases.

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Resident Assessment Validation and Entry (RAVEN)

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distribution of financial resources among competing groups (e.g., hospital departments, state health care organizations).

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resource allocation

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uses data analytics to measure whether a health care provider or organization achieves operational goals and objectives within the confines of the distribution of financial resources, such as appropriately expending budgeted amounts as well as conserving resources and protecting assets while providing quality patient care.

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resource allocation monitoring

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payment system that reimburses physicians practices expenses based on relative values for three components of each physicians services: physician work, practice expence, and malpractice insurance expense

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resource based relative value (RBRVS) system

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reimbursement system in which hospitals report actual charges for inpatient care to payers after discharge of the patient from the hospital.

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retrospective reasonable cost system

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a four-digit code that indicates location or type of service provided to an institutional patient; reported in FL 42 of UB-04.

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assessment process that is conducted as a follow-up to revenue cycle monitoring so that areas of poor performance can be identified and corrected.

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revenue cycle auditing

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process facilities and providers use to ensure financial viability.

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revenue cycle management

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involves assessing the revenue cycle to ensure financial viability and stability using metrics (standards of measurement).

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revenue cycle monitoring

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likelihood of dying.

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risk of mortality (ROM)

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extent of physiological decompensation or organ system loss of function.

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severity of illness (SOI)

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reduction of payment when office-based services are performed in a facility, such as a hospital or outpatient setting, because the doctor did not provide supplies, utilities, or the costs of running the facility.

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site of service differential

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each cpt and hcpcs level ii code is assined a statis indicator as a payment indicator to identify how each code is paid (or not paid) under the OPPS S - significant procedures for which the multiple procedure payment does NOT apply T - service to which the multiple procedures payment reduction applies

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statis indicator (SI)

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adjusts payments to account for geographic variations in hospitals' labor costs. add ons - such as pass-through payments that provide additional reimburcement to hospitals that use innovative biologicals, drugs, and technical devises, outlier payments for high cost services hold harmless payments for some hospitals and tranditional payments to limit loss under OPPS can increase payments

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HCFA (NOW CMS) IMPLEMENTED THE FIRST PROSPECTIVE PAYMENT SYSTEM (PPS) TO CONTROL THE COST OF HOSPITAL INPATIENT CARE TRUE ______ AN AMBULATORY SURGICAL VENTER IS A FEDERALLY LICENSED, MEDICARE CERTIFIED SUPPLIER OF SURGICAL HEALTH CARE SERVICES THAT MUST ACCEPT ASSIGNMENT OF MEDICAL CLAIMS FALSE ________ HOSPITAL INPATIENT DEPARTMENTS THAT PERFORM SURGERY ARE REIMBURSED UNDER OPPS, THE OUTPATIENT PAYMENT SYSTE, FALSE ______ THE MEDICARE DURABLE MEDICAL EQUIPMENT PROSTECTIC/ORTHOICS AND SUPLIERS (DMEPOS) FEE SCHEDULE WAS ESTABLISHED BY THE DEFICIT REDUCTION ACT OF 1984 TRUE ____ A VALID ICD-9 CM DIAGNOSIS CODE MUST BE REPORTED FOR EACH LINE ITEM ON ELECTRONICALLY-SUBMITTED CLAIMS TRUE ------ CPT CODES DIRECTLY AFFECT DRG'S ASSINGMENT FALSE ______ DRG'S ARE ORGANIZED INTO MUTUALLY EXCLUSIVE CATEFORIES CALLED MAJOR DIAGNOSTIC CATEGORIES (MDCS) TRUE ____ PAYING ACCORDING TO A COMPOSITE RATE IS A COMMON FORM OF MEDICARE PAYMENT, ALSO KNOWN AS UNBUNDLING. FALSE _____ A FACILITY CASE MIS IS A MEASURE OF THE TYPES OF PATIENTS TREATED,AND IT REFLECTS PATIENT UTILIZATION OF VARYING LEVELS OF HEALTH CARE RESOURCES TRUE ____ DECISION TREEE ARE USED BY CODERS AND BILLERS TO CALCULATE REIMBURSMENT FALSE ______ HOSPITALS THAT TREAT USUALLY COSTLY CASES AND RECIEVE INCREASED MEDICARE PAYMENTS ARE CALLED OUTLIERS TRUE _____ A MEDICARE ADMINSTRATIVE CONTACTOR IS A THIRD PARTY PAYER THAT CONTACTS WITH MEDICARE TO CARRY OUT THE OPERATIONAL FUNCTIONS OF THE MEDICARE PROGRAM TRUE ______ AN OUTPATIENT ENCOUNTER INCLUDES ALL OUTPATIENT PROCEDURES AND SERVIES PROVIDED DURING THE PATIENTS ENTIRE STAY FALSE ______ APC GROUPER SOFTWARE IS USED TO ASSIGN AN APC TO EACH CPT AND OR HCPC LEVEL II CODE REPORTED ON AN INPATIENT CLAIM, AS WEL AS TO REPORT ICD 9-CM DIAGNOSIS CODES AS APPROPRIATE FALSE ----- THE MEDICARE PHYSICIANS FEE SCHEDULE REIMBURES PROVIDERS ACCORDING TO PREDETERMINED RATES ASSIGNED TO SERVICES AND IS REVISED BY CMS EACH YEAR TRUE ____ WHAT DOES THE ACRONYM SOI STAND FOR SERVERITY OF ILLNESS ---- WHAT DOES THE ACRONYM ROM STAND FOR RICK OF MORTALITY _____ REIMBURSMENT ACCORDING TO ____ MEANS THAT HOPSITALS REPORTED ACTUAL CHARGES FOR INPATIENT CARE TO PAYERS AFTER DISCHARGE OF THE PATIENTS FROM THE HOSPITAL PAYMENT SYSTEM _____ WHICH OF THE FOLLOWING IS A FEDERAL HEALTH CARE PROGRAM ALL OF THE ABOVE ____ WHICH IS A PREDETERMINED REIMBURSEMENT METHODOLOGY PAYMENT SYSTEM ------- WHAT IS THE NAME OF THE PAYMENT SYSTEM FOR AMBULANCE SERVICES PROVIDED TO MEDICARE BENEFICIARIES AMBULANCE FEE SCHEDULE _____ WHICH OF THE FOLLWOING IS A LEVE OR AMBULANCE SERVICE ALL OF THE ABOVE ----- _____ IS A DATA SET BASED ON LOCAL FEE SCHEDULES FOR OUTPATIENT CLINICAL DIAGNOSTIC LABORATORY SERVICES CLINICAL LABORATORY FEE SCHEDULE ____ MEDICARE REIMBURSES LABORATY SERVICES ACCORDING TO ALL OF THE ABOVE ____ A FACILITIES_______ IS A MEASURE OF THE TYPES OF PATIENTS TREATED, AND IT REFLECTS PATIENT UTILIZATION OF CARYING LEVELS OF HEALTHER CARE RESOURCES CASE MIX ____ LONG TERM ACURE CARE HOPSITALS ARE DEFINED BY MEDICARE AS HAVING AN AVERAGE INPATIENT LENGTH STAY OF GREATER THEN 25 DAYS ___ THE ____ REIMBURSES PROVIDERS ACCORDING TO PREDETERMINED RATES ASSIGNED TO SERVICES AND IS REVISED BY CMS A YEAR MEDICARE PHTSICIAS SCHEDULE _____ MEDICARE IS ALWAYS A SECONDARY PAYER WHEN A MEDICARE BENEFICIARY ALSO HAS COVERAGE FROM WHICH OF THE FOLLOWING GROUPS ALL OF THE ABOVE ___ WHICH OF THE FOLLOWING INFORMATIN IS NECCESSARY TO CLACULATE THE AMOUNT OF MEDICARE SECONDARY BENIFITS PAYABLE ON A GIVEN CLAIM BOTH A AND C ___________ THE ____ IS A DOCUMENT THAT CONTAINS A COMPUTER GENERATED LIST OF PROCEDURES, SERVICES, AND SUPPLIES WITH CHARGES FOR EACH --- BOthh A & B

Which is a facility's measure of the types of patients treated and reflects patient utilization of varying levels of health care resources?

Which is associated with a particular category of patient and is established by payer prior to the provision of health care services?

Which is the relative volume and types of diagnostic/therapeutic and inpatient beds services used to manage an inpatient disease?

Which is the data set developed to measure the outcomes of all adults patients receiving home health services?