Which is the relative volume and types of diagnostic/therapeutic and inpatient bed services?

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

All Patient Refined DRG (APR-DRG)

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 tow subclasses to each DRG the 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, in subdivided into four areas; (1) minor, (2) moderate, (3) major, and (4) extreme

payment system for ambulance services provided to Medicare beneficiaries

ambulatory surgical center (ASC)

state-licensed Medicare-certified supplier (not provider) of surgical healthcare services that must accept assignment on Medicare claims

ambulatory surgical center payment

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

billing beneficiaries for amounts not reimbursed by payers (not including co-payments and co-incursance amounts); this practice is prohibited by Medicare regulations

the types and categories of patients treated by a healthcare facility or provider

charge description master (CDM)

clinical laboratory fee schedule

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

clinical nurse specialist (CNS)

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

CMS Quarterly Provider Update (QPU)

an outline 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

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

Diagnostic and Statistical Manual (DSM)

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

disproportionate share hospital (DSH) adjustment

hospitals that treat a high-percentage of low-income patients receive increased Medicare payments

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

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

employer group health plan (EGHP)

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)

ESRD composite payment rate system

bundles end-state renal disease (ESRD) drugs and related laboratory tests with the composite rate payments, resulting in one reimbursed 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 healthcare resources (e.g., patient's age)

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

health insurance prospective payment system (HIPPS) code set

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

Home Assessment Validation and Entry (HAVEN)

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

home health resource group (HHRG)

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

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

indirect medical education (IME) adjustment

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)

inpatient prospective payment system (IPPS)

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

Inpatient Rehabilitation Validation and Entry (IRVEN)

software used as the computerized data entry system by inpatient rehabilitation facilities to create a file in a standardized formate 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 objectivity measure and compare facility performance and quality; data also provides researchers with information to support the development of improved standards

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

IPPS 3-day payment window

requires that outpatient pre-admission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by teh IPPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or non-diagnostic) services when the inpatient principal diagnosis code (ICD-9-CM) exactly matches that for pre-admission services

see IPPS 3-day payment window

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

large group health plan (LGHP)

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

maximum fee a physician may charge

long-term (acute) care hospital prospective payment system (LTCPPS)

classifies patients according to long-term (acute) care DRGs which are based on patient's clinical characteristics and expected resource needs; replaced the reasonable cost-based payment system

major diagnostic category (MDC)

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

Medicare severity diagnosis related groups (MS-DRGs)

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 co-morbidities (CC) list to assign all ICD-9-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.

Medicare Benefit Policy Manual

replaced current Medicare general coverage instructions that were found in Chapter II of the Medicare Carriers Manual Intermediary Manual, various provider manuals, and Program Memorandum documents

Medicare National Coverage Determination Manual

replaced the Medicare Coverage Issues Manual; contains two chapters ; Chapter 1 includes a description of national coverage determinations made by CMS, and Chapter 2 contains a listing of HCPCS codes that are related to each determination

Medicare Physician Fee Schedule

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

Medicare Secondary Payer (MSP)

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

Medicare Summary Notice (MSN)

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

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

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

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

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

prospective payment system (PPS)

issues predetermined payment for services

prospective cost-based rates

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

prospective price-based rates

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

relative value units (RVUs)

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

Resident Assessment Validation and Entry (RAVEN)

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

retrospective reasonable cost system

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

four digit codes that indicate location or type of service provided to an institutional patient; reported in FL 42 of UB-04

process facilities and providers use to ensure financial viability

severity of illness (SOI)

extent of physiological decompensation or organ system loss function

site of service differential

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 facility

adjusts payments to account for geographic variations in hospitals' labor costs

Which is the original DRG system adapted for use by third party payers to reimburse hospitals for inpatient care?

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

Which is added to DSH or IME adjustments made for hospitals that treat unusually costly cases resulting in increased medical payments quizlet?

Which established the Medicare clinical laboratory fee schedule which is a dataset based on local fee schedules for outpatient clinical diagnostic laboratory services?