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chapter 9 cms reimbursment methodologies Flashcards

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1
Q

ALL PATAIENT DIAGNOSIS RELATED GROUP

A

DRG SYSTEM ADAPTED FOR USE BY THIRD PARTY PAYERS TO REIBURSE HOSPITALS FOR INPATIENT CARE PROVIDED TO NON MEDICARE BENFICIARIES

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2
Q

ALL PATIENT REFINED DOAGNOSIS RELATED GROUP

A

SYSTEM THAT CLASSIFIES PATIENTS ACCORDING TO REASON FOR ADMISSION SEVERITY OF ILLNESS AND RISK OF MORTALITY

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3
Q

AMBULABCE FEE SCHEDULE

A

PAYMENT SYSTEM FOR AMBULANCE SERVICES PROVIDED TO MEDICARE BENEFICIARIES

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4
Q

AMBULATORY SURGICAL CENTER

A

STATE LICENSED MEDICARE CERIFIED SUPPLIER OF SURGICAL HEALTH CARE SERVICES THAT MUST ACCEPT ASSIGMENT ON MEDICARE CLAIMS

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5
Q

AMBULATORY SURGICAL CENTER PAYMENT RATE

A

PEDETERMINED AMOUNT FOR WHICH ASC SERVICES ARE REIMBURSED AT 80 PERCENT FOR RREGIONAL WAGE VARIATIONS

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6
Q

AMBULATORY SURGICAL CENTER QUALITY REPORTING PROGRAM

A

PAY FOR REPORTING PROGRAM THA TREQUIRED AMBULATORY SURGICLA CENTERS TO MEET ADMINISTRATIVR DATA COLLECTIONS REPORTING AND OTHER PROGRAMS REQUIREMENTS OR RECEIVE A REDUCTION OF 2.0 PERCENT POINTS IN THEIR ANNUAL PAYMENT UPDATE FOR FAILURE TO MEET THERSE PROGRAM REQUIREMENTS.

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7
Q

BALANCED BILLING

A

BILLING BENEFICIARIES FOR AMOUNTS NOT REIMBURSED BY PAYERS THIS PRACTICE IS PROHIBITED Y MEDICARE REGULATIONS

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8
Q

BUNDLED PAYMENT

A

PREDETERMINED PAYMANENT AMOUNT FOR ALL SERVICES PROVIDED DURING AN EPISODE OF CARE

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9
Q

CASE MIX

A

THE TYPES AND CATEGORIES OF PATIENTS TREATED BUY HEALTH CARE FACILITY OR PROVIDER

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10
Q

CASE MIX INDEX

A

RELATIVE WEITGHT ASSIGNED FOR AS FACILITYS PATIENT POPULATION IT IS USED IN A FORMULA TO CALCUATE HEALTH CARE REIMBURSEMENT

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11
Q

CASE MIX MANAGEMENT

A

ALLOWS HEALTH CARE FACILITIES AND PROVIDERS TO DETERMINE ANTICIPATED HEALTH CARE NEED S BY REVIEWING DATA ANALYTICS ABOUT TYPES ANDN OR CATOEGORIES OF PATIENT TREATED

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12
Q

CASE RATE

A

PREDETERMINED PAYEMNT FOR AN ENCOUNTER REGARDLESS OF THE NUMBER OF SERVICES PROVIDED OR LENGHT OF ENCOUNTER

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13
Q

CLINICAL LABORATORY FEE SCHEDULE

A

CLINICAL DOCUMENTATION IMPROVEMENT

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14
Q

CONCERSION FACTOR

A

DOLLOR MULTIPLIER THAT CONVERTS RELATIVE VALUE UNITS INTO PAYMENTS

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15
Q

DIAGNOSTIC AND STATISTICAL MANUAL

A

CLASSIFIES MENTAL HEALTH DISORDERS AND IS BASED ON ICD PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCIATION

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16
Q

DISPROPORTIONATE SHARE HOSPITAL ADJUSTMENT

A

POLICY IN WHICH HOSPITALS THAT TREAT A HIGH PERCENTAGE OF LOW INCOME PATIENTS RECEIVE INCREASED MEDICARE PAYMETNTS

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17
Q

DURABLE MEDICAL EQUIPMENT PROSTHETIC/ ORTHOTICS ADN SUPPLIES FEE SCHEDULE

A

MEDICARE REIMBRSES DEMPOS DEALEARS ACCORDING TO EITHER 80 PERCENT OF THE ACTUAL CHAREGE FOR THE ITEM OR THE FEE SCSHEDUAL AMOUNT WHICHEVER IS LOWER

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18
Q

END STAGE RENAL DISEASE COMPOSIT PAYMENT RATE SYSTEM

A

BUNDLES END STAGE RENAL DISEASE DRUGS AND RELATED LAB TESTS WITH THE COMPOSITE RATE PAYMENTS RESULTING IN ONE REIMBURSEMENT AMOUT PAID FOR ESRD SERVICES PROVIDED TO PATIENTS

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19
Q

EPISODE OF CARE HOME HEALTH

A

PERIOD OF TIME DURING WHICH HOME HEALTH CARE IS PROVIDED FOR A PARTICULAR CONDITION

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20
Q

FEDERALLY QUALIFIED HEALTH CENTER

A

SAFTEY NET PROVIDERS THAT PRIMARILY PROVIDE SERVICES TYPICALLY FURNISHED IN AN OUTPATIENT CLINIC

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21
Q

FEDERALLY QUALIFIED HEALTH CENTERS PROSPECTIVE PAYMENT SYSTEM

A

NATIONAL ENCOUNTER BASED RATE WITH GEOGRAPHIC AND OTHER ADJUSTMENTS ESTABLISHED BY THE AFFORADABLE CARE ACT AND I,PLENTED IN 2014

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22
Q

GLOBAL PAYEMENT

A

ONE PAYMENT TAHT COVERS ALL SERVICES RENDERED BY MULTIPLE PROVIDERS DURING AN EPISODE OF CARE

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23
Q

GROUPER SOFTWARE

A

DETERMINES APPROPRIATE GROUP GROUP HOME HEALTH RESOURCE GROUP AND SO ON TO CLASSIFY A PATIENT AFTER DATA ABOUT TEH PATIENT IS INPUT

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24
Q

HEALTH INSURANCE PROSPECTIVE PAYMENT SYSTEM CODE SET

A

FIVE DIGIT ALPHANUMERIC CODES TAHT REPRESENT CASE MIX GROUPS ABOU TWHICH PAYMENT DETERMINATIONS ARE MADE FOR HH PPS

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25
HOME ASSESSMENT VALIDATION AND ENTRY
DATA ENTRY SOFTWARE USED TO COLLECT OASIS ASSESMETN DATA FOR TRANSMISSON TO STATE DATABASES
26
HOME HEALTH PATIENT DRIVEN GROUPINGS MODEL
IMPLEMENTED IN 20220 TO REPLAE HOME HEALTH RESOURCCE GROUPS RELIES MORE HEAVILY ON CLINICAL CHAREACTERISTICS ANDOTHE RPATIENT INFORMATION TO PLACE HOME HEALTH PERIODS OF CARE INTO MEANINGFUL PAYMETN CATGORIES ELIMINATED USE OF THERAPY SERVICES THRESHOLDS RESULTHED IN UNIT OF HOME HEALTH PAYMENT BEING REDUCED FOR 60 TO 30 DAY PERIOD
27
HOME HEALTH VALUE BASED PURCHASING MODEL
DESIGNED TO PROVIDE MEDICARE CERTIFIED HHAS WITH INCENTIVES TO PROVIDE HIGHER QUALITY AND MORE EFFICIENT CARE HHA PAYMENTS ARE ADJUSTED FOR SERVICES BASED ON QUALITY OF CARE
28
HOSPITAL ACQUIERED CONDITION HAC
MEDICAL CONDITIONS OR COMPLICATIONS THAT PATIENTS DEVELOP DURING INPATIENT HAOSPITAL STAYS AND THAT WERE NOT PRESENT AT ADMISSION
29
HOSPITAL Q=ACQUIRED CONDITION REDUCTION PROGRAM
ENCOURGES HOSPITALS TO REDUCE HACS BY ADJUSTIING PAYEMNTS TO HOSPITALS THAT RANK IN THE WORST PERFORMING 25 PERCENT WHITH RESPECT TO HAC QUAILITY MEASURES
30
HOSPITAL REDMISSION REDUCTION PROGRAM
REQUIRED CMS TO REDUCE PAYEMTNS TO IPPS HOSPITALS WITH EXCESS READMISSIONS
31
INCIDENT TO
MEDICARE REGULATIONS WHICH PERMITTED BULLING MEDICARE UNDER THE PHYSICIANS BILLING NUMBER FOR ANCILLARY PERSONNEL SERVICES WHEN THOSE SERVICES WERE INCIDENT TO A SERVICE PERFORMENT BY A PHYSICIAN
32
INDIRECTED MEDIAL EDUUCATION ADJUSTMENT
APPROVED TEACHING HOSPITALS RECIVE INCREASED MEDICARE PAYMENTS WHICH ARE ADJUSTED DEPENTDING ON THE RATAIO OF RESIDENTS TO BEDS
33
INPATIENT PROSPECTIVE PAYMENT SYSTEM
SYSTEM IN WHICH MEDICARE REIMBYSES HOSPITALS FOR INPATIENT HOSPITAL SERVICES ACCORDING TO A PREDETERINED RATE FOR EACH DISCHARGE
34
INPATIENT PSYCHIATRIC FACILITY QUALITY REPORTING PRGRAM
PAY FOR REPORTING PROGRAM INTENDED TO EQUIP CONSUMERS WITH QYALITY OF CARE INFORMATION TO MAKE MORE INFORMED DECIXIONS ABOUT HEALTH CARE OPTIONS AND ENCOURAGE HOSPITALS AND CLINICIANS TO IMPROVE THE QUALITY OF INPATIENT CARE PROVIDED TO BENEFICIARIES
35
INPATIENT REHABILITATAION VALIDATION AND ENTRY
SOFTWARE USED AS THE COMPUTERIZED DATA ENTRY SYSTEM BY INPATIENT REHABILATION FACILITIES TO CREATE A FILE IN A STANDARD FORMAT THAT CAN BE ELECTRONICALLY TRANSMITTED TO A NATIONAL DATABASE
36
INTERNSITAY OF REASOURCES
relataive volume and types of diagnostic theraputic and inpatient bed services used to manage an inpatient disease
37
intensity of services
determining wheather provided services are apporopriate for patients current pr proposed leave of care
38
ipps 3 day payment window
requires that outpaatient preadmission services provided by a hospital for a period of up to three days prior to a patients inpatient admission be covered by ipps drg
39
IPPS 72 HOUR RULE
IPPS 3 DAY PAYMETN WINDOW
40
IPPS TRANSFER RULE
ANY PATIENT WITH A DIAGNOSIS FORM INE OF TEN FCMS DETERMINED DRGS WHO IS DISCHARGE DTO POST ACUTE PROVIDER IS TREATED AS A TRASFER CASE
41
LIMITING CHARGE
MAXIMUM FEE A PROVIDER MAY CHARGEQ
42
LONG TERM ACUTE CARE HOSPITAL PROSPECTIVE PAYEMENT SYSTEM
CLASSIFIES PATIENTS ACCORDING TO LONG TERM ACUTE CARE DRGS WHICH ARE ABSED ON PATIENTS CLINICLA CHARACTERISTICS AND EXPECTED REASURCES NEEDS
43
MAJOR DIAGNOSTIC CATEGORIES
ORGANIZES DIAGNOSIS REALATED GROUPS INTO MUTUALLY EXCLUSIVE CATAEGORIES
44
MEDICARE PHYSICIAN FEE SCHEDULEQ
PAYMENT SYSTEM THAT REIMBURSES PROVIDERS FOR SERVICES AND PROCEDURES
45
MEDICARE SEVERITY DIAGNOSIS RELATED GROUPS
IMPROVE RECOGNITION OF SEVERITY OF ILLNESS AND REASURCE CONSUMPTION AND REDUCE COST VARTIATION AMONG DRGS
46
MEDICARE SUMMARY NOTICE
NOTIFIES MEDICARE BENFICIARIES OF ACTIONS TAKEN ON CLAIMS
47
OUTLIER
HOSPITALS THAT TREAT UNUSUALLY COSTLY CASES RECEIVE INCREASED MEDICARE PAYMENTS
48
OUTPATIENT ENCOUNTER
ALL OUTPATIENT PROCEDURES AND SERVICES
49
OUTPATIENT VISIT
OUTPATIENT ENCOUNTER
50
PATAIENT ASSESSMENT INSTRUMENT
CLASSIFIDES PATIENTS INTO GROUPS PASED ON CLINICAL CHAREACTERISTICS AND EXPECTED RESOURCE NEEDS
51
PATTIENT DRIVEN PAYMENT MODEL
CASE MIX REIMBURSEMENT SYSTEM THAT CONNECTS PAYMENT TO PATIENTS CONDITIONS AND CARE NEEDS INSTEAD OF THE VOLUME OF SERVICES PROVIDED
52
PAY FOR PERFORMANCE
INITATIVES THAT LINK REIMBURSEMENT TO PERFORMANCCE CRITERIA SO THAT THE RIGHT CARE IS PROVIDED FOR EVERY PATIENT EVERY TIME
53
PAYEMTNT SYSTEM
REIMBURSEMENT METHOD THE FEDERAL GOVERNMENT USES TO COMPENSATE PRIVIDERS FOR PATIENT CARE
54
PRESENT ON ADMISSION
CONDTITION THAT EXIXT AT THE TIME AN ORDER FOR INPATIENT ADMISSION OCCUS=RS
55
PROSPECTIVE COST BASED RATES
RATES ESTABLISED IN ADVANCE BUT BASED ON REPORTED HEALTH CARE COSTS
56
PROSPECTIVE PRICE BASED RATES
RATES ASSOCIATED WITH A PARTICULAR CATEGORY OF PATIENT AND ESTABLISHED BY THE PAYER
57
RELATIVE VALUE UNITS
PAYMENT COMPONENTS CONSISTING OF PHYSICIAN WORK
58
RESIDENT ASSESSMENT VALIDATION AND ENTRY
DATA ENTRY SYSTEM USED TO ENTER MDS DATA ABOUT SNF PATIENTS AND TRANSMIT THOSE ASSESSMENTS IN CMS STANDAARD FORMAT TO INDIVIDUAL STATE DATABASE
59
RETROSPECTIVE REASONABLE COST SYSTEM
SYSTEM IN WHICH PROVIDERS REPORTED ACTUAL CHARGES
60
RETROSPECTIVE REIMBURMENT METHODOLOGY
RETROSPECTIVE REASONABLE COST SYSTEM
61
RISK OF MORTALITY
LIKEKUHOOD OF DYING
62
SEVERITY OF ILLNESS
EXTENT OF PHYSILOLGICAL DECOMPENSATION OR ORGAN SYSTEM LOSS OF FUNCTION
63
SITE OF SERVICE DIFFERENTIAL
REDUCTION OF PAYMENT WHEN OFFICE BASED SERVICES ARE PERFIRMENTD IN A FACILITY
64
SKILLED NURSING FACILITY VALUE BASED PURCHASING PROGRAM
IMPLEMENTED WITH THE INTENT OF REWARDING QUALITY AND IMPROVING HEALTH CARE
65
VALUE BASED PURCHASING
MEDICARES INPATIENT PROSEPECTIVE PAYMETN SYSTEM
66
WAGE INDEX
ADJUSTS PAYMETNS TP ACCOUNT FOR GEOGRAAPHIC VARIATIONS IN HOSPITALS LABOR COSTS
67
AMBULATORY SURGICAL CENTER PAYMENT RATES
PREDETERMINED AMOUNT FOR WHICH ASC SERVICES ARE REIMBYRSED
68
FEDERALLY QUALIFIED HEALTH CENTERES
SAFTY NET PROVIDERS THAT PRIMARILY PROVIDE SERVICES TYPICALLY FURNISHED IN AN OUTPATIENT CLINIC
69
MAJOR DIAGNOSTIC CATEGORIES
ORGANIZE DIAGNOSIS RELATED GROUPS INTO MUTUALLY EXCLUSICE CATEGORIES
70
INTENSITY OF SERVICES
WHETHER PROVIDED SERVICES ARE APPROPRIATE FOR PATIENTS CURRENT PR PROPOSED LEVEL OR CARE
71
HOSPITAL ACQURIED CONDITIONS
MEDICAL CONDITIONS THAT PATIENTS DEVELPOP DURING INPATIENT HOSPITAL STAYS AND THAT WERE NOT PRESENT AT ADMISSION
72
PATIENT ASSESSMETN INSTRUMENT
CLASSIFIES PATIENT INTO GROUPS BASED ON CLINICAL CHARACTERISTICS AND EXPECTED RESOURCE NEEDS

medicial billing and coding (8 decks)

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