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medicial billing and coding > chapter 9 cms reimbursment methodologies > Flashcards

chapter 9 cms reimbursment methodologies Flashcards

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
Q

HOME ASSESSMENT VALIDATION AND ENTRY

A

DATA ENTRY SOFTWARE USED TO COLLECT OASIS ASSESMETN DATA FOR TRANSMISSON TO STATE DATABASES

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26
Q

HOME HEALTH PATIENT DRIVEN GROUPINGS MODEL

A

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

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27
Q

HOME HEALTH VALUE BASED PURCHASING MODEL

A

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

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28
Q

HOSPITAL ACQUIERED CONDITION HAC

A

MEDICAL CONDITIONS OR COMPLICATIONS THAT PATIENTS DEVELOP DURING INPATIENT HAOSPITAL STAYS AND THAT WERE NOT PRESENT AT ADMISSION

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29
Q

HOSPITAL Q=ACQUIRED CONDITION REDUCTION PROGRAM

A

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
Q

HOSPITAL REDMISSION REDUCTION PROGRAM

A

REQUIRED CMS TO REDUCE PAYEMTNS TO IPPS HOSPITALS WITH EXCESS READMISSIONS

31
Q

INCIDENT TO

A

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
Q

INDIRECTED MEDIAL EDUUCATION ADJUSTMENT

A

APPROVED TEACHING HOSPITALS RECIVE INCREASED MEDICARE PAYMENTS WHICH ARE ADJUSTED DEPENTDING ON THE RATAIO OF RESIDENTS TO BEDS

33
Q

INPATIENT PROSPECTIVE PAYMENT SYSTEM

A

SYSTEM IN WHICH MEDICARE REIMBYSES HOSPITALS FOR INPATIENT HOSPITAL SERVICES ACCORDING TO A PREDETERINED RATE FOR EACH DISCHARGE

34
Q

INPATIENT PSYCHIATRIC FACILITY QUALITY REPORTING PRGRAM

A

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
Q

INPATIENT REHABILITATAION VALIDATION AND ENTRY

A

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
Q

INTERNSITAY OF REASOURCES

A

relataive volume and types of diagnostic theraputic and inpatient bed services used to manage an inpatient disease

37
Q

intensity of services

A

determining wheather provided services are apporopriate for patients current pr proposed leave of care

38
Q

ipps 3 day payment window

A

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
Q

IPPS 72 HOUR RULE

A

IPPS 3 DAY PAYMETN WINDOW

40
Q

IPPS TRANSFER RULE

A

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
Q

LIMITING CHARGE

A

MAXIMUM FEE A PROVIDER MAY CHARGEQ

42
Q

LONG TERM ACUTE CARE HOSPITAL PROSPECTIVE PAYEMENT SYSTEM

A

CLASSIFIES PATIENTS ACCORDING TO LONG TERM ACUTE CARE DRGS WHICH ARE ABSED ON PATIENTS CLINICLA CHARACTERISTICS AND EXPECTED REASURCES NEEDS

43
Q

MAJOR DIAGNOSTIC CATEGORIES

A

ORGANIZES DIAGNOSIS REALATED GROUPS INTO MUTUALLY EXCLUSIVE CATAEGORIES

44
Q

MEDICARE PHYSICIAN FEE SCHEDULEQ

A

PAYMENT SYSTEM THAT REIMBURSES PROVIDERS FOR SERVICES AND PROCEDURES

45
Q

MEDICARE SEVERITY DIAGNOSIS RELATED GROUPS

A

IMPROVE RECOGNITION OF SEVERITY OF ILLNESS AND REASURCE CONSUMPTION AND REDUCE COST VARTIATION AMONG DRGS

46
Q

MEDICARE SUMMARY NOTICE

A

NOTIFIES MEDICARE BENFICIARIES OF ACTIONS TAKEN ON CLAIMS

47
Q

OUTLIER

A

HOSPITALS THAT TREAT UNUSUALLY COSTLY CASES RECEIVE INCREASED MEDICARE PAYMENTS

48
Q

OUTPATIENT ENCOUNTER

A

ALL OUTPATIENT PROCEDURES AND SERVICES

49
Q

OUTPATIENT VISIT

A

OUTPATIENT ENCOUNTER

50
Q

PATAIENT ASSESSMENT INSTRUMENT

A

CLASSIFIDES PATIENTS INTO GROUPS PASED ON CLINICAL CHAREACTERISTICS AND EXPECTED RESOURCE NEEDS

51
Q

PATTIENT DRIVEN PAYMENT MODEL

A

CASE MIX REIMBURSEMENT SYSTEM THAT CONNECTS PAYMENT TO PATIENTS CONDITIONS AND CARE NEEDS INSTEAD OF THE VOLUME OF SERVICES PROVIDED

52
Q

PAY FOR PERFORMANCE

A

INITATIVES THAT LINK REIMBURSEMENT TO PERFORMANCCE CRITERIA SO THAT THE RIGHT CARE IS PROVIDED FOR EVERY PATIENT EVERY TIME

53
Q

PAYEMTNT SYSTEM

A

REIMBURSEMENT METHOD THE FEDERAL GOVERNMENT USES TO COMPENSATE PRIVIDERS FOR PATIENT CARE

54
Q

PRESENT ON ADMISSION

A

CONDTITION THAT EXIXT AT THE TIME AN ORDER FOR INPATIENT ADMISSION OCCUS=RS

55
Q

PROSPECTIVE COST BASED RATES

A

RATES ESTABLISED IN ADVANCE BUT BASED ON REPORTED HEALTH CARE COSTS

56
Q

PROSPECTIVE PRICE BASED RATES

A

RATES ASSOCIATED WITH A PARTICULAR CATEGORY OF PATIENT AND ESTABLISHED BY THE PAYER

57
Q

RELATIVE VALUE UNITS

A

PAYMENT COMPONENTS CONSISTING OF PHYSICIAN WORK

58
Q

RESIDENT ASSESSMENT VALIDATION AND ENTRY

A

DATA ENTRY SYSTEM USED TO ENTER MDS DATA ABOUT SNF PATIENTS AND TRANSMIT THOSE ASSESSMENTS IN CMS STANDAARD FORMAT TO INDIVIDUAL STATE DATABASE

59
Q

RETROSPECTIVE REASONABLE COST SYSTEM

A

SYSTEM IN WHICH PROVIDERS REPORTED ACTUAL CHARGES

60
Q

RETROSPECTIVE REIMBURMENT METHODOLOGY

A

RETROSPECTIVE REASONABLE COST SYSTEM

61
Q

RISK OF MORTALITY

A

LIKEKUHOOD OF DYING

62
Q

SEVERITY OF ILLNESS

A

EXTENT OF PHYSILOLGICAL DECOMPENSATION OR ORGAN SYSTEM LOSS OF FUNCTION

63
Q

SITE OF SERVICE DIFFERENTIAL

A

REDUCTION OF PAYMENT WHEN OFFICE BASED SERVICES ARE PERFIRMENTD IN A FACILITY

64
Q

SKILLED NURSING FACILITY VALUE BASED PURCHASING PROGRAM

A

IMPLEMENTED WITH THE INTENT OF REWARDING QUALITY AND IMPROVING HEALTH CARE

65
Q

VALUE BASED PURCHASING

A

MEDICARES INPATIENT PROSEPECTIVE PAYMETN SYSTEM

66
Q

WAGE INDEX

A

ADJUSTS PAYMETNS TP ACCOUNT FOR GEOGRAAPHIC VARIATIONS IN HOSPITALS LABOR COSTS

67
Q

AMBULATORY SURGICAL CENTER PAYMENT RATES

A

PREDETERMINED AMOUNT FOR WHICH ASC SERVICES ARE REIMBYRSED

68
Q

FEDERALLY QUALIFIED HEALTH CENTERES

A

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

69
Q

MAJOR DIAGNOSTIC CATEGORIES

A

ORGANIZE DIAGNOSIS RELATED GROUPS INTO MUTUALLY EXCLUSICE CATEGORIES

70
Q

INTENSITY OF SERVICES

A

WHETHER PROVIDED SERVICES ARE APPROPRIATE FOR PATIENTS CURRENT PR PROPOSED LEVEL OR CARE

71
Q

HOSPITAL ACQURIED CONDITIONS

A

MEDICAL CONDITIONS THAT PATIENTS DEVELPOP DURING INPATIENT HOSPITAL STAYS AND THAT WERE NOT PRESENT AT ADMISSION

72
Q

PATIENT ASSESSMETN INSTRUMENT

A

CLASSIFIES PATIENT INTO GROUPS BASED ON CLINICAL CHARACTERISTICS AND EXPECTED RESOURCE NEEDS

medicial billing and coding (8 decks)

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