Chapter 6; Chapter 8 Medicare-Medicaid Prospective Payment Systems for Inpatients – Flashcards

Groupers

Medicare Administrative Contractors

Medicare payments to hospitals grew annually by 19 percent; the Medicare hospital deductible had expanded, placing a burden on beneficiaries; the solvency of the Medicare Trust Fund was endangered by escalating costs; expenditures for hospital inpatient care jeopardized Medicare's ability to fund other necessary health programs; Medicare's payments for comparable services were vastly different across hospitals nationwide; and the cost-based system imposed burdensome reporting requirements.

Because DRGs are a fully packaged system, the predetermined payment for each MS-DRG is full payment for all hospital services performed during an encounter, so facilities accept profit or loss based on the cost of providing the services.

The severity of illness refinement allows cases with a higher severity of illness ranking to be more appropriately reimbursed. Yes, the refinement was supported by the healthcare community.

1. Pre-MDC Assignment 2. MDC Determination 3. Medical/Surgical Determination 4. Refinement

The length-of-stay adjustment was implemented because data showed that per-diem costs for psychiatric cases decreases as LOS increases.

Costly comorbidities necessitated an adjustment. An adjustment was implemented for older patients because regression analysis shows the cost per day as increasing with increasing patient age. Another adjustment was implemented for patients receiving electroconvulsive therapy, the cost of which is associated with longer stays and increased use of ancillary services.

70.317 percent is the labor portion and 29.683 percent is the non-labor portion.

CMS did not want to provide an incentive for facilities to prematurely discharge patients and then subsequently re-admit them because the length of stay adjustment is weighted heavier for the beginning days for an admission.

Medical necessity must be established by the physician at the start of the inpatient psychiatric admission. Medical necessity must be re-evaluated and established for admissions that extend past the 18th day.

Wage index adjustment

Services included in the consolidated billing of SNFs are outpatient services that a resident may receive from outside vendors, such as laboratory tests, x-rays, and pharmaceuticals. Services excluded from consolidated billing are emergency services, inpatient services, and other extensive procedures (such as radiation therapy).

Per-diem rates are case-mix adjusted using the groups of the RUG-IV.

Its average length of stay for Medicare patients must be 25 days or more.

The principal diagnosis is the primary determinant of the MS-LTC-DRG, but secondary diagnoses affect the assignment. Grouper software classifies patients for MS-LTC-DRG assignments using principal diagnosis, additional diagnoses, procedures performed, sex of the patient, and discharge status.

functional status; functional status assessment tool

False

True

Home assistance validation and entry (HAVEN).

DME is excluded from the per-episode HHPPS reimbursement system and is reimbursed under the DME fee schedule.

The codes are "intelligent" because the number or letter in each position provides information: First position: Payment grouping step for episode (numeric characters only) Second, third, and fourth positions: clinical, functional, and service dimensions, in order (alphabetic characters only) Fifth position: Severity of nonroutine medical supplies (NSR severity) (alphanumeric characters)

Rate per discharge for operating and capital related components for an acute care hospital. Prospectively set payment rate made for services that Medicare beneficiries receive in healthcare settings. The base rate is adjusted for geographic location, inflation case mix, and other factors.

Sum of facilities relative proportion of wages and salaries, employee benefits professional fees, postal services, other labor-intensive services, and the labor-related share of capital costs from the appropriate market basket. Labor-related share is typically 70 to 75 percentof healthcare facilities cost adjusted annually and published in the Federal Register.