Question 1

prospective payment systems - PPS; cost-based rates; price-based

Accepted Answer

established predetermined rates based on pt category or type of facility (w/annual incr. based on inflatn index and geographic wage index). Cost-based on healthcare costs from wh. a predetermined per diem rate determined. Price-based on category of pt (inpts) & established prior to healthcare svcs.

Question 2

ambulance fee schedule

Accepted Answer

in 2002, cost-based. reporting of HCPCS codes on ambulance svcs. ambulance suppliers must accept Medicare.

Question 3

Ambulatory surgical center

Accepted Answer

is st. lic supplier of surgical svcs tt must accept assignment of Medicare claims. Cost-based: uses ambulatory payment classification (APC) groups, wh, group svcs according to similar clinical characteristics and in terms of resources required.

Question 4

Durable medical equip, prosthetics,/orthotics and Supplies; Clinical Lab

Accepted Answer

DMEPOS - fee schedule: cost-based, Clinical Lab: established 1984, also cost-based. Both paid the lowest charge.

Question 5

End Stage Renal Disease composite rate schedule

Accepted Answer

composite rate paid for routine bundled svcs. Newer svcs pd on per-service basis.

Question 6

case mix

Accepted Answer

a measure of the types of pts treated - reflecting pt unitization of healthcare svcs.

Question 7

home health resource groups (HHRGs)

Accepted Answer

In 1997, 80 levels of severity used to establish prospective reimbursement rates for ea. 60 day episode of home care. Pts assessed by using the OutcomesAssessmentInformationSet. Reported to Medicare using HealthIns.PPS 5 digit code set representing pt groups using HomeAssessmentValidationEntry software

Question 8

Hospital Inpt (IPPS)

Accepted Answer

In 1983, reimbursed for inpt services thru a predetermined rate for ea. discharge. In 2008, ea. discharge is categorized into a MedicalSeverity-Diagnosis-RelatedGroup (MS-DRG), based on pts principal and secondary diagnoses as well as procedures. DRGs organized into MajorDiagnosticCategories, loosely based on body systems. IPPS payment based on adjusted average pymt rate

Question 9

All pt-refined DRGs

Accepted Answer

Expanded DRG system to add two subclasses to ea. DRG that adjusts Medicare inpt reimbursement rates for severity of disease (SOI) and (ROM) risk of mortality. Ea. subclass, subdivided into four areas: 1)minor 2)moderate 3)major 4)extreme. Recognized 335 base DRGs out of over 750, wh. are further refined by complications and comorbidities (CC). Reevaluated all ICD-9 and 10 codes as non-CC status.

Question 10

IPPS 3-day payment window or 72-hour rule

Accepted Answer

Preadmission svcs provided by hospital on the day of or three days prior to admission be reported on UB-04

Question 11

Hospital Outpt (OPPS)

Accepted Answer

In 2000, all svcs pd according to APCs. Each CPT and HCPCS II code assigned a \'status indicator\" to identify how much ea. code is pd or not pd.

Question 12

Inpt Psychiatric Facility PPS; Skilled Nursing Facility; Inpt Rehab & LongTerm Care Hospital

Accepted Answer

In 1999, per diem or cost-based. SNF uses cost-based Resource utililization groups (RUGs) reimbursement methodology for case-mix adjustment. Rehab and Long-Term are priced based, implemented by BBRA in 1999.

Question 13

Medicare Physician Fee Schedule (MPFS)

Accepted Answer

In 1992, MD svcs and procedures reimbursed according to Resource-Based Relative Value Scale (RBRVS). All svcs standardized into Relative Value Units, whose components are 1) Physician work 2) Practice expense 3) Malpractice expense. RVUs adjusted by geographic adjustment factors (GCPracticeIndices) and annual conversion factor, wh. converts RVUs into payments

Question 14

Other service components: anesthesia, radiology and pathology

Accepted Answer

anesthesia: based on time anesthesiologist spends w/pt. Radiology varies w/place of service. Pathology service payments very according to the number of pts served.

Question 15

Non-PARticipating Providers

Accepted Answer

Do not accept assignment from Medicare, who reimburses them 5% less than MPFS. Medicare requires the nonPAR to charge the pt no more than the diff. tween what Medicare reimburses and the limiting charge, wh. is calculated by multiplying the reduced MPFS (or allowable charge) by 115%. Medicare reimburses 80% of the reduced amt (by 5%). Write-off is MD charge minus limiting charge.

Question 16

Medicare secondary payer

Accepted Answer

Medicare pays lowest of: 1) charge of MD minus amt pd by primary payer 2) Amt Medicare would pay if svcs not covered by primary 3)third party payer\'s allowable charge to primary minus the amt actually pd by primary

Question 17

Nonphysician Practitioners

Accepted Answer

NP, ClinicalNurseSpecialist, PA. Pd 80% of actual charge or 85% of MPFS, whichever is less.

Question 18

site of service differential

Accepted Answer

When office-based svcs performed in facility, pymt reduced cause MD did not provide supplies & utilities, etc.

Question 19

CMS Quarterly Provider Update

Accepted Answer

online CMS publication that contains information regulations and major policies.

Question 20

chargemaster; revenue codes

Accepted Answer

computer generated list of procedures, services and supplies w/ charges. Contains dept code, svc code, svc description, revenue code, charge amt and RVUs. Revenue codes: 4-digit codes preprinted on chargemaster to indicate location of type of svc provided

Question 21

revenue cycle management

Accepted Answer

process by wh. facilities and providers ensure their financial viability by increasing revenue, improving cash flow and enhancing pt experience. Pt registration, w/ consents and ins. info - charge capture - coding - pt discharge processing - billing and claims processing - resubmitting claims - 3rd party payer reimbursement processing - appeals process - pt billing - pt reimbursement posting - collections - collections reimbursement processing - auditing process

Question 22

UB-04; Nat\'l Uniform Billing Committee

Accepted Answer

data entry blocks called form locators. NUBC responsible for identifying and revising UB-04 data elements

Question 23

allowable charge

Accepted Answer

maximum fee a physician may charge

Question 24

All Patient diagnosis-related group (AP-DRG)

Accepted Answer

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.

Question 25

ambulatory surgical center payment rate

Accepted Answer

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

Question 26

balance billing

Accepted Answer

A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patient\' health plan or other third-party payer (not allowed under Medicare or Medicaid)

Question 27

chargemaster (charge description master [cdm])

Accepted Answer

term hospitals use to describe a patient encounter form

Question 28

clinical laboratory fee schedule

Accepted Answer

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

Question 29

clinical nurse specialist (CNS)

Accepted Answer

is an APRN who is an expert clinician in a specialized area of practice (Fig. 1-1). The specialty may be identified by a population (e.g., geriatrics), a setting (e.g., critical care), a disease specialty (e.g., diabetes), a type of care (e.g., rehabilitation), or a type of problem (e.g., pain) (National CNS Competency Task Force, 2010). The CNS practice is in all health care setting

Question 30

CMS program transmittal

Accepted Answer

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

Question 31

conversion factor

Accepted Answer

dollar multiplier that converts relative value units into payments

Question 32

diagnostic and statistical manual

Accepted Answer

official criteria and classification system used by mental health professionals; published by the American Psychiatric Association

Question 33

disproportionate share hospital (DSH) adjustment

Accepted Answer

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

Question 34

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

Accepted Answer

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

Question 35

employer group health plan (EGHP)

Accepted Answer

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).

Question 36

grouper software

Accepted Answer

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 37

health insurance prospective payment system (HIPPS) code set

Accepted Answer

5 digit alphanumeric codes that represent case-mix groups about which payment determinations are made for the HIPPS

Question 38

Home Assessment Validation and Entry (HAVEN)

Accepted Answer

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

Question 39

incident to

Accepted Answer

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 40

indirect medical education (IME) adjustment

Accepted Answer

approved teaching hospitals received 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).

Question 41

inpatient prospective payment system (IPPS)

Accepted Answer

Medicare reimbursed hospitals for inpatient hospital services according to predetermined rates

Question 42

Inpatient Rehabilitation Validation and Entry (IRVEN)

Accepted Answer

A computerized data-entry system used by inpatient rehabilitation facilities (IRFs). Captures data for the IRF Patient Assessment Instrument (IRF PAI) and supports electronic submission of the IRF PAI. Also allows data import and export in the standard record format of the Centers for Medicare and Medicaid Services (CMS) Data collected is used to assess the clinical characteristics of patients in rehabilitation hospitals and rehabilitation units in acute care hospitals

Question 43

intensity of resources

Accepted Answer

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

Question 44

IPPS 3-day payment window

Accepted Answer

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 non-diagnostic) services when the inpatient principal diagnosis code (ICD-9-CM) exactly matches that for pre-admission services. (Same as IPPS 72-hour rule.)

Question 45

IPPS 72-hour rule

Accepted Answer

see IPPS 3 day payment window

Question 46

IPPS transfer rule

Accepted Answer

any patient with a diagnosis from one 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 patients stay not to exceed the prospective payment DRG rate

Question 47

large group health plan (LGHP)

Accepted Answer

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.

Question 48

limiting charge

Accepted Answer

The maximum amount a physician can charge

Question 49

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

Accepted Answer

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

Question 50

major diagnostic category (MDC)

Accepted Answer

organizes diagnosis related groups DRGs into mutually exclusive categories which loosely based on body systems

Question 51

Medicare severity diagnosis related groups (MS-DRGs)

Accepted Answer

adopted by Medicare in 2008 to improve recognition of severity of illness and resource consumption and reduce cost variation among DRGs

Question 52

nurse practitioner (NP)

Accepted Answer

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

Question 53

Outcomes Assessment Information Set

Accepted Answer

OASIS 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

Question 54

outlier

Accepted Answer

hospitals that treat unusually costly cases receive increased medicare payments

Question 55

outpatient encounter

Accepted Answer

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. (Same as outpatient visit.)

Question 56

payment system

Accepted Answer

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

Question 57

physician assistant (PA)

Accepted Answer

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.

Question 58

relative value units (RVUs)

Accepted Answer

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

Question 59

resident assessment validation and entry (RAVEN)

Accepted Answer

A computerized data entry system developed by CMS for SNF. It collects MDS assessments in a database and transmit them in CMS standard format to their state database.

Question 60

retrospective reasonable cost system

Accepted Answer

reimbursement system in which hospitals report actual charges for inpatient care to payers after discharge of patient from hospital. Payers then reimbursed hospitals 80 percent of allowed charges.

Question 61

revenue code

Accepted Answer

A four-digit number assigned to each service or item provided by the hospital that designates the type of service or where the service was performed.

Question 62

risk of mortality

Accepted Answer

likelihood of dying.

Question 63

severity of illness

Accepted Answer

The physiologic complexity that comprises the extent and interactions of a patient\'s disease(s) as presented to medical personnel

Question 64

wage index

Accepted Answer

Adjusts payment to account for geographic variations in hospitals\' labor cost.

Ch. 9 – CMS Reimbursement Methodologies – Flashcards

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