Medicare Medicaid Prospective Payment Ch 6 – Flashcards
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Which Congressional act called for the creation of a PPS for the psychiatric inpatient setting?
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Balanced Budget Refinement Act of 1999
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Select the highest level of the IPPS hierarchy:
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Major diagnostic category
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Which is the correct formula for wage index adjustment?
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(payment rate * labor portion * WI) + (payment rate * labor portion) (payment rate * labor portion * WI) + (payment rate * non-labor portion)
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How are per-diem rates for SNF PPS patients determined for various cases?
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Per-diem rates are case mix adjusted using the fifty-three groups of the refined RUG-III.
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Describe at least two of the patient-level adjustments for IPF PPS claims and why they are used.
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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.
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Why does the IPF PPS length-of-stay adjustment factor grow smaller during the patient encounter?
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Cost regression indicated that the per-diem cost for psychiatric cases decreased as the length of stay increased
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List the steps of MS-DRG assignment.
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Pre-MDC Assignment MDC Determination Medical/Surgical Determination Refinement
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steps of MS-DRG
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The four steps for assigning MS DRGs are Pre-MDC Assignment this step determines if the encounter qualities for MS-DRG if it does then this process are complete. Step two would be the MDC determination, her e the principal diagnosis is used to place the encounter into one of the 25 MDC categories the step two is complete. Step three would Be Medical / Surgical determination, here if there was a procedure preformed and it qualifies for and OR procedure it is assigned a surgical status. If it does not qualify for an OR procedure then it is assigned a medical status. Step four is refinement and it is used to isolate he correct MS-DRG.
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Which of the following points is a guideline for the acute hospital prospective payment system?
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) Incentive for cost control because hospitals retain profits or suffer losses based on differences between payment rate and actual costs
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List at least two major reasons that Medicare administrators turned to the prospective payment concept for Medicare beneficiaries.
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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.
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Why was a severity of illness refinement performed on the DRG system? Was it supported by the healthcare community?
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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.
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Medicare inpatient reimbursement levels are based on _______.
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MS-DRG calculated for the encounter
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Why was the initial stay and readmission provision included in the IPF PPS?
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CMS did not want to provide an incentive for facilities to prematurely discharge patients and then subsequently re-admit them since the length of stay adjustment is weighted heavier for the beginning days for an admission.
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What is the average of the sum of the relative weights of all patients treated during a specified time period?
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Case mix index
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Describe at least two of the patient-level adjustments for IPF PPS claims and why they are used.
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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.
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How do DRGs encourage inpatient facilities to practice cost management?
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Because DRGs are a fully packaged system, the predetermined payment for each 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.
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New medical technologies are often very expensive. What is the CMS' position on the use of new technologies to treat Medicare beneficiaries?
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CMS encourages the use of new technologies through a regulatory process that formally identifies a status of "new technology" and, thereby, allows a payment for the full DRG plus 50 percent of the new technology's cost.
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Which of the following is NOT a provision of the IPPS?
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Length of stay outlier
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. A Medicare patient was discharged from one acute IPPS and admitted to another acute IPPS hospital on the same day. How will the two acute IPPS hospitals be reimbursed?
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The first hospital receives a per-diem payment derived from the potential MS-DRG and the second hospital receives the full MS-DRG.
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In the IPPS, what is the term for each hospital's unique standardized amount based on its costs per Medicare discharge?
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Base payment rate
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In MS-DRGs, for what is the case mix index a proxy?
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Consumption of resources
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What condition does CMS require be met for a facility to receive the indirect medical education adjustment?
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Medical residents in an approved graduate medical education program
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What is the general term for software that assigns inpatient diagnosis related groups?
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Grouper
