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Health Ins. and Claims Chapter 9

What is a state licensed, Medicare certified supplier of surgical healthcare services that must accept assignment on claims? Ambulatory Surgical Center (ASC)
In IPPS, this is an indicator to differentiate between conditions present upon admission and those that develop during the hospital stay. Present on Admission (POA)
Medicare reimburses laboratory services based on what? submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest
How does Medicare reimburse DMEPOS? 80% of the acutal charge amount or the fee schedule amount, whichever is lowest
In the Home Health PPS, patient assessments are completed using what? Outcomes and Assessments Information Set (OASIS)
In the IPPS what rule requires outpatient pre-admission services provided by a hospital up to 3 days prior to the patient's admission to be covered by the IPPS payment. IPPS 72-hour Rule, or IPPS 3-day window Rule
Medicare reimbursement for physician's services is based on Relative Value Units assigned to each service/procedure consisting of what? physician work expense, practice expense, and malpractice expense
This is a condition that arises during the hospitalization that can change the patient's outcome or may require additional treatment. complication
This is a pre-existing condition treated during the hospitalization, but may not be what required the hospitalization. co-morbidity
Medicare non-par physicians are held to a limiting charge amount. This is what perentage of the non-par Medicare physician'sfee schedule amount? 115%
NPPS can bill services provided to Medicare beneficiaries as what? It means that their services are bille dunder a supervising physician. incident to
Home Health services are reimbursed based on each___________ episode of care. 60-day
DRGs are organized into what? major diagnostic categories (MDC)
IPPS adjustment available for hospitals that treat a high-percentage of low-income patients. Disproportionate share hospital (DSH)
IPPS adjustment for hospitals that treat unusually costly cases. Outliers
IPPS adjustment for approved teaching hospitals. Indirect medical education (IME)
Medical Severity diagnosis-related groups MS DRGs
What classification system is used for the Inpatient PPS? MS DRG
What classification system is used for the Physician Fee Schedule payment system? Resource Based Relative Value System (RBRVS)
What classification system is used for the Outpatient PPS? Ambulatory Payment Classifications (APCs)
What classification system is used for the Skilled Nursing PPS? Resource Utilization Groups (RUGs)
What classification system is used for the Home Health PPS? Home Health Resource Groups (HHRGs)
What is a measure of the types of patients treated, and reflects a patient utilization of varying levels of healthcare resources for a facility? case mix
This determines appropriate group (e.g. MS DRG, HHRG, and so on) to classify a patient after data about the patient is input. grouper software
Predetermined reimbursement methodology payment system
Extent of physiological decompensation or organ system loss of function severity of illness
Hospitals use this to describe their patient encounter form. chargemaster
Date elements collected by long-term care facilities. Minimum data set (MDS)
What do institutional and other selected providers submit their claim data on to payers for reimbursement of patient services? UB-04
What does the acronym NPP stand for? Nonphysician practitioner
Name three nonphysician practitioners nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA)
Created by: Kcompleta