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STACK 6
AAHAM CRCS STACK 6
| Question | Answer |
|---|---|
| What does SNF-PDPM stand for and describe | SNF-patient driven pmt model pts are classified in diff pmt groups cld Case Mix Groups (CMG's) using 6 components: 5 are case mix adjustments to cover SNF resources that vary by pt characteristic. 1 is to address SNF resources that do not vary by case. |
| What does MPPS stand for? | Medicare Payment Prospective System pmt system in which MC will pay based on a predetermined, fixed amt. There are several pmt formulas. |
| What does APC stand for and what is required to assign an APC? | Ambulatory Pmt Classification - CPT/HCPCS codes E&M codes Reason for visit (ICD-10/dx codes) Site of svc (some sites are exempt from APC's) |
| What does MS-DRG stand for and how does it work? | MC Severity DX Group 25 major diagnostic categories (MDC) Each category considers age, dx (severity and comorbidity) discharge disposition and procedure Outlier may be pd for very high charges Most widely used Can file adj up to 60 days after EOB |
| What is the OPPS and to whom does it apply? | OP Prospective Pmt System Implemented under MC by CMS under the Balanced Budget Act of 1997. Hospital OP svcs, certain part B svcs furnished to inpts w/ no part A cov, partial hospitalization svcs furnished by comm mental health centers |
| What does NDC stand for? | National Drug Code Unique 11 digit number w/ 3 segments: 1st = labeler (manufacturer/distributor) 2nd = Type of product 3rd = size/type of package |
| What does HCPCS stand for? | Healthcare Common Procedure Coding System |
| What are the 3 levels of HCPCS? | 1. CPT codes - 5 digit number for svc/proc perf by physicians and other HC pro's 2. 5 digit numeric w/ alpha prefixes A-V - supplies/svcs not in CPT codes (DME, Ambo, Supplies) 3. Local codes, at state level by MA to designate addt'l svcs. Prohibited un |
| What does NPI stand for and what are taxonomy codes? | -National Provider Number - 10 digits, issued by CMS -administrative codes to ID practitioner type, specialty. A hierarchical code consisting of codes, descriptions and definitions. |
| What are the 3 different RVU's associated with calculating a payment under MPPS? | RVU - Relative Value Unit 1. Work Required (Work RVU) 2. Practice Expense (PE) Malpractice Ins Expense (MP) These amounts make up the fee schedule and is how MC pays physician fees. |
| What does HIPPS stand for? RUG? | Health Ins Prospective Pmt Systems used by SNF's and have 5 digits, 2 components: 3 digit classification code assigned to each RUG (Resource Utilization Group) 2 digit assessment indicator, specifies type of assessment used to support the billing. |
| What are UCR Charges? | Usual, Customary and Reasonable. - used by many 3rd party payers (commercial, liability, WC) -relies on physician charge data accumulated over time. - ranks the charges for a given svc from low to high & uses a specific % as the basis for UCR pmts. |
| What is the Resource Based Relative Value Scale? | Scale on which MC pays physician svcs. 3 major elements: 1. Fee sched based on RVU 2. MC volume performance standard (MVPS) for rates of incr in MC expenditures 3. Limit on amts non-participating phys can charge |
| Who is exempt for Outpatient prospective payment systems? | Critical access hospitals Certain hospitals in MD Cancer hospitals IHS Facilities |
| Who is affected by Outpatient prospective payment systems? | Acute Care Hospital OP svcs Hospitals and distinct part hospital units exempt from IP PPS Partial hospitalization programs associated with community health centers |
| When will MC pay an IP procedure on an OP claim? | When the pt dies prior to admission - bill w/ IP CPT, use CA modifier. |
| What are the elements of the Chargemaster and what fields are they on the UB-04? | Fields 42-49 - Dept # Rev code -CM numbers Charge Description Charge Amt CPT/HCPCS codes Modifiers GL # |
| What does CDM stand for? REVIEW AT LEAST ANNUALLY | Chrg Description Master: E-file residing in prov info system w/ chrgs that can be posted to pt acct. Ea item has a sys entry to include price & description & CPT/HCPCS codes. ID's the GL acct it impacts and, for drugs and supplies, inv info. |
| Fee for Service | Oldest Method of payment. Provider is pd for each medical svc rendered to a pt. |
| Per Diem | Provider is paid per diem for each day a pt is inpatient regardless of actual charges/cost. can vary based on svc or be uniform regardless of intensity of svc. |
| Capitation | Provider is pd a set $ amt for each pt for a specific time period, which covers all care for that group of patients. Claims must still be submitted for records purposes. |
| What does CAH stand for and describe: | Critic Access Hospital Must be > 35 mile drive from hospital or CAH < than 26 IP beds, can be used for swing bed svcs ALOS of 96 hrs or less for acute care. may operate a distinct part rehab/phych unit up to 10 beds ea. must furnish 24/7 er care. |
| Define POA indicators Define HAC | Present on Admission Helps ID non-payable complications such as HAC's Hospital acquired conditions (ex - infections acquired in hospital, sponges left in pt) |
| What is a conditional payment? | When another payer is responsible but is not expected to pay promptly (w/i 120days of receipt) MC might make a conditional pmt (must indicate conditional pmt code on the claim). This is to prevent pt from paying OOP. |
| Rules for having 2 commercial plans (COB decisions) | - person's own employer is primary to spouse's employer. - child is covered by parent's ins whose bday comes first in the year. If divorced, child is covered by parent w/ custody, then that parent's new spouse, then the parent without custody. |
| What does COB stand for and explain | Coordination of Benefits Defined on CMS site as a program that determines which plan or ins policy will pay 1st. If 1 plan is MC, federal law may decide which pays first. |
| E&M - what does it stand for and what are the levels? | Evaland & Mgmnt. Process of & chrg for examining a pt and developing a plan of trmt based on: Hist, Exam, Med decision making (these are the 3 key components in deciding which charge to use) Counseling, coordination of care, nature of prob, time spent |
Created by:
Amy17349
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