Health Ins. and Claims Chapter 9
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| What is a state licensed, Medicare certified supplier of surgical healthcare services that must accept assignment on claims? | Ambulatory Surgical Center (ASC)
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| 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)
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| Medicare reimburses laboratory services based on what? | submitted charge, national limitation amount, or local fee schedule amount, whichever is lowest
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| How does Medicare reimburse DMEPOS? | 80% of the acutal charge amount or the fee schedule amount, whichever is lowest
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| In the Home Health PPS, patient assessments are completed using what? | Outcomes and Assessments Information Set (OASIS)
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| 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
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| 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
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| This is a condition that arises during the hospitalization that can change the patient's outcome or may require additional treatment. | complication
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| This is a pre-existing condition treated during the hospitalization, but may not be what required the hospitalization. | co-morbidity
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| 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%
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| NPPS can bill services provided to Medicare beneficiaries as what? It means that their services are bille dunder a supervising physician. | incident to
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| Home Health services are reimbursed based on each___________ episode of care. | 60-day
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| DRGs are organized into what? | major diagnostic categories (MDC)
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| IPPS adjustment available for hospitals that treat a high-percentage of low-income patients. | Disproportionate share hospital (DSH)
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| IPPS adjustment for hospitals that treat unusually costly cases. | Outliers
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| IPPS adjustment for approved teaching hospitals. | Indirect medical education (IME)
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| Medical Severity diagnosis-related groups | MS DRGs
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| What classification system is used for the Inpatient PPS? | MS DRG
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| What classification system is used for the Physician Fee Schedule payment system? | Resource Based Relative Value System (RBRVS)
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| What classification system is used for the Outpatient PPS? | Ambulatory Payment Classifications (APCs)
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| What classification system is used for the Skilled Nursing PPS? | Resource Utilization Groups (RUGs)
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| What classification system is used for the Home Health PPS? | Home Health Resource Groups (HHRGs)
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| 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
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| 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
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| Predetermined reimbursement methodology | payment system
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| Extent of physiological decompensation or organ system loss of function | severity of illness
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| Hospitals use this to describe their patient encounter form. | chargemaster
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| Date elements collected by long-term care facilities. | Minimum data set (MDS)
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| What do institutional and other selected providers submit their claim data on to payers for reimbursement of patient services? | UB-04
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| What does the acronym NPP stand for? | Nonphysician practitioner
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| Name three nonphysician practitioners | nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA)
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