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PBT Billing/Coding

Medicare/Medicaide MHC

TermDefinition
PPS Prospective Payment System: 1983 to limit & standardize Medicare/Medicaid pymts made to hospitals.
DRGs Diagnostic-related groups: Hospitals are reimbursed a set amt. per pt. procedure using Established disease categories (AHA established)
APC Ambulatory Patient Classification: System implemented in 2000 for determining pymts to HC facilities for Medicare/Medicade pt.'s only.
Fee for Service Traditional pymt model of reimbursement for HC service after service is rendered.
ICD International Classification of Diseases
ICD-9-CM 9th revision Clinical Modification: Used in past by all major payers. Grouped similar diseases and operations for reimbursement.
ICD-10-CM 10th revision Clinical Modification: For coding of Dx. Contains more codes & covers more content than ICD-9.
ICD-10-PSC 10th revision Procedural Coding System: Procedural Classification system used only in U.S. inpatient hospital settings. Much broader range of codes with room for expansion and specificity.
PCS In 2014, goal of HIPAA was to move to one universal procedural coding system (PCS) as the future standard.
CMS Centers for Medicare and Medicaid Services: Replaced the list of procedure codes in the ICD-9-CM with new code set: PCS aka ICD-10-PCS. Must be used by all HIPAA covered entities. ICD-9 can no longer be used.
CPT Current Procedural Terminology: codes orig. dev. in 1960s by the AMA to provide a terminology & coding system for physician billing. (classify, billing, reporting)
MEDICARE 1965. Fed. funded (65+ & disabled) Entitlement program is a right earned via employment. Financed through Soc Sec payroll deductions/copayments Benefits (2 categories) Part A (hospital) Part B (supplementary medical insurance or SMI) which is optional.
MEDICAID 1965. Fed/State program provides medical assistant for low-income Americans. No Entitlement; must prove eligibility. Funds come from Fed. Grants/State/Local Govt.'s & administered by the state.
AHCCCS Arizona Health Care Cost Containment System: Differs in that providers (private phys. groups) must bid annually for contracts to serve this populations. Pt's able to choose HC Provider via annual open enrollment.
ACO Accountable Care Organization: A network of hospitals, phys. & providers. voluntarily offer to coordinate care for Medicare patients. Jointly accountable for health of pt., & giving them financial incentive to cooperate/share info/avoid tests & expense.
Managed Care Generic term for a pymt. system attempting to control cost & access to health care. Strive to meet high-quality standards via limiting providers used by pt., PCP use as gatekeepers to control referrals, utilize review of all HC services.
Case Management Primary Care PCP; gatekeeper, responsible for coordinating all of a pt.'s health care. Not always a physician.
MCOs Managed Care Organizations: evolved rom prepaid HC plans (ex. HMOs and PPOs.) Contract w/ local providers to est. a complete network of services to reduce total cost of care, while maintaining pt. satisfaction. Right care from right provider at right time
HMOs Health Maintenance Organizations: Group practices reimbursed on a prepaid, negotiated and discounted basis of admission.
PPOs Preferred Provider Organizations: Independent groups of phys. or hospitals offering services to employers at discounted rates in exchange for steady supply of patients.
IDNs Integrated Delivery Networks aka IDSs Integrated Delivery Systems: includes a # of assoc. medical facilities which furnish coordinated HC services from pre-birth to death. Ex. Acute Care, AMB surgery Centers, Phys. Offices, OP clinics, Pharmacy, Rehabs
SNFs Skilled Nursing Facilities
MD Doctor of Medicine
DO Doctor of Osteopathy
HOSPITALS: 4 main characteristics Permanent Inpatient beds. 24 hour nursing services. Therapeutic/Diagnostic services. Organized Medical Staff. 24/7 functionality.
CLS (Labs) Clinical Laboratory Services: perform tests on pt. specimens.
Traditional Labs - 2 major divisions 1. Clinical Analysis Area 2. Anatomical & Surgical Pathology Area
Created by: MCasler