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PBT Billing/Coding
Medicare/Medicaide MHC
Term | Definition |
---|---|
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 |