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Reimbursement

Terminology Covering Reimbursement for Acute and outpatient

TermDefinition
APC – Ambulatory Payment Classification Hospital Outpatient Prospective Payment System (HOPPS) classification that determines payment for outpatient services.
APC Payment Group Basic unit of the APC system that groups diagnoses and procedures that are similar in terms of resources used, complexity of illness, and conditions represented, into an APC group where only one payment is made for outpatient services provided.
ASC – Ambulatory Surgical Center A place other than a hospital that performs outpatient surgery, may be physician owned and operated.
ASC Payment Group Payment made to an Ambulatory Surgery Center for facility-related costs. Procedures that are classified as ASC procedures are classified into a payment group which has a fixed payment rate.
Bundling Combination of supply and pharmaceutical costs or medical visits with associated procedures or services for one lump sum payment.
Carrier Entity that has a contract with the Center for Medicare and Medicaid Services (CMS) to determine and make Medicare payments for Part B benefits.
CC – Comorbidities and complications A comorbidity is an additional diagnosis that describes a pre-existing condition that because of its presence with a specific principal diagnosis will likely cause an increase in the patient's length of stay in the hospital.
CMS – Center for Medicare and Medicaid Service A division of the Department of Health and Human Services (DHHS) that is responsible for administering the Medicare program and the federal portion of the Medicaid program.
Charge Description Master Database used by healthcare facilities to maintain the price list for all services provided to patients.
Commercial Insurer A private insurance company that provides healthcare coverage to subscribers.
CPT Code – Current Procedural Terminology Code A code that represents a procedure or service that is consistent with contemporary medical practice and is performed by many physicians in clinical practice in multiple locations.
DRG – Diagnosis Related Group Inpatient classification that categorizes patients who are similar in terms of diagnosis and treatments, age, resources used, and lengths of stay.
Fee Schedule Third party payor’s predetermined list of maximum allowable fees for each healthcare service, method in which physicians are reimbursed for Medicare Part B services.
FI – Fiscal Intermediary Intermediaries are public or private insurance companies that contract with CMS to act as agents of the federal government in dealing directly with participating providers of Medicare services.
Global Period A Medicare payment policy that states that the global surgical fee includes both the procedure itself and all associated related services and visits that occur within a designated period of time.
HCPCS – Healthcare Common Procedure Coding System Coding system created and maintained by CMS that provides codes for outpatient procedures, services, and supplies not represented by CPT codes.
HOPD – Hospital Outpatient Department A hospital department/unit where non-urgent ambulatory medical care is provided. The outpatient clinic provides diagnosis and care for patients that do not need to stay overnight.
HOPPS/OPPS – Hospital Outpatient Prospective Payment System Reimbursement system established by Medicare for services provided to Medicare patients in a hospital outpatient setting.
ICD-10-CM – International Classification of Diseases 10th Revision Clinical Modification – Coding and classification system used to report diagnoses in all healthcare settings.
LCD – Local Coverage Determination Reimbursement and medical necessity policies established by Medicare Administrative Contractors (MACS) that vary from jurisdiction to jurisdiction (group of states).
Created by: nathlauer77