Question 1

APC – Ambulatory Payment Classification

Accepted Answer

Hospital Outpatient Prospective Payment
System (HOPPS) classification that determines payment for outpatient services.

Question 2

APC Payment Group

Accepted Answer

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.

Question 3

ASC – Ambulatory Surgical Center

Accepted Answer

A place other than a hospital that performs outpatient
surgery, may be physician owned and operated.

Question 4

ASC Payment Group

Accepted Answer

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.

Question 5

Bundling

Accepted Answer

Combination of supply and pharmaceutical costs or medical visits with associated procedures or services for one lump sum payment.

Question 6

Carrier

Accepted Answer

Entity that has a contract with the Center for Medicare and Medicaid Services
(CMS) to determine and make Medicare payments for Part B benefits.

Question 7

CC – Comorbidities and complications

Accepted Answer

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.

Question 8

CMS – Center for Medicare and Medicaid Service

Accepted Answer

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.

Question 9

Charge Description Master

Accepted Answer

Database used by healthcare facilities to maintain the price
list for all services provided to patients.

Question 10

Commercial Insurer

Accepted Answer

A private insurance company that provides healthcare coverage to subscribers.

Question 11

CPT Code – Current Procedural Terminology Code

Accepted Answer

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.

Question 12

DRG – Diagnosis Related Group

Accepted Answer

Inpatient classification that categorizes patients who are
similar in terms of diagnosis and treatments, age, resources used, and lengths of stay.

Question 13

Fee Schedule

Accepted Answer

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.

Question 14

FI – Fiscal Intermediary

Accepted Answer

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.

Question 15

Global Period

Accepted Answer

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.

Question 16

HCPCS – Healthcare Common Procedure Coding System

Accepted Answer

Coding system created and maintained by CMS that provides codes for outpatient procedures, services, and supplies
not represented by CPT codes.

Question 17

HOPD – Hospital Outpatient Department

Accepted Answer

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.

Question 18

HOPPS/OPPS – Hospital Outpatient Prospective Payment System

Accepted Answer

Reimbursement system established by Medicare for services provided to Medicare patients in a hospital outpatient setting.

Question 19

ICD-10-CM – International Classification of Diseases 10th Revision

Accepted Answer

Clinical Modification – Coding and classification system used to report diagnoses in all healthcare settings.

Question 20

LCD – Local Coverage Determination

Accepted Answer

Reimbursement and medical necessity policies
established by Medicare Administrative Contractors (MACS) that vary from jurisdiction to
jurisdiction (group of states).

Term	Definition
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).

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Reimbursement

Terminology Covering Reimbursement for Acute and outpatient