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Ch9-12 Reimburstment
| Question fac | Answer |
|---|---|
| are also was established in advance, but they are based on reported health care costs from which predetermined per diem rate is determined. | Prospective cost-based rates |
| are associated with a particular category of patient and rates are established by the payer prior to the provision of health care services. | Prospective price-based rates |
| Federal health care programs are | CHAMPVA, Indian Health Service,Medicaid,Medicare,TRICARE,Workers Compensation |
| payment system for ambulance services provided to medicare beneficiaries *cost-based | Ambulance Fee Schedule |
| predetermined amount for which ASC services are reimbursed at 80% after adjustment for regional wage variations *Cost-based | Ambulatory Surgical Center payment rates |
| is a data set based on local fee schedules patient clinical diagnostic laboratory services was established in 1984 *cost-based | Clinical Laboratory Fee Schedule |
| dealers according to either the actual charge or the amount calculated according to formulas that use average reasonable charges for items during a base period form 1986 to 1987 whichever is lower *cost-based | Durable Medical Equipment,Prosthetics/Orthotics,supplies Fee Schedule |
| chronic kidney disorder that requires long-term hemodialysis or kindney transplantation bc the patien's filtration system in the kidneys has been destoryed *Price-based | End-Stage Renal Disease Composite Payment Rate System |
| reimbursement methodology for home health agencies that uses a classification system called home health resource groups which establishes a predetermined rate for health care services provided to patients for each 60 day episode of home health care *Pr | Home Health Prospective Payment system |
| System in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge *Price-based | Hospital Inpatient Prospective Patient System |
| uses ambulatory payment classifications to calculate reimbursement was implemented for billing of hospital based medicare outpatient claims *Price-based | Hospital Outpatient Prospective Payment System |
| system in which medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use and costs *Cost-based | Inpatient Psychiatric Facility Prospective Payment System |
| implemented as a result of the BBA if 1997 utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. *Price-based | Inpatient Rehabilitation Facility Prospective Payment System |
| Classifies patients according to long-term care DRGs which are based on patients clinical characteristics and expected resourse needs replaced the reasonable cost-based payment system *Price-Based | Long-Term are Hospital Prospective Payment System |
| to cover all costs related to services furnished to medicare part A beneficiaries *Cost-based | Skilled Nursing Facility Prospective Payment System |
| payment system that reimburses physicians practice expenses based on relative values for three components of each physicians services: physician work,practice expense, and malpractice insurance expense *Cost-based | Resource-Based Relative Value Scale System |
| is a measure of the types of patients treated, and it reflects patient utilization of varying levels of health care resources. Patients are classified according to age,gender,health status. | Case mix |
| group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcomes-based quality improvement. | Outcomes Assessment information Set (OASIS) |
| data entry software used to collect Oasis assessment data for transmission to state databases | Home Assessment Validation and Entry (HAVEN) |
| which is based on the patients principal and secondary diagnoses as well as principal and secondary procedures. it determines how much payment the hospital receives. | Diagnosis-related group (DRG) |
| indicator differentiates between patient conditions present upon inpatient admission and those that develop during the inpatient admission. | Present on admission (POA) |
| which group services according to similar clinical characteristics and terms of resources required. | ambulatory payment classifications |
| to determine an IPPS payment,hospitals submit a UB-04 claim each patient to a ____ which is a third party payer that contracts with medicare to carry out the operational functions of the medicare program. | Medicare administrative contractor (MAC) |
| requires outpatient preadmisson services provided by a hospital up to be covered by the IPPS | IPPS 3 payment window |
| classifies mental health disorders and based on ICD,published by the American psychiatric association | Diagnostic and statistical manual (DSM) |
| is the computerized data entry system used by inpatient rehabilitation facilities to create a file in a standard format that be electronically transmitted to a national database | Inpatient Rehabilitation Validation and Entry (IRVEN) |
| dose not accept assignment from medicare, which means the amount medicare reimburses for services provided is subject 5% reduction of the medicare physician fee schedule | Nonparticipating Physicians |
| contains the diagnostic statement and may include physician's rationale for the diagnosis | assessment |
| review if patient records and CMS-1500 claims to assess coding accuracy and whether documentation is complete | auditing process |
| medicare administrative contractors create edits for national coverage determination rules that are | local coverage determination |
| a particular diagnosis may not receive direct treatment during an office visit | medically managed |
| using paragraph format to document haelth care | narrative clinic note |
| rules developed by cms that specify under what clinical circumstances a service or procedure is covered and correctly coded | national coverage determination |
| documentation of measurable or objective observations made during physical examination and diagnostic testing | objective |
| varies from a short narrative description of a minor procedure that is performed in the physicians office to a more formal report | operative report |
| software that edits outpatient claims submitted by hospitals community mental health centers | outpatient coder editor |
| statement of the physicians future plans for the work-up and medical management of the case | plan |
| outline format for documenting health care | soap notes |
| part of the note that contains the chief complaint and the patients description of the presenting problem | subjective |
| the legal business name of the providers practices | billing entity |
| items numbers 1 through 4 preprinted in block 21 of the cms-1500 claim | diagnosis pointer number |
| implemented to improve accuracy of medicare payments by detecting and denying unlikely medicare claims on prepayment basis | medically unlikely edits projects |
| supplemental plans designed by the Federal government but sold by private commercial insurance companies to cover the costs of medicare deductibles | medigap |
| developed by cms to assign unique identifiers to health care provider and health plans | National Plan Provider Enmeration |
| device used for optical character recognition | optical character reader |
| uses a device to convert printed or handwritten characters into text that can be viewed by an optical character reader | optical scanning |
| covers the deductible and copay or coinsurance of a primary health insurance policy | supplemental plan |
Created by:
RHIT2010