Acute Care PPS
Total Relative Weight/Total Volume
What is Case Mix Index
RBRVS - which codes set is utilized to report services and procedures?
Name the RVU elements
What pays likely payer a higher fee? Facility or NonFacility
HCPCS/CPT
W*PE*MP
NonFacility- Can you explain why?
•Data collection tool used in a SNF
•Extensive database of clinical data that represents documentation of the resident’s care and is part of the health record
• Patient assessments must be completed within required time frames
what is
–Minimum Data Set (MDS) 3.0
KPIs are used for what?
Used by RCM or providers to decide on what optimal performance(s) are necessary for units of their facility?
Reward-based models and penalty-based models
What are the two major categories of pay-for-performance models?
–Definition: established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
Principal Diagnosis
The Fee associated with an RVU is aka?
How can physician payments be adjusted for the price differences among various parts of the country?
What is the most efficient way for US Congress to alter the Physician Payments
What is the Medicare Fee Schedule?
GPCI
Alter the Conversion Factor
Structure of Payment within a SNF uses a
_____ _______ group and Adjusts the base rate for patient resource intensity with 3 components
Nursing, Therapy & non-case-mixed adjusted component
what is a RUG
Resource Utilization Group
a. HIPAA requires all healthcare facilities to use standardized code sets (i.e. ICD-10-CM and CPT) & what else related to claims submission?
b. if CMS release of updates to codes and billing guidance -or- a new service(s) will be provided at your facility...which department will be responsible the "fee" and it's necessary information (description, CPT code, Revenue Code)
c.Will the ChargeMaster include ICD-10-CM?
a. HIPAA requires an ELECTRONIC claim Submission
b. Charge Master
c. NEVER
The CMS quality reporting program is a ___ for reporting program. Each facility must report quality data that meets certain requirements. If the facility submits data on time and in accordance with regulations, then the facility will receive full reimbursement for the services they provide in a designated future rate year
Pay for Reporting
Refinement –Various questions are used to isolate the correct MS-DRG assignment.
•This process allows the MS-DRG system to group together like patient from the clinical perspective with like resource consumption.
what is Step 4 to a DRG?
Can a patient be charged a professional charge and a Facility(technical) charge for the same service?
Is Radiology a good example?
What are te names of the required claim forms?
what modifiers would be used?
Yes.
Radiology is the perfect example
CMS 1500-for professional
UB04-for Technical
26 Pro & TC for Tech
In most situations, for a facility to be defined as an LTCH, the lengths of stay of its Medicare patients must be at least how long?
25 days or longer
The ___ is a unique identification number for covered health care providers. All covered health care providers and all health plans and health care clearinghouses must use the ___s in the administrative and financial transactions adopted under HIPAA. The ___ is a 10-position, intelligence-free numeric identifier (10-digit number).
National Provider Identifier Standard (NPI)
a. The term for the process of identifying the clinician who provided the care, is responsible for the care’s quality, and is accountable for the care’s cost?
b.Measurement, transparency, and accountability
a. what is Attribution
b. What are three fundamental characteristics that value-based purchasing (VBP) and pay-for-performance (P4P) systems share?
IPPS Provision w/
–High percentage of low income patients
–Additional payment
–Adjustment is hospital specific
•Bed size & Hospital type (rural, sole community, urban)
•Disproportionate share hospital status (DSH)
•Significant procedures with status (__) are paid at a reduced rate when performed with other procedures during the same visit
•Significant procedures with status (__) are not discounted when multiple procedures are performed
•Services with a status (N) are bundle into other APCs and are considered incidental
T
S
N - aka Nope! Not happening
a.The tool that drives payment, and is used to collect information about Medicare patients in the IRF PPS?
b.In an IRF, on what tool is are patients’ abilities to perform activities of daily living recorded?
a.what is the PAI or Inpatient rehabilitation facility patient assessment instrument (IRF PAI)
b. What is the Functional Independence Measure (FIM) Assessment
Medicare Coverage Determination Process -Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process. In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on what?
LCD - Local Coverage Determination
The term for a model of primary care that seeks to meet the health care needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency?
what is patient-centered medical home
In which government publication are the details about the various PPS introduced, commented on and finalized?
Federal Register
Which statement(s) are true
An ASC must have a sole purpose of delivering services in connection with surgical procedures that do not require inpatient hospitalization
An ASC must maintain its own licensure and accreditation
Both are true
a. The tool does CMS require that home health agencies use to collect and to report clinical data on patients?
b. In Medicare’s PPS system for home health services, what software is used to electronically submit data?
c. Is DME is EXCLUDED from the HHPPS?
a.Outcome Assessment and Information Set (OASIS)
b. Home Assistance Validation and Entry (HAVEN)
c. Yes ...it is True
Medicare Notice __also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service.
What is An Advance Beneficiary Notice (ABN)
CMS-identified “Hospital-Acquired Conditions” means that when a particular diagnosis is not “present on admission” CMS determines it to be
what is reasonably preventable