Prospective Payment Model Systems

Acute Care

100

I am a per _____ system and my grouping name is? 

Discharge ; DRG

200

This begins when admitted to acute care and ends when the patient has been out of the hospital or subacute for 60 consecutive days 

illness episode 

300

This program issues a reduction of payment up to 3% to all medicare payments if a hospital sees an increased amount of "recurrent" patients for the same diagnosis 

Readmission Reduction Program 

400

In determination of hospital payment what happens if a patient is transferred? 

Payment is split between the facilities based on what services were provided 

500

If these hospital acquired conditions are shown to increase or have a high prevalence it will cause a 1% reduction in payment to hosptials who are the worst performing 

CLASBI, CAUTI, SSI, MRSA, C-diff 

Inpatient Rehab

100

This rule requires that most of diagnosis be from the list of 13 

60% rule

200

what is the intensity of therapy services required? 

3hrs / 5 days a week 

300

Under conditions of particpation what needs to happen within 4 days? once a week? within 36 hours? 

Individualized POC ; Interdisciplinary team meeting ; submission of IRF-PAI

400

This is the grouping that determines payment based on diagnosis, age, functional and cognitive status 

Case Mix Groups (CMG) 

500

What are he 4 items that are proposed to be added to IRF-PAI in 2025? 

living situation, food, utilities, transportation 

SNF/subacute

100

I am a per ____ payment 

diem

200

After day 20, what is the payment of medicare and beneficiary? 

medicare = 100% after copay; beneficiary = $204 per day 

300

admission to this facility must be within ____ days of a ___ day qualified stay 

30 ; 3 

400

I am equivalent to the IRF-PAI but for subacute 

Minimum Data Set - MDS 

500

the payment model that is specific to the individual 

patient driven payment model 

Home Health

100

what is the name of my grouping?

HHRG - home health realted group

200

what is the homebound criteria? 

patient needs a device/person in order to leave or medical condition prohibits them from leaving 

300

what services are covered? 

part-time/intermittent skilled nursing care, part-time/intermittent HH aide, PT/OT/SLP, medical social services 

400

The patient driven group model takes into account what for payment for a 30-day episode of care? 

admission source/timing, clinical grouping, OASIS, comorbidity adjustment, HHRG 

500

What is the tool that is used in the OASIS and the other evaluation tools across the settings? 

CARE tool