Term
|
Definition
| Diagnosis related groups. Determine Medicare inpatient hospital reimbursement. |
|
|
Term
|
Definition
| a fixed amount for inpatient services based on the severity-adjusted diagnostic group. |
|
|
Term
| CMS changed the payment methodology in 2009 to |
|
Definition
| Medicare Severity-Diagnosis Related Groups (MS-DRGs) to improve the explanation of cost variation by 9.1 percent over the standard CMS DRGs. |
|
|
Term
| The improvement in cost variation |
|
Definition
| recognizes severity of illness and resource usage more appropriately. More for sicker and less for less complex care. |
|
|
Term
|
Definition
| The prospective payment system used by Medicare and many other payers for inpatient payments. |
|
|
Term
|
Definition
| a fixed amount based on MS-DRG. |
|
|
Term
| Omnibus Budget Reconciliation Act of 1986 (OBRA '86) |
|
Definition
| Marked the congressional request for an outpatient prospective payment system to be developed. |
|
|
Term
| An outpatient facility model was developed by |
|
Definition
| 3m Health Information Systems (3m HIM): The outpatient Prospective Payment System. (OPPS) |
|
|
Term
| Prospective Payment System |
|
Definition
| is a reimbursement method in which payment is a pre-determined, fixed amount based on a classification system of service. |
|
|
Term
| Ambulatory Patient Group (APG) |
|
Definition
| system created in 1990 by 3M HIS which several non medicare payers have implemented. (medicaid, BCBS) |
|
|
Term
| For Medicare how is each claim paid for outpt facility reimbursment? |
|
Definition
| Each Claim is paid based on the determined interim out patient reimbursement rate |
|
|
Term
| Which Ancillary Service is not subject to APC reimbursement? |
|
Definition
| Occupational, Speech, and physical therapy |
|
|
Term
| Special payments under OPPS may be made for new technology items under what circumstance? |
|
Definition
| Pass-through paymetns for certain drugs, biological agents, brachytherapy devices, and other medical devices for a period of at least two years but no more than three years |
|
|
Term
| Medicare reimbursable drugs are found in this code book? |
|
Definition
|
|
Term
| Which Service is reimbursed based on the APC payment method? |
|
Definition
| Patient X-ray of left foot in the outpatient department |
|
|
Term
| Packaged services include? |
|
Definition
| OR, procedure room, txt room, recovery room, and materials, including supplies and equpiment for the administration and monitoring of anesthesia, observation services, certain pharmaceuticals, drugs, and bilogicals, Ancillary services, clinical dx laboratory tests, procedures described by add on codes, implantable medical devices, guidance svcs, image processing svcs, intraoperative svc's, imaging supervision and interpretation svc's, professional services, such as anesthesia professional svc's |
|
|
Term
| By what payment method is the inpatient hospital facility reimbursed by Medicare? |
|
Definition
|
|
Term
|
Definition
| Is an unadjusted national payment that includes beneficiary copayment and the medicare paymetn |
|
|
Term
| Medicare part B pays which out patient svcs? |
|
Definition
emergency rooms
clincial visits
blood and blood products
x ray's
ambulance svc's |
|
|
Term
| Medicare assigns paymetn status indicator svcs to CPT and HCPCS lvl II codes provided in? |
|
Definition
|
|
Term
| What services are not paid under other Medicare paymetn systems? |
|
Definition
| Preventive injections/vaccines from a home health agency if not paid under a home health care plan |
|
|
Term
| Pass-through paymetns are? |
|
Definition
| additional payments made for certain drugs, biologicals, and medical devices |
|
|
Term
| The cost to charge ratio is used to determine? |
|
Definition
| outlier payments and payments for pass-through devices |
|
|
Term
|
Definition
| using the APC status indicator methodology |
|
|
Term
| The implementation regulations for opps can be located in which publication? |
|
Definition
|
|
Term
| the payment rate for hospitals and CMHCs includes? |
|
Definition
| Medicare payments amount for the services, deductible, and copayment or coinusrance |
|
|
Term
| Which regulation marked the congressional requrest for an opps to be developed? |
|
Definition
| The Omnibus Budget reconcillation act of 1986 |
|
|
Term
|
Definition
|
|
Term
| MS-Drg's have proved to be benefical for payers in? |
|
Definition
| Controlling the costs for hospital admissions that the OBRA '86 marked the congressional request for an out patient prospective paymetn system to be developed |
|
|
Term
|
Definition
| Groups together procedures using similar resources and assigns a composite rate to that APC |
|
|
Term
| When did CMS implement OPPS? |
|
Definition
|
|
Term
What does the OPPS system cover?
|
|
Definition
| Hospital outpatient services recieved in the hospital or a community mental health center (CMHC) |
|
|
Term
| What does OPPS not apply to? |
|
Definition
| Beneficiaries of the medicare advantage plan |
|
|
Term
| The payment for a hospital or CMHC is a? |
|
Definition
| national rated adjusted to reflect personnel earnings in hospitals in the area where the services are provided |
|
|
Term
| When does Medicare update the payment rates? |
|
Definition
|
|
Term
| what is the primary objective of OPPS? |
|
Definition
| to simplify payment, encourage hospital effciency, an densure payments are adequate to compensate hospitals for legitimate costs |
|
|
Term
| Under the Hospital OPPS, hospitals and CMHC are paid a set amount for o/p svcs to beneficiaries coverd by medicare, The payment rate includes? |
|
Definition
Meidcare payment for the service
yearly medicare part b deductible
copayment or coinsurance. |
|
|
Term
|
Definition
| an unadjusted national payment amount that includes the beneficiary copayment and the medicare payment (part B deductable and copay) |
|
|
Term
|
Definition
| adjusted for area wage differences using the inpatient wage index value for the locality in which the hospital or a CMHC is located. It accounts for hospital personnel salaries that vary from state to state. |
|
|
Term
| Medicare uses opps to pay for svc's from other facitilites, these services include? |
|
Definition
- some medicare part B svc's for i/p hospital care for beneficiaries w/o or with insufficent medicare part a benefits
- preventive injections/vaccines, antigens, casts, and splints from a home health agency if not paid under a home health care plan
- preventative injections/vaccines from a comprehensive o/p rehabiliation facility
- splints, antigens and casts to a hospice pt to treat a non terminal illness
- some o/p services through a SNF
- partial hospitaliztion svc's from a CMHC
- independ ambulatory surgery centers
|
|
|
Term
| O/P Svc's paid under OTHER medicare payment systems: |
|
Definition
- clincial dx laboratory svcs
- professional svcs of physicians and NPP's are paid under the physician fee schedule (PFS)
- screening mammograms
- ambulance services
- physcial therapy, occupational therapy, or speech-language therapy services
- DME, non implantable prosthetics, and orthotics
- dialysis for ESRD
- svc that requires an i/p stay paid under the hospital IPPS
- O/p hospital svc from CAHs
- O/P svcs from and IHS hospital
- O/P svcs from any hospital in maryland
- O/P svcs from andy hospital located in 50sttates
|
|
|
Term
| what was OPPS designed to do? |
|
Definition
| control hospital reimbursments for outpatient svcs. |
|
|
Term
|
Definition
| special drugs, chemo drugs and supplies, new techonology and are paid in addition to APC package paymetns |
|
|
Term
|
Definition
- saves medicare money
- allows facilites to look @ procedures, pymts and projected budgets
|
|
|
Term
True or False?
3rd party payers have their own respective reimbursement guidelines? |
|
Definition
|
|
Term
True or False?
3rd party payers may reimburse with or with out a CPT Or HCPCs code? |
|
Definition
| True-must at least have a revenue code |
|
|
Term
| special payment for OPPS may be made for new tech items and services in 2 ways.. |
|
Definition
- transitional pass through paymetns
- special APC groups established if it is not eligable for pass through paymetn or insufficient datea to assign an APC group
|
|
|
Term
| All services and items with in an APC group are? |
|
Definition
| comparable clinically and use similar resources |
|
|
Term
|
Definition
| a payment methodology for out patient, or ambulatory facility serivces |
|
|
Term
| The apc payment system does not include? |
|
Definition
| professional componest of ambulatory care |
|
|
Term
True or False
Relative weight for each APC classification is not recalibrated each year |
|
Definition
| False- done every year based on previous years claims and cost reported data for o/p services |
|
|
Term
| services not incudled in OPPS payemtn for OP hospital services |
|
Definition
- physician or NPP professional fees
- Services not covered by Medicare statute
- ambulance services and transportation
- therapies
- clinical labaratory
- screening for dx mammography
- dialysis
- i/p svcs
- services not reasonable and necessary for the dx or txt of the illnesss or disease
- DME supplied by the hospital for the pt to take home
|
|
|
Term
There are seperate APC's for:
|
|
Definition
- partial hospitlization
- procedures
- medical visits
- select ancillary svcs
- transitional pass through services and drugs
- new technologies
- blood and blood products
|
|
|
Term
|
Definition
| identify whether a procedure is eligible for an apc assignment. it determines under what payment system the services are paid. it is assigned to every HCPC's code |
|
|
Term
| What is important to remember about status indicators? |
|
Definition
| each code has the same status indicators as the APC in which it is assigned to |
|
|
Term
|
Definition
| all inclusive and not seperatly billable |
|
|
Term
| When mulitple surgeries are billed the APC will? |
|
Definition
| Bill the seccond lesser procedure at 50% |
|
|
Term
| Medicare pays each claim in an O/P facility based on? |
|
Definition
| Interium O/P reimbursement rate |
|
|
Term
| How are Ancillary svcs paid when performed in the ancillary areas of the hospital? |
|
Definition
| paid accord to an ancillary vicist gropu APC assignment, also paid in combination with medical and surgical services when provided. |
|
|
Term
| Which ancillary svcs are not subject to APC reimbursment now? |
|
Definition
| Lab services, physical, occupational and speech therapies |
|
|
