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| A Uniform Bill insurance claim developed by the National Uniform Billing committee for hospital inpatient billing and payment transactions. |
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| A computer program that is linked to carious hospital departments and includes procedures codes, procedure descriptions, service descriptions, fees, and revenue codes. |
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| A condition that is chiefly responsible for admission. |
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| A patient classification system that categorized patients who are medically related with respect to diagnosis and treatment and statistically similar in length of hospital stay. |
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| A patient who receives services in a health care facility, such as a physician's office, clinic, urgent care center, emergency department, or ambulatory surgical center and goes home the same day. |
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| Quality Improvement Organization (QIO) Program |
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Definition
| A program that replaces the peer review organization program and it designed to monitor and improve the usage and quality of care for Medicare beneficiaries. |
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| A review for appropriations and necessity of admissions. |
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| A review of diagnosis & procedure to determine appropriateness. |
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| A review of patients readmitted to a hospital within 7 days with problems related to the first admission, to determine whether the first discharge was premature or the second admission is medically necessary. |
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| A review of potential day outliers to determine the necessity of admission and number of days before the day outlier threshold is reached as well as the number of days beyond the threshold. |
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| A single charge for a day in the hospital regardless of any actual charges or costs incurred. |
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| A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and the patient. |
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Definition
| A system of outpatient hospital reimbursement based on procedures rather than diagnoses. |
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Definition
| A system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided. |
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Definition
| A term used when a patient is admitted to the hospital for oversight stay. |
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Definition
| A typical case that has an extraordinary high cost when compared with most discharges classified to the same DRG. |
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| AKA spinal tap; obtains cerebrospinal fluid into subarachnoid space in the lumbar region. |
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| American Health Information Management Association |
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| American Hospital Association |
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| An agreement between a managed care company and a reinsure in which absorption of prepaid patient expenses is limited. |
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Definition
| An average after a flat rate is given to certain categories and procedures. |
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| An ongoing condition that exists along with the condition for which the patient is receiving treatment. |
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Definition
| Bone marrow collected from the patient, processed & later transplanted back into the patient. |
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Definition
| Bone marrow sample taken with a needle inserted into marrow cavity and pulled into a syringe. |
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| Cases that cannot adequately be assigned to an appropriate DRG owing to unique combination of diagnoses and surgeries, very rare conditions or other unique clinical reasons. |
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| Coding that is inappropriately altered to obtain a higher payment rate. |
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| Describes the combination of the professional and technical components. |
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| Describes the services of a physician, including supervision & interpretation of the report. |
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| Describes the services of the technological as well as the use of the equipment, film & other supplies. |
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Definition
| Electronic Data Interchange |
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Definition
| Fiscal intermediary, field locator |
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Definition
| General Accounting Officer |
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| Method used to obtain exposure of a lesion; an anatomical location. |
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| Nineteen criteria for admission under the prospective payment system, separated into two categories, severity and intensity of illness. |
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| Outpatient Prospective Payment System |
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Definition
| Registered Health Information Administrator |
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Definition
| Registered Health Information Technician |
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Definition
| Review of transfers to different areas of the same hospital that are exempted from prospective payments. |
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| Tax Equity and Fiscal Responsibility Act |
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| The automated grouper process of searching all listed diagnoses for the presence of any comorbid condition or complication or searching all procedures for operating room procedure or other specific procedures. |
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Definition
| The computer software program that assigns DRGs of discharge patients using the following information, patient's age, sex, principal diagnosis, complications, co morbid conditions, principal procedure, and discharge status. |
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Definition
| The correct order of diagnostic codes when submitting an insurance claim that affects maximum reimbursement. |
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| The dollar amount a hospital bills an outlier case on the itemized bill. |
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Definition
| The fixed percentage of the collected Premium rate that is paid to the hospital to cover services. |
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Term
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Definition
| The process in which computer software checks for errors before a claim is submitted to an insurance carrier for payments. |
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Term
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Definition
| To find out whether the diagnostic and procedural information affection DRG assignment is substantiated by the clinical information in the patient's chart. |
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Term
| Preadmission Testing (PAT) |
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Definition
| Treatment and tests done 72 hours before admission. |
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