Skilled Nursing Facility Prospective Payment System
Under the SNF PPS, which one of the following healthcare services is excluded from the consolidated payment?
routine care, ancillary services, and capital costs
What healthcare services are included from the consolidated payment under the SNF PPS?
resource utilization groups
resource utilization groups (RUGs)
Which classification system is used to case-mix adjust the SNF payment rate?
minimum data set
minimum data set (MDS)
In the SNF PPS, which data set determines a resident's classification into a resource utilization group?
The therapist in the skilled nursing facility is treating multiple patients who are each performing different therapies. How does CMS classify this mode of delivery?
practice of one professional therapist treating multiple patients at the same time while the patients are performing different therapeutic activities.
In the PAC payment systems, which tool does CMS use to adjust its payment rates to account for geographic variations in costs?
Mix of goods and services appropriate to the setting, such as home health services or SNF.
How many types of PACs?
SNF, LTCH, IRF, and HHA
Name the 4 types of PACs.
inpatient rehabilitation facility
In which of the PAC payment systems, is the unit of payment the 60-day episode of care?
PAC payment system where unit of pay is 60-day episode of care.
Generally, what is the average length of stay of long-term care hospitals?
multiple acute and chronic diseases
LTCH treat patients with the following?
Medicare-severity, long-term care, diagnosis-related groups
exactly the same
In terms of their composition, how do the groups of the MS-LTC-DRGs compare to the groups of the acute care MS-DRGs?
principal diagnosis, up to 8 additional diagnoses, and up to 6 procedures
Both MS-LTC-DRGs and acute care MS-DRGs are based on what 3 things?
based on the principal diagnosis
In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar?
constant that converts the MS-LTC-DRG weight into a payment
In the LTCH PPS, what is the standard federal rate?
quality of, access to, and continuity of care; efficient provision of rehab services, and fairness and equity to facilities, beneficiaries, and taxpayers
According to CMS, what are the 3 purposes of the IRF PPS?
stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of the femur (hip), brain injury, neurological disorder, burn; active, polyarticular rheumatoid arthritis; psoriatic arthritis, and seronegative arthropathy; systemic vascularities with joint inflammation (unresponsive to aggressive, sustained and appropriate outpatient treatment; severe or advanced osteoarthritis involving greater-than-or-equal-to 2 major weight-bearing joints; knee or hip replacement with bilateral replacement, extreme obesity, or age greater-than-or-equal-to 85.
To meet the definition of an IRF, facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which conditions are counted in the definition?
standard federal rate
National base payment amount in the PPS for LTCH. This amount is multiplied with the relative weight of the LTC-DRG to calculate the unadjusted payment. SFR is published annually in the Federal Register.
This diagnosis is NOT used in the IRF PPS.
patient assessment instrument
IRF PPS tool that collects information that drives payment?
Outcome Assessment Information Set
What data set provides the underpinning of the HHPPS?
all therapy (PT, OT, S), skilled nursing visits, home health aide visits, medical social services; all medical supplies, including non-routine medical supplies
All of the following services are consolidated into a single payment under the HHPPS.
nursing, therapy, and noncase-mix-adjusted
3 components of the per diem (daily rate) for SNF PPS include:
rehabilitation impairment category
rehabilitation impairment category, total scores from motor (M) items from functional independence assessment tool, total scores from cognitive (C) items from functional independence assessment tool (used only with selected diagnoses related to stroke and traumatic brain injury), age (used only with selected diagnoses related to stroke, traumatic spinal cord injury, and joint replacement), and comorbid conditions
5 elements part of the IRF PPS:
inpatient rehabilitation facility patient assessment instrument
episode of care
unit of payment for HH PPS:
episode of care
All home health services delivered to a patient during a 60-day period:
skilled nursing care, therapy (OT, PT, S), medical social work, home health aide
Services provided by HHA:
OASIS collects how many major domains?
sociodemographic, environment, support system, health status, functional status, behavioral status
Name 6 major OASIS domains that are collected:
NOT part of the HH PPS case mix:
home health resource group
How many HHRGs are there?
number of therapy visits by a therapist
For what variations in resource consumption does the HHPPS account?
Element directly adjusted by the local wage index:
In which of the PAC payment systems, is the adjusted rate multiplied by the patient's number of Medicare days to determine the reimbursement amount?
What is the term used in a rehabilitation facility to mean "a patient's ability to perform activities of daily living"?
software used in payment calculation
In regards to SNF, what is a pricer?
The functional independence assessment tool is comprised of 18 items, and scores are based on a scale of ____ to _____.
What score from the independence assessment tool is assigned to "not assessed"?
What score from the independence assessment tool is assigned to "complete dependence"?
What score from the independence assessment tool is assigned to "complete independence"?
functional independence assessment tool
Major element of the IRF PAI:
identification, admission, payer, medical, medical needs, function modifiers, functional independence assessment, discharge, quality measures
9 types of patient information comprising the IRF PAI:
pressure ulcer, patient falls
2 examples of quality measures that might be listed in the IRF PAI:
inpatient rehabilitation validation and entry
Computer software for data entry in inpatient rehabilitation facilities (IRF). Captures data for the IRF PAI and supports electronic submission of the IRF PAI. Allows data import and export in the standard record format of the Centers for Medicare and Medicaid Services.
True or False: OASIS is used in the long term care setting?
high cost outlier, rural adjustment, teaching hospital, low income patients
After the generic payment formula is calculated, sometimes there are adjustments made to account for the characteristics of facilities. Name these 4 types of adjustments that could be made.