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a preexisting condition that is present on admission and may lead to increased resource used

comorbidity

The condition that after study is established as chiefly responsible for occasioning the admission of the patient to the hospital is called

principal diagnosis

DRG stands for

diagnosis related group

the billig form that is currently in use in hospitals is

ub 04

calculate the case mix for the following patients using the wieghts from appendix E

0.9077 case mix index

PEPPER

program for evaluating payment patterns electronic report

RW

relative weight

RAC

recovery audit contract

ALOS

average length of stay

CMI

case mix index

GMLOS

geometric length of stay

IPPS

inpatient prospective payment system

QIO

quality improvement organization

PPS

prospective payment system

HPR

hospital payment rate

HMO

type of managed care in which care is provided at a discounted rate

complication

condition that arises during a patients hospitalization which may lead to increased resource use

encoder

coding software that is used to assign diagnosis and procedure codes

comorbidity

preexisting condition which may lead to increased resource use

maximization

supporting documentation in the health record, or with disregard for coding conventions, guidelines, and uhdds definitions

principal diagnosis

condition established after study as chiefly responsivle for occasioning admission of the patient to the hospital for care

optimization

process of striving to obtain optimal reimbursement or the highest possible payment to which the facility is legally entitled, on the basis of documentation in the health record

grouper

coding software used to assign the appropriate ms drg

chargemaster

listing of the services, procedures, drugs and supplies that can be applied to a patients bill

local coverage determinations

local policy that may include certain time frames for testing, that a peatient be a certain age, and that a particular diagnosis or condition is present to be considered medically necessary

medical necessity

criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service

department number

ancillary departments such as radiology, laboratory, emergency room will have a specific hospital department number

national coverage determinations

national policy that may include certain time frames for testing that a patient be a certain age than that a particular diagnosis or condition is present ot be considered medically necessary

charge description number

a number that designates a particular service or procedure and is used to generate a charge on a patient bill

revenue code

a four digit code that is utilized on the ub-04 to indicate a particular type of service

if a patient was admitted to the hospital for a kidney problem, which mdc would be assigned

mdc 11

other factors that may play a role in msdrg assignment besides principal and secondary diagnoses and procedures include

sex, discharge disposition, and birthweight for neonates

an electronic report sent to hospitals taht contains hospital-specific information for specific msdrg target areas is known as

PEPPER

an org that acts under the direction of cms and is contracted to minitor the quality of health care and to make sure that medicare pays only for services that are reasonable and necessary is

QIO

the msdrg payment for msdrg 055 if the hospital payment rate is 3000

3248.40

the purpose of a cdip is to improve clinical docs in the patient record;should improve case mix index and same time for coders and physicians by reducing the number of queries T/f

True

1.8673

During the month of July, the following Medicare patients were discharged from Hospital B. Using Appendix E (starting on page 761 of textbook), calculate the case mix for the following:

2 patients MS-DRG 100

2 patients MS-DRG 460

1 patient MS-DRG 066

3 patients MS-DRG 740

2 patients MS-DRG 418

The CMI for July is:

items that are related to retrospective payment system

based on charges, based on drg so payment is determined before the care is rendered, incentive to decrease complications, need to provide quality care in an efficient manner to maintain bottom line

items that are related to a prospective payment system

based on charges, payment is determined after the patient is discharged based on drg so payment is determined before the care is rendered, does not promote best practices an dquality care because the hospital gets paid for complications.

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