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66 terms

ICD-9-CM Coding Chapter 26

Reimbursement Methodologies
STUDY
PLAY
AHIMA
American Health Information Management Association
ALOS
Average Length of Stay
CC
Complication/ComorbidityPreexisting
CDIP
Clinical Documentation Improvement Program
CDM
Charge Description Master
CHF
Congestive Heart Failure
CMI
Case-Mix Index
CMS
Centers for Medicare & Medicaid Services
COPD
Chronic Obstructive Pulmonary Disease
DHHS
U.S. Department of Health and Human Services
GMLOS
Geometric Length of Stay
HCPCS
Healthcare Common Procedure Coding System
HH
Home Health
HMO
Health Maintenance Organization
HPR
Hospital Payment Rate
IPPS
Inpatient Prospective Payment System
LCDs
Local Coverage Determinations
LMRP
Local Medical Review Policies
LOS
Length of Stay
LTC
Long-Term Care
MAC
Medicare Administrative Contractor
MDC
Major Diagnostic Category
MI
Myocardial Infarction
MIC
Medicaid Integrity Contractor
MS-DRG
Medicare Severity Diagnosis-Related Group
NCDs
National Coverage Determinations
NPI
National Provider Identifier
PEPPER
Program for Evaluating Payment Patterns Electronic Report
PPO
Preferred Provider Organization
PPS
Prospective Payment System
QIO
Quality Improvement Organization
RAC
Recovery Audit Contract
RPS
Retrospective Payment System
RW
Relative Weight
SNF
Skilled Nursing Facility
SOW
Scope of Work
TEFRA
Tax Equity and Fiscal Responsibility Act
UB-40
Uniform Bill-04
ZPIC
Zone Program Integrity Contractor
MS-DRG Reimbursement Formula
RW x HPR = MS-DRG Payment
Case-Mix Index
A measurement used by hospitals to define how sick their patients are
Charge Description Number
A number that designates a particular service or procedure, used to generate a charge on a patient bill
Chargemaster/CDM
A listing of the service, procedures, drugs, and supplies that can be applied to a patient's bill
Comorbidity
A preexisting condition (present on admission) that may lead to increased resource use
Complication
A condition that arises during a patient's hospitalization that may lead to increased resource use
Department Number
Ancillary departments such as radiology, laboratory, and emergency room will have a specific hospital department number
Encoder
Coding software that is used to assign diagnosis and procedure codes
Grouper
Specialized software used to assign the appropriate MS-DRG
Health Maintance Organization (HMO)
Type of managed care in which hospitals, physicians, and other providers contract to provide health care for patientsm usually at a dicounted rate
Local Coverage Determinations (LCDs)
Local policy that may include certain time frames for testing, certain age requirements, and that a particular diagnosis or condition must be present for a procedure or treatment to be considered medically necessary
Maximization
The manipulation of codes to result in maximum reimbursement without supporting documentation in the health record or with disregard for coding conventions, guidelines, and UHDDS definitions
Medical Necessity
Criteria or guidelines for what is determined to be reasonable and necessary for a particular medical service
National Coverage Determinations (NCDs)
National policy that may include certain time frames for testing, certain age requirements, and that a particular diagnosis or condition be present for a procedure to be considered medically necessary
Optimization
The process of striving to obtain optimal reimbursement or the highest possible payment to which a facility is legally entitled on the basis of documentation in the health record
Preferred Provider Organization (PPO)
Type of managed care in which hospitals, physicians, and other providers have an arrangement with a third party payer to provide health care at discounted rates to third party payer clients
Principal Diagnosis
Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
Prospective Payment System
Method of reimbursement in which payment is made on the basis of a predetermined, fixed amount rather than for billed charges
Reimbursement
Payment for healthcare services
Revenue Code
A four-digit code that is utilized on the UB-40 to indicate a particular type of service
Self-insured Plans
Self-insurance fund is set up by an employer to provide health claim benefits for employees
Third Party Payer
Makes payments for health services on behalf of the patients; may be a governemtn program, insurance company, or managed care plan
What are 4 commonly missed CCs or MCCs?
1.) Atelectasis
2.) COPD
3.) Malnutrition
4.) Respiratory Failure
The billing form that is currently in use in hospitals is?
UB-40
The interrelated parts of a case-mix are?
1.) Severity of illness
2.) Prognosis
3.) Treatment difficulty
4.) Need for intervention
5.) Resource intensity
MCC
Major Complication/Comorbidity
Who implemented the Medicare Severity Diagnosis-Related Groups and in what year?
CMS in October 1, 2007