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Charge Description Number
A number that designates a particular service or procedure, used to generate a charge on a patient bill
A listing of the service, procedures, drugs, and supplies that can be applied to a patient's bill
A condition that arises during a patient's hospitalization that may lead to increased resource use
Ancillary departments such as radiology, laboratory, and emergency room will have a specific hospital department number
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
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
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
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
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
A four-digit code that is utilized on the UB-40 to indicate a particular type of service
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?
4.) Respiratory Failure
The interrelated parts of a case-mix are?
1.) Severity of illness
3.) Treatment difficulty
4.) Need for intervention
5.) Resource intensity
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