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day outlier review

to certify necessity of admission and medical necessity of services for additional reimbursement

quality improvement organization

responsible for admission review, readmission review, procedure review, day outlier review, cost outlier review, DRG validation, transfer review

readmission review

performed for patients readmitted within 7 days with problems related to the first admission

principal diagnosis

condition that is assigned a code representing the diagnosis established after study that is chiefly responsible for the admission of the pt to the hospital

UB04 (CMS1450)

summary statement; compiles all charges and is accompanied by a detailed statement, which shows itemized charges

insurance billing editor

reviews the claim prior to mailing

Patient's Bill of Rights

a nationally recognized code of conduct published by the American Hospital Association - states the pt has the right to request, examine and question a detailed statement

Phantom charges

physician orders admission procedures for each pt who enters the hosptial; if a pt refuses some of these tests, the charges should be deleted from the financial record before the bill is sent

DRG system

used by Medicare to hold down rising costs; classifications were formed from more than 10,000 ICD9 codes that were divided into 25 major diagnostic categories

tentative DRG

assigned on the basis of admission diagnosis, scheduled procedure, age, and known secondary diagnosis


computer program calculates and assigns the DRG payment (the grouper is not able to consider ay difference between chronic and acute conditions

DRG creep

an unethical practice to code a patient's DRG category for a more severe diagnosis than indicated by the patient's condition


pre-existing condition that because of its effect on the specific principal diagnosis will require more intensive therapy or cause an increase in length of stay by at least 1 day in approx 75% of cases

Appropriateness Evaluation Protocols (AEP)

criteria used by the Utilization Review Department for admission screening

Services provided by the hospital/billed by the hospital

ER dept, facility fee supplies, lab technical component, radiology technical component, physical and occupational therapy facility fees.

Ambulatory payment

outpt classification scheme developed by Health Systems International based on procedures rather than diagnosis

Capitation or percentage of revenue

reimbursement to the hospital on a per-member, per-month basis to cover costs for the member of the plan

Case Rate

an averaging after a flat rate has been given to certain categories of procedures

Diagnosis-related groups (DRGs)

a classification system that categorizes inpatients who are medically related with respect to diagnosis and treatment and are statistically similar in length of hospital stay

Differential by day in hospital

term for the first day of a hospital stay being paid at a higher rate

Differential by service type

type of arrangement in which the hospital receives a flat per-admission reimbursement for the service to which the patient is admitted

Fee schedule

a comprehensive listing of charges based on procedure codes that states fee maximums paid by the health plan

Flat rate

a single charge per hospital admission paid by the managed care plan


method by which part of the plan's payment to the hospital may be withheld or set aside in a bonus pool

Reinsurance stop loss

a form of reinsurance in which the hospital buys insurance to protect against lost revenue and receives less of a capitation fee, and the amount the hospital does not receive helps pay for the insurance


dollar amount owed to a participating provider for health care services rendered to a plan member according to a fee schedule set by the managed care plan

coding inpatient services

use ICD9 volume 3; both the alphabetical and tabular list of surgical and nonsurgical procedures and misc therapeutic and diagnostic procedures

admitting clerk

registers pt by interviewing and obtain demographic info, insurance info, and admitting diagnosis (copies of the admitting facesheet are sent to the PCP or surgeons office)

attending dr. and nurse

enter daily notations on the pt's medical record as the pt receives services

hospital outpt services are coded

from the CPT book

workers compensation pt

will not have insurance card (if it is their first service) an employers first report of injury must be completed and sent to the insurance company and the state industrial accident board before a hospital or physicians insurance claim may be submitted. Non-emergency services must be pre-authorized

Managed care pt non-emergency - hospital without a contract

services must have been pre-approved otherwise the pt could be responsible for the entire bill

managed care pt emergency services

insurance must be notified within 48 hours for authorization number


admitted to hospital for an overnight stay

insurance billing specialist must have basic knowledge of insurance programs

due to diversity in reimbursement methods

larger facilities

greater opportunity for advancement

DOS or Monetary values

are entered with no spaces or decimal points


8 digit numbers

discharge summary

document completed and signed by physician after pt leaves hospital; before hospital bills for sevices

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