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39 terms

ch 7

STUDY
PLAY
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.