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Terms in this set (30)
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are
physician work (WORK), practice expense (PE), and malpractice (MP) insurance expense
To compute the reimbursement to a particular hospital for a particular MS-DRG, multiply the hospital's base payment rate by the
relative weight [for the MS-DRG]
A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called
APCs or ambulatory payment classifications
The prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service.
Medicare Physician Fee Schedule (MPFS) [MPFS reimburses providers according to predetermined rates assigned to services]
These are financial protections to ensure that certain types of facilities (e.g. children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments.
"CMS assigns one _______ to each APC and each _______ code.
payment status indicator, HCPCS
In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the
geographic practice cost indices (GPCI)
The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to __________ for patients with Medicare
skilled nursing facilities (SNF)
"Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS Web site or on a CD-ROM.
HAVEN (Home Assistance Validation and Entry)
The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called
Resource Utilization Groups (RUGs)
This prospective payment system is for ________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).
inpatient rehabilitation facilities (IRF)
This process involves the gathering of charge documents from all departments within the facility that have provided services to patients. The purpose is to make certain that all charges are coded and entered into the billing system
The _____ is a statement sent to the provider to explain payments made by third-party payers.
remittance advice (RA)
The _______ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider
Medicare summary notice (MSN)
Currently, which prospective payment system is used to determine the payment to the "physician" for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient?
RBRVS - Resource-based relative value scale
These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid
payment status indicator
The prospective payment system used to reimbursement home health agencies for patients with Medicare utilizes data from the
OASIS (Outcome and Assessment Information Set)
When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n)
What prospective payment system reimburses the provider according to prospectively determined rates for a 60-day episode of care?
home health resource groups (HHRG)
How many major diagnostic categories are there in the MS-DRG system?
When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital
Absorbs the Loss
The case mix index (CMI) for the top 10 MS_DRGs above is
Based on this patient volume, during this time period, the MS-DRG that brings in the highest "total" reimbursement to the hospital is?
Based on this patient volume, the MS-DRG that brings in the highest total profit to the hospital is?
The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS)
The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement.
"All of the following statements are true of MS-DRGs, EXCEPt
a patient claim may have multiple MS-DRGs
"CMS adjusts the Medicare Severity DRGs and the reimbursement rates every
fiscal year beginning October 1
A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by
B and C: ambulatory surgery centers (ASC) & home health agencies (HHA)
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