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Healthcare Billing & Reimbursement Test (Chapters 6-10)
Terms in this set (26)
Set of categories of patients (type and volume) treated by a healthcare organization and representing the complexity of the organization's caseload.
Illness or injury that coexists with the condition for which the patient is primarily seeking healthcare.
Inpatient classification that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and lengths of stay. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.
Diagnosis-related group (DRG)
Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes.
Highest level in hierarchical structure of the federal inpatient prospective payment system (IPPS). The 25 MDCs are primarily based on body system involvement, such as MDC No. 06, Diseases and Disorders of the Digestive System. However, a few categories are based on disease etiology, for example, Human Immunodeficiency Virus Infections.
Major diagnostic category (MDC)
Method of reimbursement in which payment rates for healthcare services are established in advance for a specific time period. The predetermined rates are based on average levels of resource use for certain types of healthcare.
Prospective payment system (PPS)
Hospital Outpatient Prospective Payment System (HOPPS); classification is a resource-based reimbursement system; payment unit is the ambulatory payment classification group (APC group)
Ambulatory Payment Classification (APC)
Freestanding outpatient facility in which outpatient surgeries are performed
Ambulatory Surgical Center (ASC)
national dollar multiplier that sets the allowance for the relative values; a constant
Conversion Factor (CF)
small facility that gives limited outpatient and inpatient hospital services to people in rural areas
Critical Access Hospitals (CAHs)
physician, practitioner, or therapist defined by statue who is eligible to participate in the Medicare Physician Quality Reporting Initiative and int eh Medicare E-Prescribing Incentive Program; the eligible professionals' services must be paid under the Medicare physician fee schedule and not under some other fee schedule or reimbursement method
Eligible Professional (EP)
index based on relative difference in the cost of a market basket of goods across geographic areas; a separate GPCI exists for each element of the relative value unit (RVU), which includes physician work, practice expenses, and malpractice; GPCIs are a means to adjust the RVUs, which are national averages, to reflect local costs of services
Geographic Practice Cost Index (GPCI)
mix of goods and services appropriate to the setting, such as home health services or skilled nursing facilities
component or element of the relative value unit (RVU) that should cover the physician's salary; this work is the time the physician spends providing a service and the intensity with which that time is spent; the 4 elements of intensity are: 1) mental effort and judgment, 2) technical skill, 3) physical effort, and 4) psychological stress
physician work (WORK)
element of the relative value unit (RVU) that covers the physician's overhead costs, such as employee wages, office rent, supplies, and equipment; there are 2 types: facility and nonfacility
Practice Expense (PE)
core-based statistical area (CBSA)
department in a healthcare facility that manages the amounts owed to a facility by customers who have received services but whose payment is made at a later date
Accounts Receivable (AR)
database used by healthcare facilities to house the price list for all services provided to patients
Charge Description Master (CDM)
newly established contracting authority to administer Medicare Part A and B as required by section 911 of the medicare modernization Act of 2003.
Medicare Administrative Contractor (MAC)
Statement that describes services rendered, payment covered, and benefits limits and denials for medicare beneficiaries
Medicare Summary Notice (MSN)
the supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
Revenue cycle management (RCM)
Assignment of the costs of a patient's care and the outcomes of care to a specific individual provider or group of providers; allows allocation of rewards or penalties (also known as enrollee or beneficiary assignment).
Type of providers' payment system that is based on performance and incentives. See Value-based purchasing.
Pay-for-performance (P4P or PFP)
Primary-care led physician and hospital organization that has voluntarily formed a network to provide coordinated care and to receive a share of the savings it produces while meeting quality and cost targets.
Accountable care organization (ACO)
Strategy that links payment to the quality of care, rewarding providers for delivering high-quality, efficient clinical care.
Value-based purchasing (VBP)
From the AHIMA Code of Ethics name 5 ethical principles based on the core values of the American Health Information Management Association and apply to all AHIMA members and certificants.
1)Advocate, uphold and defend the individuals rights to privacy.
2)Put service and health, welfare of persons before self interest and conduct
3)Preserve, protect, secure personal health information in all forms to highest regard.
4)Refuse to participate in or conceal unethical practices or procedures
5)Advance health information management knowledge and practice through education.
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