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Diagnostic Related Group
Patient case classification that determines lump sum reimbursement through PPS. Based on ICD-9 code diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities.
Prospective Payment System
Determines Medicare reimbursement based on a predetermined, fixed amount. Reimbursement varies by setting, e.g. inpatient hospital vs. inpatient rehab vs. outpatient vs. SNF.
Describe the service that was rendered for billing purposes. For OTs: therapeutic exercise, therapeutic activity, ADL's, splinting etc. Used by insurers to determine reimbursement.
Describe why a service was provided, e.g. what was the specific diagnosis? Developed and monitored by the WHO. In the U.S a division of CMS (Centers for Medicare and Medicaid Services) oversees all changes and modifications to codes, in cooperation with WHO.
Current ICD system used in the U.S. (since 1977). Dates from the period of Super 8 (Spielberg movie).
Resource Utilization Group
Groups categorizing SNF residents, based on functional status and anticipated use of services and resources. Functional status determined by functional assessment upon arrival.
Determines how many minutes of rehab Medicare reimburses for SNF residents (included in the overall payment via the MDS):
Ultra High (RUH) - 720 minutes
High (RH) - 500 minutes
Medium (RM) - 325 minutes
Low (RL) - 150 minutes (Jen F thinks....)
Minimum Data Set
Determines overall reimbursement in SNFs. Assesses 400 items, including FIM scores, medications, routinely required procedures or lab tests. The SNF is reimbursed according to the amount of rehab provided (RUGs) and the "burden of care" required.
Image to help remember what setting MDS and RUGs belong to.
SNFs contain a minimum number of throw rugs. They present fall risks.
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