The overall coding system that consists of level I (CPT) used mostly for surgical procedures, labs, etc., and level II which is for durable medical equipment, surgical supplies.
Level I codes are ?
CPT codes 5 numerical digit codes assigned for procedures.
Level II codes are ?
Alpha numeric codes to report durable medical equipment, surgical supplies.
** Each code in HCPCS (Hospital Outpatient Prospective Payment System) has been assigned what ?
A payment status indicator.
** What does a payment status indicator establish?
How a service, procedure, or item is paid (by fee schedule, APC, reasonable cost, or unpaid)
Regarding Payment Status Indicator C - Because OPPS uses CPT codes, which consist of inpatient and outpatient procedures and services, CMS designated which procedures are and are not appropriate for the outpatient setting for ?
If on the Inpatient-only list - must be provided inpatient beneficiaries in what setting ?
Inpatient setting only if you want reimbursement.
To be moved off inpatient-long list, must be preformed in what setting?
In non-inpatient settings at least 60 percent of the time.
Maintenance revisions are published ______ .
In the Federal Register.
Proposed are published in _____rules typically published _____?
Federal Register, in July
When is the final rule in the Federal Register?
Implementation is in what month and runs through ?
Regarding Ambulator Payment Classifications, most services paid under OPPS are reimbursed ?
Under APCs (can have one DRG, but multiple APCs for outpatient side) 2 procedure can be the same APC
Each APC group comprises procedures or services that are ?
Clinically related and comparable with respect to resource use.
** Define Packaging and Bundling.
To combine, into one lump sum payment, the costs of ancillary services, supplies, and pharmaceuticals with their associated major procedures.
Packageing and Bundling is achieved via ?
Payment status indicator N (Means it is a packaged service).
What does packaging or bundling provide ?
An incentive for healthcare facilities to improve efficiency by providing only medically necessary services.
Regarding Packaging, OPPS (Outpatient prospective payment system), uses a ?
Partially package system.
Since OPPS (Outpatient Prospective Payment System) uses a partially package system what does that mean?
Some services are packaged into the APC payment for the service or procedure with which they are associated while other services are not packaged into the APC payment for the service or procedure with which they are associated.
Regarding Packaging and Bundling, not everything is packaged. Give some examples of some services that are not packaged.
X-ray, MRI, Injections.
Billing allows for an ______ ______ of APCs assigned per encounter.
In the outpatient setting treatment pathways greatly vary from patient to patient, why?
It is difficult to determine the resources that will be utilized for a clinical issue and Cost for a “typical” outpatient encounter cannot be accurately forecasted.
Why use a partially packaged system?
It provides adequte reimbursement and allows for treatment flexibility.
Classifications into RUG (Resource Utilization Group) adjusts for ?
** What are RUGs (Resource utilization Groups) ?
Homogeneous groups (of like htherapies that a patient may receive) with similar health characteristics and requirements for use of resources.
** Components of payment rate for each RUG (Resource Utilization Group) are ?
Nursing component, Therapy component, Noncase-mix-adjusted component and noncase-mix therapy component.
RUG (Resource Utilization Grou) is the equivalent of what?
DRG in the SNF.
BBA of 1997 Section 4432 mandated what?
SNF PPS effective ?
July 1, 1998
What does IRF stand for?
Inpatient Rehabilitation Facilities
What do IRF Services provide and what is their purpose?
Provide intense multidisciplinary services to inpatients. Purpose is to restore or enhance patients’ function after injury or illness Members of multidisciplinary term provide services. Services are medically necessary, based on assessment, and individualized for each patient’s needs
To be considered an IRF (Inpatient Rehabilitation Facility ?
Must be licensed under applicable state laws to provide skilled nursing care to inpatients 24 hours per day.
IRF (Inpatient Rehabilitation Facilities) can be ?
Free Standing hospitals or Distinct specialized rehabilitation units in acute care hospitals.
**What are the 13 qualifying conditions for designation as IRF (Inpatient Rehabilitation Facility?
Stroke, Spinal cord injury, Congenital deformity, Amputation, Major multiple trauma, Hip fracture, Brain injury, Neurological disorders (MS, Parkinsonism, etc.), Burns, Active arthritides or arthropathies (special circumstances), Systemic vasculidities(special circumstances), Severe osteoarthritis (special circumstances), Hip or knee replacement (special circumstances)
In 1997, what authorized development and implementation of IRF prospective payment system (PPS)