HIM Reimbursement test 3 part 2

rad2329's version from 2016-11-04 16:28

Section 1

Question Answer
** What is HCPCS ?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 ?Medicare beneficiaries.
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?In October
Implementation is in what month and runs through ?January through December.

Section 2

Question Answer
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.Unlimited number.
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.

Section 3

Question Answer
** Regarding APC system structure classification system - Each CPT/HCPCS code is assigned to ____ .One and only one APC group (but can have multiple APC’s on a claim).
APC assignment does not change based on what ?Diagnosis or severity of illness (with one exception - partial hospitalization).
Regarding Post Implementation - APCS is a very Complex system to manage due to what?Predicitin utilization and numerous pieces of legislation. cost analysis and containment.
** Define Postacute care (PAC).Settings that provide patients with health care services for their recuperation and rehabilitation after illness or injury.
** What are the four settings designated by Medicare Payment Advisory Comission (MedPAC) for Postacute care?SNFs (Skilled nursing facilities), LTCHs (Long-term care hospitals), IRFs (Inpatient rehabilitation facilities, HHAs (Home health agencies).
PAC (Post Acute Care) allows continuing safe recover in settings _____ ?Less intensive and more appropriate than acute-care inpatient hospitals.
** What is Medicare’s overarching goal for PAC (Post Acute Care) ?Ensure that beneficiaries receive appropriate high-quality care in least costly setting appropriate for their clinical condition
PPS in all 4 PAC settings have what?Slow "tremendous" rate of growth in expenditures, a series of Federal laws from 1998 through 2002 have effected PAC, and spending has slowed.
** List PPS (Prospective Payment System) characteristics in PAC (Post Acute Care) settings . Specialized data collection instruments - Case-mix groups with relative weights - Base rates converting weights to dollars - Geographic adjustment for varying costs of labor across U.S.
** CMS publishes updates in ______ and has web site with data files for ______ ?Federal Register - Post Acute Care (PAC)
Nursing Homes are ______ ?Healthcare facilities licensed by a state that offer 24-hours per day both skilled nursing care and personal care services.
SNF (Skilled nursing facilities are ______ ?A type of nursing home that provides short-term skilled nursing care and rehabilitation services to Medicare beneficiaries after an acute-care inpatient hospitalization.

Section 4

Question Answer
** The SNF PPS was mandated in _____ ?The Balanced Budget Act of 1997 and was effective in 1998.
SNF PPS pays a daily rate for each day of care (per diem) and covers the costs or ______ ?Skilled nursing care, rehabilitative services, ancillary services, capital costs, and other goods and services.
CMS has required SNFs to prepare the Minimum Data Set (MDS) since ?The late 1980's.
** Define MDS (Minimum Data Set) .Represents clinical documentation of the resident’s care. It is an extensive database of clinical data. The MDS is part of the resident’s health record.
What does the linical data on the MDS include ?Comprehensive assessments. Assessments must completed within prescribed timeframes.
** Regarding Data Collection and Reporting, what are the required assessments ?Standard assessments for admissions and readmissions, Other assessments: Start of Therapy (SOT), Change of Therapy (COT), End of therapy (EOT), Significant change in status assessment (SCSA).
** Regarding Data Collection and reporting Schedule of Standard Assessments, Medicare requires what type of schedule ?A set schedule.
** What are the three components for Structure of Payment ?Base rate - SNF case-mix group - Adjustment.
What is Base rate ?Per diem, known as federal base rate or federal per diem, CMS calculates using past cost reports from base year (prior years).
Adjustments to base rate (per diem) may be from ?Geographic factors and inflation, other mandated by regulation or statute, Patient case-mix based on complexity of resource intensity of residents’ conditions.
Case mix takes into account what ?Differences among residents, ADLs (Activities of daily living), Represents complexity and resource intensity of residents' conditions.
SNF case-mix group is _____ .Resource Utilization Group (RUG)

Section 5

Question Answer
Classifications into RUG (Resource Utilization Group) adjusts for ?Case-mix.
** 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
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)The Balanced Budget Act (BBA)

Section 6