HIM Reimbursement test 3 part 3

rad2329's version from 2016-11-08 18:21

Section 1

Question Answer
What amendments did the development of the Balanced Budget Act (BBA) of 1997 affect.Balanced Budget Refinement Act (BBRA) of 1999. Benefits Improvement and Protection Act (BIPA) of 2000
Rehabilitation hospitalizations are covered under which type of medicare?Part A.
What is required from Medicare Part A for inpatient reahpilitation hospitals?Preadmission screening to establish beneficiary's eligibility, Patient must be able to tolerate and benefit from 3 hours per day or 15 hours per week (7 consectutive days).
Regarding medicare Part A and Inpatient rehabilitation Hospitalizations "cost-sharing" and deductibles ?Admissions directly from acute inpatient hospital do not pay a second deductible. Admissions from community do pay a deductible. (if a patient is coming from home the patient will have to pay a deductible).
CMS requires that inpatient rehabilitation services are reasonable and medically necessary, what are the requirements ("coverage criteria") ?Documentation of preadmission screening, Close medical supervision, Director of rehabilitation, Plan of care, Coordinated multidisciplinary team approach. Must meet timeframes, required for payment under IRF PPS
What is IRF Patient Assessment Instrument (PAI)?A data collection and reporting data collection tool that drives payment. IRF PAI must be completed twice for each Medicare Part A and Part C patient. (At admission and discharge).
List the types of patient information required on the IRF PAI?Idendification including admission, Payer, Medical, Functional modifiers, Funcitional independence assessment, Discharge, Therapy, Quality measures, Certification of instrument's accuracy (signatures, dates, etc.)
IRF PAI (Patient Assessment Instrument) used for rehab hospitals requires assignment of codes for ?Reason for admisstion (impairment group code IRF PAI data code), Etiology of impairment (ICD code), Comorbidities and complications (ICD codes), Reason for interruption, transfer, or death (ICD codes)
What is a Funcitional cabatilities functional independence assessment tool?How independent that patient is. (i.e. how well does the patient get around).
What are uses of IRF PAI data?Research, Grouping patients to case-mix groups, Determining payment tier.
IRF PAI Data Does not follow ?UHDDS or UB04 guidelines
** What code is the primary reason for admission to IRF ?IGC (Impairment Group Code

Section 2

Question Answer
How many IGCs (Impairment Group Codes) are there?85 IGCs organized into 17 impairment groups.
What is the Structure for IGC (Impairment Group Codes)Two-digit ID number-decimial point, Two to four digits for subgroups.
Data collection and reporting assignment of codes - etiologic diagnosis are ?These are Reported on IRF PAI, Problem that led to the condition requiring admission to IRF, ICD 10 CM code, Principle diagnosis as defined by UHDDS not reported on IRF PAI.
Regarding data collection & reporting assignment of codes - what are the comorbidities and complications?Comorbidity - specific condition present on admission (Chronic illnesses that a patient may have), Complication – comorbidity that occurs after admission to IRF, Comorbidity and complications may affect etiologic diagnoses and impairments
Comorbidities may report up to how many ICD codes?Up to 10 ICD codes.
There are about 900 comorbidities that affect IRF PPS assigned to tiers by cost what are they?1. high cost - 2. medium cost - 3. low cost
Regarding data collection what tool captures residents functional status?Functional independence assessment tool
What is meant by functional status?The ability to perform ADLs .
Explain the scale that is widely used to measure severity of patients impairments.Scale is 0 to 7: 7 = complete independence, 1 = complete dependence, 0 = CMS added for "not assessed". The lower score equals fewer funcitional abilities and greater resources used.
When must the IRF PAI be completed and how is it submitted?At admission and discharge, electronically.
Regarding the completion of the IRF PAI what will failure to follow timeframes result in?Penalties, Generally, 24% reduction in payment, Medicare Part C forfeit ability to include calculation of compliance percentage.
** What are the three components in IRF PPS?1. Standard payment (base rate), 2. IRF case-mix group 3. Adjustments

Section 3

Question Answer
The Balanced Budget Act of 1997 did what?Authorized case-mix adjusted prospective payment system for inpatient rehabilitation facilities.
IRF PPS (Inpatient Rehabilitation Facility PPS) is based on what?Classifying patients with similar characteristics into case-mix groups.
**Minimum percentage of patients must have what?A qualifying condition in order to be admitted to an inpatient Rehabilitation Facility.
**Which University is associated with the development of Medicare's resource-based relative value scale payment?Harvard
**Which element of the relative value unit accounts for the operational costs of delivering healthcare services, such as rent, wages of technicians, and supplies and equipment? Practice Expense
**Under OPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called?APCs
** APCs are based on what type of codes?CPT or HCPCS code(s).
**What is the maximum amount of APCs that are assigned per HCPCS or CPT code?One
** How many PACs can be on a claim?Unlimited.
** What are the elements of an RVU (Relative Value Unit)?Physician work (work), Physician practice expenses (PE), Malpractice (MP)/Professional Liability Insurance(PLI)
** What is the name of the researcher who developed a system of classifying health services using resource based relative values?Dr. William Hsaio
**Which University is the researcher who developed a system of classifying health services assicated with?Harvard

Section 4

Question Answer
**In the RBRVS, what is another term for the element that represents the cost of malpractice insurance?Professional liability insurance (PLI)
** In the RBRVS, what is the term for the across-the-board multiplier that transforms the geographically adjusted RVU into MPFS (Medicare physician fee schedule ) payment amount?The Conversion Factor (CF)
** What does GPCI stand for?Geographic Practice Cost Index is used along with Relative Value Units by Medicare to determine allowable payment amounts for medical procedures. There are multiple GPCIs: Cost of Living, Malpractice, and Practice Cost/Expense.
** True or False, Payments under the RBRVS (Resource-based relative value scale for physicians) are unaffected by the clinician's type?False
** What tool does CMS require that SNFs use to collect and report clinical data about residents?RUG (Resource Utilization Groups)
** What tool does the SNF PPS use annually to adjust payment rates?The market basket index, which is based on the mix of goods and services included in the SNF prospective payment system (PPS). MDS - Minimum data set
** What cost sharing applies to beneficiaries residing in an LTCH for 90 days?An inpatient deductible must be paid for the 90-day benefit period; plus, a daily coinsurance payment applies for the 61st through 90th day.
** True or False, Even though MS-LTC-DRGs differ form acute-care MS-DRGs because MS-LTC-DRGs have different relative weights and use quintiles for low volumes.True
** What converts the MS-LTC-DRG into an unadjusted payment amount?Standard federal rate
**What are the key components of payment system?Data collection on specified instrument, Electronic submission, Single per discharge unit of payment, Case-mix grouping.