1.6 CM Reimbursement and Payment Methodologies Flashcards
2 main reimbursement categories for paying healthcare?
Fee-for- service, episode-of-care
with this reimbursement, each service rendered is priced separately. And believed to encourage overuse of healthcare resources.
Fee-for-service
With this reimbursement, the episode is reimbursed in one lump sum, eliminating individual fees or charges.
Episode-of-care
There are 2 types of episode-of-care reimbursement. What are they?
- bundled/case rates
2. Prospective Payment System
This episode of care reimbursement type makes a single payment for all services related to a treatment or condition. ex: total hip replacement
bundled/case rates
This is an episode of care reimbursement type in which payment is made based on a predetermined, fixed amount (ex: incentive for hospital to call in staff during weekend to make a diagnosis/do a procedure)
Prospective Payment System (PPS)
Medicare’s PPS determines the payment amount for a particular service based on the classification system of that service. For example, for an inpatient hospital stay, the classification system is the ______________.
Diagnosis Related Group (DRG)
_____ ______ _______ (VBP) is a Centers for Medicare and Medicaid Services (CMS) initiative that rewards acute care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries.
Value Based Purchasing
Is a coding system used to report medical diagnoses and procedures on claims as well as to gain data for public health surveillance.
International Classification of Diseases (ICD)
The ICD code is the ____/____ for the encounter with the health system
Diagnosis/reason
Is a code to report services performed to payers for reimbursement purposes, assigning a code for each procedure done during that visit.
Current Procedural Terminology (CPT)
While the ICD-10 code tells the reason for the visit, the CPT code lists the _____ performed (e.g. evaluation and management, venipuncture, ECG).
Service
Combines ICD-10 codes with patient demographics, discharge status, and the presence of complications or comorbidities to classify a hospital admission into a payment category, based on the assumption that similar diagnoses should have similar hospital resource use adn length of stay patterns.
Diagnosis Related Group (DRG)
Each diagnosis includes a ______ ______ that providers, institutions, and agencies use for billing and data collection.
Diagnostic Code
