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CIC > Basics > Flashcards

Basics Flashcards

1
Q

ACF

A 
Acute Care Facility: a healthcare facility that provides continuous professional medical care to patients in an acute phase of illness. Inpatients generally have severe symptoms.
Include: 
*General Hospitals
*Specialty Hospitals
*Private Hospitals 
*Public Hospitals
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2
Q

Admitting Office

A 
Collects all pertinent information related to patient care. 
Insurance cards/info
Demographics
Type of service patient requires
Patient consent for treatment
Diagnostic information
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3
Q

ASC

A

Ambulatory Surgical Center

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4
Q

Requirements for an ASC (3)

A

If hospital owned:

  • must be a separately identifiable entity, physically, administratively, and financially independent and distinct from other operations of the hospital
  • meet all health and safety requirements
  • is surveyed and approved as complying with conditions for coverage in an ASC
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5
Q

Ambulatory Surgery

A

Surgical Procedures performed on a patient who is admitted, treated, and released on the same day.

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6
Q

Business Office

A 
Generate claims
Processes Remittance Documents
Appeal denials/rejected Claims
Post Payment 
AKA: patient financial services
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7
Q

CAH

A

Critical Access Hospital: A hospital certified under a set of Medicare Conditions of Participation (CoP), which are structured differently Than the acute care hospital CoP. Requirements for CAH certification include having no more than 25 inpatient beds (inpatient or swing beds). maintains an annual average length of no more than 96 hours for acute inpatient care; offering 24-hour, 7-day-a-week emergency care; and being located in a Rural area, at least 35 miles drive way from any other hospital or CAH.
Be certified by the state as being a. Necessary provider of healthcare services. May also operate a distinct part rehab or psychiatric unit, with a max of 10 beds each.

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8
Q

Chargemaster

A

Master inventory list of everything that can be reported or performed in the hospital

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9
Q

Clinic

A

An outpatient facility that provides scheduled diagnostic, curative, rehab, and education services for walk-in (ambulatory) patients

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10
Q

Consultation

A

Advice or opinion rendered at the request of another qualified provider

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11
Q

Cost Report (Medicare)

A

An annual report required of facility contractors participating in the Medicare Program. The report details the cost and charges the provider incurred in rendering services to all patients, and the Medicare payments received during a specific reporting period. Cost and reporting procedures are defined by the Medicare Program.

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11
Q

CORF

A

Comprehensive Outpatient Rehabilitation Facility

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12
Q

CORF covered services (8)

A
  • Provider services related to the administrative functions
  • PT, Occupations Therapy, speech pathology services, and respiratory therapy
  • Social and psychological services
  • Nursing care provided under the supervision of a registered professional nurse
  • prosthetic/orthopedic devices-including testing, fitting, or training in the use of the device
  • Supplies, appliances and equipment, including purchase or rental of DME from the CORF
  • Drugs and biologicals that cannot be self-administered
  • a single home visit to evaluate the potential impact of the home environment on the rehabilitation goals
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13
Q

DRG

A

Diagnosis Related Groups: A patient classification scheme that relates the type of patients a hospital treats to the costs incurred by the hospital.

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13
Q

Reimbursement for CORF

A

All services are paid under MPFS, except: drugs, biologicals, and DMEPOS. Paid 80% of the charge, or the MPFS. Patient can be billed for 20%. The facility pays the contracted provider.

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14
Q

CAH Billing under the Standard Payment Method

A

Bill for only the facility fees, and are reimbursed:

  • 80% of the 101% of reasonable costs for outpatient CAH services, or
  • 101% of the reasonable costs for the CAH in furnishing in furnishing outpatient CAH services, less the applicable Part B deductible and coinsurance amounts.
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15
Q

CAH Billing under the Optional Payment Method

A

CAH bills for the facility fees and professional fees. Reimbursement:

  • Facility services: 101% of reasonable costs, after applicable deductions, regardless of whether the physician or practitioner has reassigned his or her billing rights to the CAH
  • Professional Fees: 115% of the allowable amount, after applicable deductions, under the Medicare Physician Fee Schedule. Payment for NPP is 115% of the allowed amount for the NPP under the Medicare PFS
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16
Q

Diagnostic Laboratory Services

A

Laboratory services required in the diagnosis of a disease or injury, regardless of where the services are rendered. For Medicare purposes, these services are paid under a separate fee schedule. These services include clinical lab tests performed on automated multichannel analyzers.

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17
Q

Diagnostic Services

A

An exam or procedure performed on a patient to obtain information to assess the medical condition of the patient or to identify a disease and/or to determine the nature and severity of an illness or injury(e.g., diagnostic lab tests, X-Rays, EKG’s, pulmonary function tests, or psychological tests).

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19
Q

Diagnostic X-ray Services

A

X-ray and other related imaging services performed for diagnostic procedures, including portable X-ray services.

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20
Q

EMTALA

A

Emergency Medical Treatment and Active Labor Act:
Requires any Medicare-participating hospital that operates a hospital ED to provide an appropriate medical screening exam to any patient that requests such an exam.

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20
Q

Direct Supervision

A

Procedure/Service performed under the physician’s overall direction and control, but his presence is not required. He is required to be on campus

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21
Q

Type A ED

A

Facility open 24 hours per day, 7 days per week- for immediate attention and urgent and emergent care

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22
Q

Type B ED

A

Facility meeting specific licensing requirements, not open 24 hours/day

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23
Q

General Supervision

A

Physician is not required to be present in the room when a service/procedure is performed, but must be immediately available.

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24
Q

HIM

A

Health Information Management Department.
AKA: Medical Records Dept
Organizes and stores the patient’s medical information.
Manage the Privacy Rule under HIPAA- protect individual PHI.

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25
Q

HIPAA Privacy Rule

A

Notify Patient about their Privacy Rights and how their info can be used
Adopt and implement Privacy Procedures
Train Employees so they understand the privacy procedures
Designate an individual to make sure the privacy procedures are adopted and followed

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26
Q

Hospital Clinic

A

Outpatient services, consultations, minor office procedures deemed as not a medical emergency. Can be scheduled or non-scheduled

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27
Q

Inpatient

A

Patients requiring an inpatient admission. Formally admitted to a hospital with a physician’s order

27
Q

Hospital Outpatient

A

A person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatients and received services (rather than supplies alone) from the hospital or CAH

28
Q

Inpatient/Inpatient CAH services include:

A
  • Bed and Board
  • Nursing Services and other related services
  • Use of the facility
  • Medical Social Services
  • Drugs, Biologicals, supplies, applicants, and equipment
  • Certain other diagnostic or therapeutic services
  • Medical/Surgical services provided by certain interns or residents in training
  • Transportation services, including ambulance
29
Q

Inpatient Admittance allowed from:

A

ED, observation, following surgical procedures, from clinics, or at a physicians request

30
Q

Inpatient Services do not Include:

A
  • Post hospital SNF care furnished by a hospital or CAH that has a swing-bed approval
  • Nursing Facility’s revives that may be furnished as a Medicaid service under title XIX of the Act in a swing-bed hospital that has an approval to furnish nursing facility services
  • Pro-Fee Physician Services
  • PA services defined in 1861(Ii) of the Act
  • NP and Clinical Nurse Specialist Services
  • Certified Nurse Mid-wife Services
  • Qualified Psychologist Services
  • Services of an Anesthetist (Anesthesiologist)
30
Q

IPPS

A

Medicare’s Inpatient Prospective Payment System: system which dictates payments made by Medicare Part A for inpatient hospital stays using Medicare Severity Diagnosis Realted Group Methodology (MS-DRG)

32
Q

Fellows

A

Physicians who are obtaining additional training in a sub specialty after residency training.

33
Q

LTCH

A

Long-term Care Hospital:
Certified as acute care hospitals, but focus on patients who, on average, stay more than 25 days. Specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home.

34
Q

Medical Documentation

A

Includes the following types of patient care records: operative notes; physical, occupational, and speech-language pathology notes; progress notes; physician certification and recertification; ER records, and the patient’s medical record in its entirety.

35
Q

Intern

A

Usually in their first year following graduation from medical school, and are completing a one-year rotation in various departments of the teaching facility departments of the hospital that depend on specialties.

36
Q

Requirements for Inpatient Status

A

Based on the physician’s judgments and the need for Medically necessary hospital care. The patient’s condition must demonstrate medical necessity to require an inpatient stay.

37
Q

Medicare Carriers Manual

A

A manual that encompasses Medicare’s policies regarding billing and reimbursement. This document is created and maintained by CM/S, which provides it to Medicare Administrative Contractors (MACs) (local Part B carriers and fiscal intermediaries [FI]s) to assist with uniform reimbursement.

37
Q

Medicare Hospital Manual

A

Manual containing information issued to hospitals participating in the Medicare program. It contains the policies and procedures applicable to the delivery of hospital services, claims process instructions, billing procedures, coverage requirements, and related Medicare matters.

38
Q

Medicare Provider

A

A facility, supplier, or physician who furnishes Medicare services.

40
Q

Medicare Part A

A
  • Covers inpatient hospital care
  • Skilled Nursing Facility care
  • Nursing home care
  • Home Health Services
40
Q

MLP

A

Mid level Practitioner: Professionals (eg, NP, nurse midwives, physical therapists, physician assistants, and others who provide medical care) without physician input or under physician direction; also called NPP’s.

42
Q

LTCH Payment

A

Through Medicare Part A; Medicare’s LTCH Prospective Payment System per discharge system, with a DRG based patient classification system that reflects the difference in patient resources and costs.

44
Q

Non-patient Services

A

Typically refers to lab tests performed on samples sent to the hospital lab from an outside source to process. The account is established, but the services are rendered on the specimen rather than to a patient seen at the hospital.

45
Q

MS-DRG

A

Medicare Severity Diagnosis Related Group Methodology: classification system that groups similar clinical conditions or diagnosis and the procedures furnished by the hospital during the patient’s stay.

46
Q

Observation Services

A

Services furnished on a hospital premises, including use of a bed and periodic monitor by a Hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient.

47
Q

Occupational Therapy

A

Therapy meant to help a patient recover from a serious illness or injury and return to the activities of daily life.

48
Q

OPPS Final Rule

A

Outpatient Prospective Payment System. CMS determines the surgeries safe to perform in an outpatient hospital and ASC.

49
Q

Included in Hospital Outpatient Surgery Charges

A 
Nursing Personnel
Rom costs (operating, treatment, cast, etc)
50
Q

Not Included in Hospital Outpatient Charges

A

*But can be billed separately if supplied by the hospital
Provider and Anesthesiologist Professional Fees
DME
Prosthetic Devices (except intraocular lens)
Ambulance Services
Outside Laboratory Services
Certain drugs and biologicals (pass-through payments)

52
Q

Outpatient Services, (includes 9 components)

A

Medical and other services provided by the hospital or other qualified supplier that are either diagnostic or aid the provider in treating the patient. Covered under Medicare Part B and include the rental or purchase of:

  • DME prescribed by the Doctor for use in the home;
  • devices, other than dental, to replace all or part of an internal body organ;
  • certain ambulance services;
  • lab services;
  • X-ray and other radiology services;
  • ER and outpatient clinic services;
  • medical supplies, splints, and casts; other diagnostic services;
  • physical, occupational therapies, and speech pathology services;
  • dialysis in the Facility or home, and outpatient surgery.
54
Q

Outpatient Cancer Center

A

Patient’s receiving chemo or radiation therapy will present to the cancer center to receive treatment

56
Q

Plan of Treatment

A

Written documentation of the type of therapy services (e.g., physical, occupation, speech-language pathology, cardiac rehab) to be provided to a patient and the amount, frequency, and duration (in days, weeks, months) of the services to be provided. An active treatment plan must identify the diagnosis, the anticipated goals of the treatment, the date the plan was established, and the type of modality or procedure used.

57
Q

Outpatient Diagnostic Testing

A

Diagnostic Testing that cannot be performed in a physician’s office or an independent diagnostic testing facility. Results are sent to the ordering physicians. Hospital bills for the Technical Component. Facility must have an order from the physician stating which test, and the diagnosis supporting Medical necessity.

58
Q

PPS

A

Prospective Payment Systems: Method of reimbursement in wich Medicare payment is made based on a predetermined fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services).

59
Q

Personal Supervision

A

Physician must be in attendance in the room during the performance of the service or procedure

60
Q

Partial Hospitalization

A

AKA: ‘step down program’
Full day programs for psychiatric serves. Goal is to help patients transition to daily life. Services are performed in an outpatient hospital department or a community mental health center (CMHC)

61
Q

Radiology Services

A

Services that include diagnostic and therapeutic radiology, nuclear medicine, CT scan procedures, MRI services, ultrasound, and other imaging procedures. Medicare reimbursement for outpatient radiology procedures in based on APC’s. CPT and HCPCS Level II codes are required for billing outpatient radiology procedures.

62
Q

Residents

A

Licensed physicians, have 2-5 (possibly more) years of training in that specialty.

63
Q

Outpatient Therapy

A

Course of treatment in which the patient needs to present to the outpatient department on a regular basis to receive the authorized services. Hospital uses a recurring account number to capture all therapy charges under the same account.

64
Q

RUG

A

Resource Utilization Group:
These are categories that reflect levels of resource needed in long terms care settings, primarily to facilitate Medicare and Medicaid payment.

65
Q

Swing Bed

A

Rural hospitals with fewer than 100 beds can provide post-hospital extended care services to Medicare beneficiaries. Swing bed facilities can swing their beds from hospital to SNF levels of care.

66
Q

Urgent Care

A

Services furnished within a short period of time to avoid the likely onset of an emergency medical condition.

67
Q

SNF

A

Skilled Nursing Facility: provide daily care for patients requiring skilled Nursing care or rehab services for injuries, disabilities, or illness. Services are provided over a longer time than those in an acute inpatient facility. Medicare covers up to 100 days.

68
Q

SNF PPS

A

Medicare’s Skilled Nursing Facility Prospective Payment System using Resource Utilization Groups (RUG’s) payment classification. PPS rates cover all operating and capital costs that would be expected in furnishing most SNF services. Separate payment is available for certain high cost, low probability ancillary services.

69
Q

Two Midnight Rule

A

Applied to Medicare Patients: When a physician expects the patient to require care that crosses 2 midnights and orders admission based on that expectation, inpatient status is generally appropriate. But hospital stays that require care less than 2 midnights, is considered outpatient care.

70
Q

Facilities Two Midnight Rule Applies to:

A

LTCH, CAH. Does not apply to IRF

71
Q

Teaching Hospital

A

Hospitals affiliated with medical schools to train physicians. Teaching settings receive direct Medicare GME (Graduate medical Education) payment for residents’ services.

72
Q

Exceptions to Two Midnight Rule

A

Procedures found on the Medicare Inpatient Only list, regardless of length of stay. Also situations of transfers and patient expiration.

CIC (3 decks)

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