Ch. 5-Medicare Hospital Acute Inpatient Payment System

Question 1

Arithmetic mean length of stay (AMLOS)

Answer 1

Sum of all lengths of stay in a set of cases divided by the number of cases

Question 2

Base payment rate

Answer 2

-rate per discharge for operating and capital-related components for an acute-care hospital
-prospectively set payment rate made for services that Medicare beneficiaries receive in healthcare settings
Base rate is adjusted for geographic location, inflation, and other factors

Question 3

Case mix

Answer 3

Set of categories of patients (type and volume) treated by a healthcare organization and representing the complexity of the organization’s caseload

Question 4

Case-mix index (CMI)

Answer 4

Single number that compares the overall complexity of the healthcare organization’s much of patients with the complexity of the average of all hospitals.
Typically for a specific period and is derived from the sum of all diagnosis-related group (DRG) weights divided by all the number of cases

Question 5

CC/MCC exclusion list

Answer 5

Set of principal diagnosis codes that is closely related to a CC or MCC code that takes away the refinement power of the CC or MCC code for an encounter

Question 6

Comorbidity

Answer 6

Pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75% of the cases

Question 7

Complication

Answer 7

-a medical condition that arises during an inpatient hospitalization
-a condition that arises during the hospital stay that prolongs the length of stay at least one day in approximately 7 75% of the cases

Question 8

Complication and comorbidity (CC)

Answer 8

Diagnosis codes that when reported as a secondary diagnosis have the potential to impact the MS-DRG assignment by increasing the MS-DRG up one level
Represent an increase in resource intensity for the admission

Question 9

Cost report

Answer 9

Report required from institutional providers on an annual basis for the Medicare program to make a proper determination of amounts payable to providers under its provisions in various prospective payment systems

Question 10

Cost-of-living adjustment (COLA)

Answer 10

Alteration that reflects a change in the consumer price index (CPI), which measures purchasing power between time periods
Based on a market basket of goods and services that a typical consumer buys

Question 11

Disproportionate share hospital (DSH)

Answer 11

Healthcare organizations meeting governmental criteria for percentages of indigent patients
Hospitals with an unequally large share of low-income patients
Federal payments to these hospitals are increased to adjust for the financial burden

Question 12

Federal Register

Answer 12

The daily publication of the US Government Printing Office that reports all regulations; legal notices of federal administrative agencies, of departments of the executive branch, and of the president: and federally mandated standards, including HCPCS and ICD-10-CM codes

Question 13

Final rule

Answer 13

Regulation published by an agency, commented on by the public, and published in it’s official form in the Federal Register
Has the force of law on it’s effective date

Question 14

Geometric mean length of stay (GMLOS)

Answer 14

The nth root of a series of n length of stay observations

Question 15

Grouper

Answer 15

Computer program using specific data elements to assign patients, clients, or residents to groups, categories, or classes

Question 16

Hospital-acquired condition (HAC)

Answer 16

Condition that developed during the hospital admission

Question 17

Indirect medical education (IME)

Answer 17

Percentage increase in Medicare reimbursement to offset the costs of medical education that a teaching hospital incurs

Question 18

Labor-related share

Answer 18

Sum of facilities’ relative to proportion of wages and salaries, employee benefits, professional fees, postal services, other labor-intensive services, and the labor-related share of capital costs from the appropriate market basket
Typically 70-75% of healthcare facilities’ costs; adjusted annually and published in the Federal Register

Question 19

Major complication and comorbidity (MCC)

Answer 19

Diagnosis codes that when reported as a secondary diagnosis have the potential to impact the MS-DRG up one or two levels
Represents the highest level of resource intensity

Question 20

Major diagnostic category (MDC)

Answer 20

Highest level in hierarchical structure of the federal inpatient prospective payment service (IPPS)
Primarily based on body system involvement; few based on disease etiology

Question 21

Measure

Answer 21

-the quantifiable data about a function or process
-an activity, event, occurrence, or outcome that is to be monitored and evaluated to determine whether it confirms to standards; commonly relates to the structure, process, or outcome of an important aspect of care(criterion)
-a measure used to determine an organization’s performance over time
-activity that affects an outcome
-compliance with treatment guidelines or standards of care

Question 22

Medicare administrative contractor (MAC)

Answer 22

Contracting authority to administer Medicare Part A and B as required by section 911 of the Medicare Modernization Act of 2003
Process and manage Part A and B claims

Question 23

Medicare severity diagnosis-related group (MS-DRG)

Answer 23

Medicare refinement to the diagnosis-related group (DRG) classification system, which allows for payment to be more closely aligned with resource intensity

Question 24

MS-DRG family

Answer 24

A group of MS-DRGs that have the same base set of principal diagnoses with or without operating room procedures, which are divided into levels to represent severity of illness (SOI)

Question 25

New technology

Answer 25

Advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries

Question 26

Nonlabor share

Answer 26

Facilities’ operating costs not related to labor (25-30%)

Question 27

Outlier

Answer 27

Cases in prospective payment systems with unusually long lengths of stay or exceptionally high costs; day outlier or cost outlier, respectively

Question 28

Performance achievement

Answer 28

Comparison of a facility’s performance with all other facilities’ performance

Question 29

Performance improvement

Answer 29

Comparison of a facility’s current performance with the facility’s baseline performance

Question 30

Post-acute-care transfer (PACT)

Answer 30

Under IPPS, a transfer to a nonacute-care setting for designated MS-DRGs is treated as an IPPS-to-IPPS transfer when established criteria are met

Question 31

Present on admission (POA) indicator

Answer 31

Code used to indicate if the condition of disease was present before the admission or developed during the hospital admission

Question 32

Principal diagnosis

Answer 32

Reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Question 33

Proposed rule

Answer 33

Regulation published by a federal department or agency in the Federal Register for the public’s review and comment prior to its adoption
Does not have force of law

Question 34

Quality reporting program

Answer 34

Federal program in which the action of reporting data in the proper format within the given time frame is what allows facilities to receive full reimbursement

Question 35

Relative weight (RW)

Answer 35

Assigned weight that reflects the relative resource consumption associated with a payment classification or group
Higher payments are associated with higher relative weights

Question 36

Resource intensity

Answer 36

Measure of the amount of resources required to treat a patient
Represented by the relative weight and is utilized to determine the final payment amount

Question 37

Severity of illness (SOI)

Answer 37

The degree of illness and extent of physiological decompensation or organ system loss of function

Question 38

Total performance score (TPS)

Answer 38

Measure of a facility’s overall performance for the clinical domain measures and other requirements included in a value-based purchasing program

Question 39

Transfer

Answer 39

Discharge of a patient from a hospital and readmission to a post-acute-care or another acute-care hospital on the same day

Question 40

Value-based purchasing (VBP)

Answer 40

Payment model that holds healthcare providers accountable for both the cost and quality of care they provide

Question 41

Wage index

Answer 41

Ratio that represents the relationship between the average wages in a healthcare setting’s geographic area and the national average for that healthcare setting
Adjusted annually and published in the Federal Register

Question 42

Withhold

Answer 42

-portion of primary care providers’ prospective payments that managed care organizations deduct and hold to create an incentive for efficient or reduced use of healthcare services
-portion of facility payments that are held back and then redistributed bases on a facility’s performance for the designated quality measures