Ch. 5-Medicare Hospital Acute Inpatient Payment System Flashcards
Arithmetic mean length of stay (AMLOS)
Sum of all lengths of stay in a set of cases divided by the number of cases
Base payment rate
-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
Case mix
Set of categories of patients (type and volume) treated by a healthcare organization and representing the complexity of the organization’s caseload
Case-mix index (CMI)
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
CC/MCC exclusion list
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
Comorbidity
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
Complication
-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
Complication and comorbidity (CC)
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
Cost report
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
Cost-of-living adjustment (COLA)
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
Disproportionate share hospital (DSH)
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
Federal Register
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
Final rule
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
Geometric mean length of stay (GMLOS)
The nth root of a series of n length of stay observations
Grouper
Computer program using specific data elements to assign patients, clients, or residents to groups, categories, or classes
Hospital-acquired condition (HAC)
Condition that developed during the hospital admission
Indirect medical education (IME)
Percentage increase in Medicare reimbursement to offset the costs of medical education that a teaching hospital incurs
Labor-related share
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
Major complication and comorbidity (MCC)
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
Major diagnostic category (MDC)
Highest level in hierarchical structure of the federal inpatient prospective payment service (IPPS)
Primarily based on body system involvement; few based on disease etiology
Measure
-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
Medicare administrative contractor (MAC)
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
Medicare severity diagnosis-related group (MS-DRG)
Medicare refinement to the diagnosis-related group (DRG) classification system, which allows for payment to be more closely aligned with resource intensity
MS-DRG family
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)
New technology
Advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries
Nonlabor share
Facilities’ operating costs not related to labor (25-30%)
Outlier
Cases in prospective payment systems with unusually long lengths of stay or exceptionally high costs; day outlier or cost outlier, respectively
Performance achievement
Comparison of a facility’s performance with all other facilities’ performance
Performance improvement
Comparison of a facility’s current performance with the facility’s baseline performance
Post-acute-care transfer (PACT)
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
Present on admission (POA) indicator
Code used to indicate if the condition of disease was present before the admission or developed during the hospital admission
Principal diagnosis
Reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
Proposed rule
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
Quality reporting program
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
Relative weight (RW)
Assigned weight that reflects the relative resource consumption associated with a payment classification or group
Higher payments are associated with higher relative weights
Resource intensity
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
Severity of illness (SOI)
The degree of illness and extent of physiological decompensation or organ system loss of function
Total performance score (TPS)
Measure of a facility’s overall performance for the clinical domain measures and other requirements included in a value-based purchasing program
Transfer
Discharge of a patient from a hospital and readmission to a post-acute-care or another acute-care hospital on the same day
Value-based purchasing (VBP)
Payment model that holds healthcare providers accountable for both the cost and quality of care they provide
Wage index
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
Withhold
-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
