Ch.5 Outpatient Prospective Systems

Question 1

Out patient Prospective Payment Systems (OPPS)

Answer 1

implemented 2000
based on fixed rates, predetermined, paid under medicare part B

Question 1

Outpatient prospective system was decided based on

Answer 1

success on inpatient , so wanted to implement PPS on continuum level of care

Question 2

OPPS services include

Answer 2

hospital based clinics
emergency dept visits
observations
ambulatory surgery depts

Question 3

goal of OPPS

Answer 3

shift financial risk to hospital rather medicare, creat incentive for cost control

Question 4

CMS maintains ?

Answer 4

inpatient-only list
which is services medicare only pay when performed in the inpatient setting

Question 5

Ambulatory Payment Classifications (APC)

Answer 5

used to reimburse outpatient services
all outpatient services assigned to APC group
payment is prospective, fixed, annually updated

Question 6

two times rule

Answer 6

median cost of most expensive item/service within a group cannot be 2x > median cost of least expensive within same group

Question 7

procedures are identified by

Answer 7

Healthcare common procedure codes system
HCPCS

Question 8

HCPCS level I

Answer 8

current procedural terminology (CPT) codes all procedures and services done by physicians, nonphys practitioners, hospital labs, outpatient facilities
consist of 5 numbers
maintain by AMA

Question 9

HCPCS level II

Answer 9

code set used by provider and medical equipment suppliers
maintained by CMS
consist of 5 characters made up of a letter, 4 number

Question 10

APC payments are determined by

Answer 10

HCPCS codes

Question 11

CPT code identify

Answer 11

procedure

Question 12

HCPCS II code is added when

Answer 12

required to report products that may have been prescribed, injected, or otherwise delivered to the pt during the service

Question 13

payment rate and copayment calculated for APC applies to

Answer 13

each service within APC group

Question 14

Packaging is when

Answer 14

minor ancillary services associated with procedure is combined for single payment
only used in OPPS

Question 15

bundling occurs

Answer 15

when predetermined set services performed together during encounter result in reimbursement for all services combined into one payment

Question 16

assigned by CMS to HCPCS codes to id whether payment is made separately or as packaged

Answer 16

status indicators

Question 17

when services with status indicators are performed

Answer 17

associate ancillary/supportive items are packaged into payment

Question 18

each APC is weighted and has a

Answer 18

prospective payment amount associated

Question 19

if patient is assigned multiple APCs the payments are

Answer 19

totaled to provide reimbursement to hospital for encounter

Question 20

weights are based on

Answer 20

average resources used to treat patients in a particular APC -avg 1.000

Question 21

applied to the relative weight by CMS

Answer 21

a conversion factor

Question 22

adjusts payments to account for geographic variations in labor cost

Answer 22

wage index

Question 23

provides additional reimbursement to hospitals that use innovative biologicals, drugs, technology

Answer 23

add ons

Question 24

Ambulatory Surgical Center (ASC)

Answer 24

furnish outpatient services to pt who do not require hospitalization - less 24 hours following admission

Question 25

payment for ASC

Answer 25

under medicare part B ASC payment system used

Question 26

Ambulatory surgical center payment rates are

Answer 26

predetermined amounts ASC reimbursed 80% after adjustment for regional variation

Question 27

outpatient code editors (OCE)

Answer 27

software programs that medicare administrative contractors (MACs) use to audit coding data

Question 28

OCE basic functions

Answer 28

1. edit data on claim for accuracy 2. specify action the MAC should take when an edit occur 3. assign APC to claim for hospital outpatient service 4. determine payment related conditions that require a direct reference to HCPCS codes on modifier

Question 29

applied to claims on individual diagnosies and procedure sets

Answer 29

edits

Question 30

goal of edits is to

Answer 30

weed out incomplete or incorrect claims, detect fraud and abuse, encourage correct application of coding guideline

Question 31

actions when OCE edit occur

Answer 31

-claim may be rejected -claim may be denied -claim may be place on suspension

Question 32

Skilled Nursing facility (SNF)

Answer 32

provide short term skilled nursing care and rehab service to medicare beneficiaries after acute inpatient hospitalization

Question 33

medicare beneficiaries are eligible for SNF services when ?

Answer 33

immediately after acute inpatient hospitalization of at least 3 days may receive up to 100 days covered per benefit period

Question 34

7 major RUG categories

Answer 34

rehabilitation extensive services special care clinically complex impaired cognition behavior only decreased physical function

Question 35

each RUG have their own

Answer 35

associated nursing and therapy weights applied to the base rate

Question 36

the payment to the SNF for resident care is a

Answer 36

combination of the base rate and the resident's RUG score

Question 37

home health services covered under

Answer 37

medicare A & b

Question 38

patient driven groupings model (PDGM)

Answer 38

focus on clinical characteristics to better align medicare payment with patient care needs

Question 39

under PDGM, 3 domain components of the home health resource group remain same which is

Answer 39

clinical functional service