EXAM 1 Flashcards
Ambulance service entities associated with a medical facility
• Hospital, CAH, SNF
Ambulance Fee Service Entity – provider
Ambulance service entities not associated with a medical facility
• Independent ambulance companies
Ambulance Fee Service Entity – supplier
Set of Categories of patients (type and volume) treated by a healthcare organization and representing the complexity of the organizations case load
Case Mix
what is the payment if patient dies prior to the ambulance being called?
BLS(Basic Life Support) base rate payment will be paid
When was ambulance fee schedule implemented?
April 1, 2002
How many MDC categories are there?
25
Medical necessity via physician certification must be provided for which type of ambulance transport?
Nonemergency transport
What is the basis for labor related share in IPF PPS?
Facilities costs related to payrolls, benefits, and professional fees
Add up the total number of CMS Relative Weights and divide by the total number of patients.
123.6651 / 155 = 0.7978
Calculation of case mix index
Multiply the “CMS Relative Weight” by the total number of cases (patients) in the MS DRG group.
11.6835 = (0.7789 x 15)
Calculating Total CMS Relative Weight
DRGs system was implemented?
October 1, 1983 or 2007
Basic life support advanced life support - level 1 advanced life support - level 2 specialty care transport paramedic als intercept fixed wing air ambulance rotary wing air ambulance
Ambulance levels of service
emergency medical technician provides basic life support, including establishment of a peripheral intravenous line
Basic life support
assessment provided by an advanced EMT or paramedic (ALS crew) to determine patient needs and the furnishing of one or more ALS interventions. An ALS intervention is a procedure beyond the scope of an EMT
Advanced life support - level 1
administration of at least three different medications or the provision of one or more ALS procedures
Advanced life support - Level 2
critically injured or ill patients, the level of interhospital service furnished is beyond the scope of a paramedic; next level care is provided by one or more healthcare professionals in an specialty care area
specialty care transport
ALS services provided by an entity that does not provide an ambulance transport
Paramedic ALS intercept
flight transport; destination is inaccessible by land vehicle or great distances or other obstacles and the patients condition is not appropriate for BLS or ALS ground transportation
Fixed wing air ambulance
Helicopter transport; destination in accessible by land vehicle or great distances or other obstacles and the patients conditions are not appropriate for BLS or ALS ground transportation
Rotary wing air ambulance
Uses a limited amount of equipment to perform initial assessments and interventions
First responders
Knowledge and skill of a first responder but is also qualified to provide basic emergency medical care in the field, as the minimum staff for an ambulance
EMT
Knowledge and skills identified at the first responder and EMT levels but is also qualified to perform essential advanced techniques and to administer a limited number of medications
Advanced EMT
Has advanced skills and can administer additional interventions and medications
Paramedic
Computer program using specific data elements to assign patients, clients, or residents to group, categories, or classes
Grouper
Adjustment for geographic differences in cost Each RVU category has a corresponding Based on “locality” or payment areas Can be Large metropolitan area Boston or San Francisco Portions of states Rest-of-state areas Entire state
GPCI – Geographic practice cost indexes
Overhead costs of the practice
Clinical and administrative payroll, office expenses, medical material and supply costs, medical equipment costs
Two PE components: Facility (hospital); Nonfacility (physician office)
Practice expense in RBRVs
Time required and intensity of procedure Mental effort and judgment Technical skill Physical effort Psychological stress
Work expense in RBRVs
Assigned to HCPCS codes are a measure of resource utilization There are 3 RVU categories Work PE MP or PLI
Relative value units
[(WORK RVU) (WORK GPCI) + (PE RVU) (PE GPCI) + (MP RVU) (MP GPCI)] = (SUM) × CF = Medicare Physician Fee Schedule (MPFS) Amount
Example: [(0.93) (0.990) + (1.11) (0.917) + (0.08) (1.005)] = (SUM) × $35.9996 = $72.66
RBRVs payment calculation
How might a hospital increase their case mix?
create a task force or group of personnel for Clinical Documentation Improvement (CDI). The role of this group is not only to review all physician/clinician documentation for accuracy and to eliminate mistakes and lack of precision that impact billing and payments, but also to create processes that eliminate the most common mistakes made in documentation.
How are payment rates established for IPPS?
base payment rate is multiplied by the DRG relative weight.
Wage Adjustments - ($771.35 * 0.75 * 0.9716) + ($771.35 * 0.25)
$754.92
Multiply the adjustment factors together
1.17 * 0.99 * 1.10 * 1.06 * 1.05 = 1.4181
1.4181 * $754.92 = $1,070.55 (adjusted per diem amount)
Day 1 1.31 * $1,070.55 = $1,402.42
Day 2 1.12 $1,199.02
Day 3 1.08 $1,156.19
Day 4 1.05 $1,124.08
Day 5 1.04 $1,113.37
Total = $5,995.08
Patient level and facility level adjustments in IPF PPS
daily publication of the US federal government that issues proposed and final administrative regulations of federal agencies. Including healthcare common coding systems
Federal register
