Medical Billing And Reimbursement Flashcards
A standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility. The MDS contains items that measure physical, psychological and psychosocial functioning. The items in the MDS give a multidimensional view of the patient’s functional capacities and helps staff to identify health problems.
Minimum Data Set
A number of groups into which a nursing home resident is categorized, based on functional status and anticipated use of services and resources.
Resource Utilization Group (RUG)
Covers inpatient hospital care, long-term care, skilled nursing facility care, home health care, and hospice care.
Medicare Part A
Covers 2 types of services
Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.
Covers things like:
Clinical research Ambulance services Durable medical equipment (DME) Mental health Inpatient Outpatient Partial hospitalization Getting a second opinion before surgery Limited outpatient prescription drugs
Medicare Part B
Contain data items that were developed for measuring patient outcomes for the purpose of performance improvement in home health care. Data items address socio-demographic, environmental, support system, health status, functional status, and health service utilization characteristics of the patient.
Medicare certified home care agencies are required to conduct patient-specific comprehensive assessments at specified times. The data are collected at start of care, 60-day follow-ups, and discharge (and surrounding an inpatient facility stay).
Assessments are collected for adult Medicare and Medicaid patients (age 18 or over) receiving skilled health services from the HHA.
OASIS (Outcome and Assessment Information Set)
Part of the federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing facilities. The entire process, called the Resident Assessment Instrument (RAI), provides a comprehensive assessment of each resident’s functional capabilities and helps nursing facility staff identify health problems.
Minimum Data Set (MDS)
In 1992, Medicare significantly changed the way it pays for physicians’ services. Instead of basing payments on charges, the federal government established a standardized physician payment schedule. Payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare and Medicaid Services). Payments are also adjusted for geographical differences in resource costs.
resource-based relative value scale (RBRVS).
In U.S. medical care, a system for grouping outpatient services provided by hospitals on the basis of similarity of costs and clinical indications; used by the Centers for Medicare and Medicaid Services to set the rates at which it will reimburse hospitals for outpatient care.
Ambulatory Payment Classification (APC)
This prospective payment system reimburses the provider according to prospectively determined rates for 60- day episode of care.
Home Health Resource Groups
Methodology is sometimes applied to radiological and similar types of procedures that involve professional and technical components.
Global payment
Based on per-person premiums or membership fees rather than on itemized per-procedure or per-service charges.
Capitation
APC Payment Status Indicator X
Ancillary services
APC Payment Status Indicator V
Medical visits (E/M codes)
APC Payment Status Indicator S
Significant procedure, multiple procedure reduction does not apply
APC Payment Status Indicator T
Surgical procedures multiple-procedure reduction applies
