Medicare Acute Care Prospective Payment System Flashcards
What are the steps for coding?
- Coder reviews medical records and documents with relevent diagnoses and procedures.
- Coder enters diagnoses and procedures into a specialized coding computer program.
3.Computer program translates the diagnoses and procedures into corresponding numerical codes
- Computer program groups all the codes into one numerical classification system, the MS-DRG
- Diagnoses codes, procedure codes, and MS-DRG are reported on a claim form.
- Completed claim form is sent for reimbursement. (Insurance company equates the numerical code and MS-DRG to a specific reimbursement account.
- Insurance company reimburses the hospital.
What is ICD-10-CM?
A directory of codes for diagnoses and procedures for outpatient services and physician visits.
What is the ICD-10-PCS?
Additional codes for procedures only in hospital inpatient settings.
What are CPT codes?
Five-digit numerical codes used for medical procedures and professional services in ambulatory or outpatient settings.
What is the difference between ICD-10 codes and CPT codes?
ICD-10 codes are used for diagnoses and inpatient hospital procedures
CPT codes are used for mainly in outpatient and physician settings.
What are DRG’s?
Classification groups of diseases, illnesses, and injuries.
How many DRG’s are grouped into one of 25 MDC’s?
Hundreds.
What is MDC?
Major Diagnostic Categories (Based upon patient’s principle diagnosis)
How are MDC’s categorized?
Medical or surgical.
How is DRG reimbursement done?
DRG Relative Weight (each DRG is assigned a relative weight) x Hospital Standard Fee = Reimbursement Amount
What are three levels of severity for each DRG in the MS-DRG system?
Diagnosis with Major complicating Condition (MCC)
Diagnosis with complication condition (CC)
Diagnosis without complicating condition
