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COC Exam > Payment Methodologies and the OPPS > Flashcards

Payment Methodologies and the OPPS Flashcards

1
Q

ASC

A

ambulatory surgical center

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2
Q

CDM

A

charge description master

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3
Q

Review!

A

Medicare Claims Processing Manual Chapter 4 part b Hospital (pg 22 study guide)

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4
Q

Do outpatient facilities keep patients overnight?

A

NO

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5
Q

What are the two types of emergency department visits?

A

Type A - for a facility open 24 hours per day

Type B - for a facility meeting specific licensing requirements for emergent or urgent care patients not open 24 hours per day

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6
Q

Is the following included in facility outpatient billing:

nursing personnel

A

YES

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7
Q

Is the following included in facility outpatient billing:

room costs

A

YES

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8
Q

Is the following included in facility outpatient billing:

Provider and anesthesiologist professional fees

A

NO

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9
Q

Is the following included in facility outpatient billing:

Durable Medical Equipment

A

NO

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10
Q

DME

A

durable medical equipment

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11
Q

Is the following included in facility outpatient billing:

prosthetic devices

A

NO (except intraocular lenses)

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12
Q

Is the following included in facility outpatient billing:

ambulance services

A

NO

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13
Q

Is the following included in facility outpatient billing:

outside laboratory services

A

NO

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14
Q

Is the following included in facility outpatient billing:

certain drugs and biologicals

A

NO

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15
Q

OPPS

A

Outpatient Prospective Payment System

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16
Q

GME

A

Graduate Medical Election

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17
Q

MS-DRG

A

Medicare Severity Diagnosis Related Group

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18
Q

CORF

A

Comprehensive Outpatient Rehabilitation Facility

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19
Q

MCO

A

managed care organization

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20
Q

In most cases, who decides if the patient will need inpatient care as opposed to outpatient care?

A

the admitting physician

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21
Q

What are the two categories that hospital inpatient charges can be divided into?

A

1) room and board

2) ancillary charges

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22
Q

What do the hospital inpatient room and board charges include?

A

not only bed and food, but also routine medical services provided to all patients in the hospital, such as nursing care

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23
Q

What do the hospital inpatient ancillary charges include?

A

vary from patient to patient and include all services that are unique to that particular patient, such as medications, X-rays, and other diagnostic imaging procedures, lab tests, radiation therapy, etc

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24
Q

Do hospital room and board charges vary from location to location within the hospital?

A

YES - because routine services provided to all patients in those locations may vary

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25
Q

OBRA 86

A

Omnibus Budget Reconciliation Act of 1986

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26
Q

APG

A

Ambulatory Patient Group

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27
Q

PPS

A

prospective payment system

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28
Q

BBA

A

Balanced Budget Act of 1997

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29
Q

BIPA

A

Benefits Improvement and Protection Act of 2000

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30
Q

What happens under OPPS?

A

Hospitals and community mental health centers are paid a set amount of money (rate-per-service) to provide some outpatient services to persons with Medicare

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31
Q

How often does Medicare update the payment rates for OPPS?

A

Every January 1

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32
Q

Medicare pays for most Part B outpatient services. What are included?

A 
X-rays
Emergency room and clinic visits
Casts
Surgical Procedures
Miscellaneous Procedures
Blood and blood products
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33
Q

Is every service delivered by a hospital outpatient department paid under OPPS?

A

NO

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34
Q

What are status indicators for the drugs, biologicals, and devices eligible for pass-through payments under OPPS?

A

G and H

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35
Q

What does status indicator N indicate?

A

drugs, biologicals, and devices that the cost is packaged into an APC with a status indicator of S, T or V

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36
Q

What happens if multiple procedures are performed with status indicator J1?

A

the single payment is based on the highest ranking J1 service, and with certain J1 pairs it may be eligible for a complexity adjustment

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37
Q

What does status indicator J2 mean?

A

these procedures have conditional payment circumstances

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38
Q

What happens if a J1 and J2 service are reported on the same claim?

A

the single payment is based on the rate associated with the J1 service and the combination of the J1 and J2 services on the claim does not make the claim eligible for a complexity adjustment

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39
Q

Are complexity adjustments applied to discontinued services reported with modifier 73 or modifier 74?

A

NO

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40
Q

APC

A

Ambulatory Payment Classification

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41
Q

Who created APC?

A

CHPP (Center for Health Plans and Providers)

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42
Q

Is the APC system different for ASCs and hospitals - even though similar surgeries may be performed in both?

A

YES - it is different because there is a difference in cost of what it takes to perform surgeries in those settings

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43
Q

Does APC system payment methodology include the professional component of ambulatory care?

A

NO - that is paid under RBRVS methodology

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44
Q

What is true about items/services within an APC group?

A

they are comparable clinically and use similar resources

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45
Q

How often is the APC relative weight re-calibrated?

A

each year - based on the previous year’s claims and cost report data

46
Q

What is OPPS based on?

A

procedure coding

47
Q

There are separate APCs for _____.

A 
partial hospitalizations
procedures or services
medical visits
select ancillary services
transitional pass-through services and drugs
new technologies
blood and blood products
48
Q

BRBA 1999

A

Balanced Budget Refinement Act

49
Q

BBA

A

Balanced Budget Act

50
Q

Services grouped for payment mandated through the Omnibus Budget Reconciliation Act is called ____.

A

Ambulatory Payment Classification

51
Q

An APC is a method by which a hospital is reimbursed based on what?

A

procedures performed instead of cost-to-charge ratio

52
Q

What is an ambulatory payment classification?

A

a classification system for payment of services under the Medicare Outpatient Prospective Payment System

53
Q

What do revenue codes identify?

A

the revenue center, whether the service is inpatient or outpatient, the bill type, validates the HCPCS code assignment, and drives reimbursement calculations

54
Q

What is the purpose of a Status Indicator?

A

determines under which payment system the services are paid

55
Q

How are claims paid with the status indicator of N?

A

paid under OPPS; payment is packaged into payment for other services, including outliers; there is no separate APC payment

56
Q

CMS defines the criteria in which services must be reported on an inpatient basis. Name the criteria.

A
  1. invasive nature of the procedure
  2. need for postoperative care (at least 24 hours)
  3. underlying physical condition of the patient requiring surgery
57
Q

What is the definition of a composite APC?

A

Medicare pays a single rate for a service that is reported with a combination of HCPCS codes on the same date or different date of service rather than paying for each procedure or service under a specific APC

58
Q

What does status indicator T mean?

A

the CPT/HCPCS code is subject to multiple procedure discounting; this means that the highest value procedure would be paid in full; any additional procedures performed at the same operative session are discounted 50%

59
Q

What happens when a surgical procedure is terminated after the patient is prepped for surgery, prior to administration of anesthesia?

A

the procedure is paid at 50% of the APC payment

60
Q

AWP

A

average wholesale price

61
Q

What is pass through payment for a drug or biological?

A

the amount by which 95% of the average wholesale price for the drug exceeds the portion of the APC payment determined to be associated with it

62
Q

What if the dosage required for treating the patient exceeds the lowest level specified in HCPCS?

A

providers may bill the number of units necessary to treat the patient and round up to the nearest unit

63
Q

ASP

A

average sale price

64
Q

Drugs and biologicals without pass-through status are paid in one of two ways: _______

A

1) packaged payment

2) separate payment (APC)

65
Q

What is the threshold for drugs/biologicals paid separately?

A

if the median cost excees $110/day

if the median cost is less than $110/day, it will be packaged into the service or procedure and not paid separately

66
Q

How does a device qualify as new technology?

A

if the device is not described by any existing category established for transitional pass-through payments

it must improve the diagnosis or treatment substantially OR improve the function of a malformed body part compared to the benefits of the device(s)

67
Q

How does CMS define “clinical improvement”?

A

1) The device offers a treatment option for a patient population unresponsive to or ineligible for currently available treatments
2) the device offers the ability to diagnose a medical condition in a patient population where it is currently undetectable OR offers the ability to diagnose a medical condition earlier than currently possible - also needs evidence that use of the device to make a diagnosis affects management of the patient

68
Q

How long is a new device eligible for pass-through payment?

A

at least 2 years but no more than 3 years, beginning on the date CMS established the category

69
Q

PHP

A

partial hospitalization programs

70
Q

DED

A

dedicated emergency department

71
Q

FI

A

fiscal intermediary

72
Q

MDC

A

major diagnostic categories

73
Q

RW

A

relative weight

74
Q

HBR

A

hospital base rate

75
Q

CC

A

complication

76
Q

MCC

A

major complication

77
Q

GMLOS

A

geometric mean length of stay

78
Q

What is the GMLOS?

A

(geometric mean length of stay); the national mean length of stay for each DRG

79
Q

ALOS

A

arthmetic mean length of stay

80
Q

What is the ALOS?

A

(arthmetic mean length of stay); the average length of stay experienced by a patient within a chosen DRG

81
Q

PA

A

prior authorization

82
Q

What are the five levels of appeals (in order)?

A
  1. Redetermination
  2. Reconsideration
  3. Administrative Law Judge (ALJ) Hearing
  4. Departmental Appeal Board Review (DAB)
  5. Judicial Review in US Federal District Court
83
Q

AAPCC

A

adjsted average per capita cost

84
Q

accrual

A

money set aside to cover a benefit plan’s expenses; estimated using data including the claims system and the plan’s prior history

85
Q

Acute Care Facility

A

ACF; a healthcare facility that provides continuous professional medical care to patients who are in an acute phase of illness

86
Q

adjudication

A

judging of a claim (eg, reviewing a claim for determination of reimbursement)

87
Q

Additional Development Request

A

ADR; issued from the fiscal intermediary (FI) to obtain a copy of medical records that supports a claim for services

88
Q

Admissions date

A

date the patient was admitted to the healthcare facility for inpatient care or to outpatient services for the start of care

89
Q

admitting diagnosis

A

the initial diagnosis made upon admission to a hospital

90
Q

ambulatory surgery

A

surgical procedure administered to a patient who is admitted, treated, and released on the same day

91
Q

APC grouper

A

software program designed to calculate APC allowances and bundled services

92
Q

appropriateness of care

A

often used to state proper setting of medical care to best treat the patient’s diagnosis

93
Q

attained age

A

the age of the member participating in the insurance or other benefits plan as of the last birthday

94
Q

blended payment rate

A

a blend of federal and local area wage indexes used to phase in a prospective payment system or reimbursement methodology

95
Q

capitation

A

set amount of money paid to an individual or entity within a managed care program for each member in the managed care program signed up with that individual orentity

96
Q

coinsurance

A

a limited amount payable by the patient and/or payer to the provider/facility for care in traditional plans or managed care plans

97
Q

condition code

A

a two-digit code that is entered on the UB-04 claim form (inpatient or outpatient facilities) to indicate that a condition applies to the bill that affects processing and payment of the claim

98
Q

coordination of benefits

A

the payment of insurance benefits when more than one policy is involved to meet the needs of the insured

99
Q

COB

A

coordination of benefits

100
Q

copayment

A

a portion of the medical expense the member must pay out of pocked

101
Q

elective admission

A

an admission category in which the health of the patient is not in immediate jeopardy; usually scheduled for admission days or weeks in advance

102
Q

ELOS

A

estimated length of stay

103
Q

estimated length of stay

A

the average number of required hospitalization days for a given illness or procedure; the information is based on the history of patients who have previously been hospitalized for the same illness or procedure

104
Q

exclusion services

A

services not covered by the patient’s insurance plan

105
Q

fee for service

A

payer reibursement methodology that allows and pays full charges or a percentage of full charges for medical services

106
Q

fee schedule

A

the max fee an insurance plan will pay for services

107
Q

formulary

A

a list of drugs approved by the insurance plan or CMS that may be prescribed by the provider; medications not included on the list are often not reimbursed

108
Q

geographic adjustment factor

A

GAF; a measure of the effect or geographic location on the cost of a service

109
Q

incident to

A

this term may be used for revenue codes for pharmacy, supplies, and anesthesia furnished along with radiology and other diagnostic services in the outpatient hospital environment

110
Q

Medicare beneficiary

A

an individual who is enrolled for coverage under the Medicare program

111
Q

Medicare eligibility

A

determined by whether an individual meets the legal requirements for Medicare coverage (age 65 or older, disabled, or requiring kidney transplant or renal dialysis due to chronic kidney disease)

COC Exam (3 decks)

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