Payment Methodologies and the OPPS Flashcards
1
Q
ASC
A
ambulatory surgical center
2
Q
CDM
A
charge description master
3
Q
Review!
A
Medicare Claims Processing Manual Chapter 4 part b Hospital (pg 22 study guide)
4
Q
Do outpatient facilities keep patients overnight?
A
NO
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
6
Q
Is the following included in facility outpatient billing:
nursing personnel
A
YES
7
Q
Is the following included in facility outpatient billing:
room costs
A
YES
8
Q
Is the following included in facility outpatient billing:
Provider and anesthesiologist professional fees
A
NO
9
Q
Is the following included in facility outpatient billing:
Durable Medical Equipment
A
NO
10
Q
DME
A
durable medical equipment
11
Q
Is the following included in facility outpatient billing:
prosthetic devices
A
NO (except intraocular lenses)
12
Q
Is the following included in facility outpatient billing:
ambulance services
A
NO
13
Q
Is the following included in facility outpatient billing:
outside laboratory services
A
NO
14
Q
Is the following included in facility outpatient billing:
certain drugs and biologicals
A
NO
15
Q
OPPS
A
Outpatient Prospective Payment System
16
Q
GME
A
Graduate Medical Election
17
Q
MS-DRG
A
Medicare Severity Diagnosis Related Group
18
Q
CORF
A
Comprehensive Outpatient Rehabilitation Facility
19
Q
MCO
A
managed care organization
20
Q
In most cases, who decides if the patient will need inpatient care as opposed to outpatient care?
A
the admitting physician
21
Q
What are the two categories that hospital inpatient charges can be divided into?
A
1) room and board
2) ancillary charges
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
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
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
25
OBRA 86
Omnibus Budget Reconciliation Act of 1986
26
APG
Ambulatory Patient Group
27
PPS
prospective payment system
28
BBA
Balanced Budget Act of 1997
29
BIPA
Benefits Improvement and Protection Act of 2000
30
What happens under OPPS?
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
31
How often does Medicare update the payment rates for OPPS?
Every January 1
32
Medicare pays for most Part B outpatient services. What are included?
```
X-rays
Emergency room and clinic visits
Casts
Surgical Procedures
Miscellaneous Procedures
Blood and blood products
```
33
Is every service delivered by a hospital outpatient department paid under OPPS?
NO
34
What are status indicators for the drugs, biologicals, and devices eligible for pass-through payments under OPPS?
G and H
35
What does status indicator N indicate?
drugs, biologicals, and devices that the cost is packaged into an APC with a status indicator of S, T or V
36
What happens if multiple procedures are performed with status indicator J1?
the single payment is based on the highest ranking J1 service, and with certain J1 pairs it may be eligible for a complexity adjustment
37
What does status indicator J2 mean?
these procedures have conditional payment circumstances
38
What happens if a J1 and J2 service are reported on the same claim?
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
39
Are complexity adjustments applied to discontinued services reported with modifier 73 or modifier 74?
NO
40
APC
Ambulatory Payment Classification
41
Who created APC?
CHPP (Center for Health Plans and Providers)
42
Is the APC system different for ASCs and hospitals - even though similar surgeries may be performed in both?
YES - it is different because there is a difference in cost of what it takes to perform surgeries in those settings
43
Does APC system payment methodology include the professional component of ambulatory care?
NO - that is paid under RBRVS methodology
44
What is true about items/services within an APC group?
they are comparable clinically and use similar resources
45
How often is the APC relative weight re-calibrated?
each year - based on the previous year's claims and cost report data
46
What is OPPS based on?
procedure coding
47
There are separate APCs for _____.
```
partial hospitalizations
procedures or services
medical visits
select ancillary services
transitional pass-through services and drugs
new technologies
blood and blood products
```
48
BRBA 1999
Balanced Budget Refinement Act
49
BBA
Balanced Budget Act
50
Services grouped for payment mandated through the Omnibus Budget Reconciliation Act is called ____.
Ambulatory Payment Classification
51
An APC is a method by which a hospital is reimbursed based on what?
procedures performed instead of cost-to-charge ratio
52
What is an ambulatory payment classification?
a classification system for payment of services under the Medicare Outpatient Prospective Payment System
53
What do revenue codes identify?
the revenue center, whether the service is inpatient or outpatient, the bill type, validates the HCPCS code assignment, and drives reimbursement calculations
54
What is the purpose of a Status Indicator?
determines under which payment system the services are paid
55
How are claims paid with the status indicator of N?
paid under OPPS; payment is packaged into payment for other services, including outliers; there is no separate APC payment
56
CMS defines the criteria in which services must be reported on an inpatient basis. Name the criteria.
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
What is the definition of a composite APC?
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
What does status indicator T mean?
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
What happens when a surgical procedure is terminated after the patient is prepped for surgery, prior to administration of anesthesia?
the procedure is paid at 50% of the APC payment
60
AWP
average wholesale price
61
What is pass through payment for a drug or biological?
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
What if the dosage required for treating the patient exceeds the lowest level specified in HCPCS?
providers may bill the number of units necessary to treat the patient and round up to the nearest unit
63
ASP
average sale price
64
Drugs and biologicals without pass-through status are paid in one of two ways: _______
1) packaged payment
| 2) separate payment (APC)
65
What is the threshold for drugs/biologicals paid separately?
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
How does a device qualify as new technology?
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
How does CMS define "clinical improvement"?
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
How long is a new device eligible for pass-through payment?
at least 2 years but no more than 3 years, beginning on the date CMS established the category
69
PHP
partial hospitalization programs
70
DED
dedicated emergency department
71
FI
fiscal intermediary
72
MDC
major diagnostic categories
73
RW
relative weight
74
HBR
hospital base rate
75
CC
complication
76
MCC
major complication
77
GMLOS
geometric mean length of stay
78
What is the GMLOS?
(geometric mean length of stay); the national mean length of stay for each DRG
79
ALOS
arthmetic mean length of stay
80
What is the ALOS?
(arthmetic mean length of stay); the average length of stay experienced by a patient within a chosen DRG
81
PA
prior authorization
82
What are the five levels of appeals (in order)?
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
AAPCC
adjsted average per capita cost
84
accrual
money set aside to cover a benefit plan's expenses; estimated using data including the claims system and the plan's prior history
85
Acute Care Facility
ACF; a healthcare facility that provides continuous professional medical care to patients who are in an acute phase of illness
86
adjudication
judging of a claim (eg, reviewing a claim for determination of reimbursement)
87
Additional Development Request
ADR; issued from the fiscal intermediary (FI) to obtain a copy of medical records that supports a claim for services
88
Admissions date
date the patient was admitted to the healthcare facility for inpatient care or to outpatient services for the start of care
89
admitting diagnosis
the initial diagnosis made upon admission to a hospital
90
ambulatory surgery
surgical procedure administered to a patient who is admitted, treated, and released on the same day
91
APC grouper
software program designed to calculate APC allowances and bundled services
92
appropriateness of care
often used to state proper setting of medical care to best treat the patient's diagnosis
93
attained age
the age of the member participating in the insurance or other benefits plan as of the last birthday
94
blended payment rate
a blend of federal and local area wage indexes used to phase in a prospective payment system or reimbursement methodology
95
capitation
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
coinsurance
a limited amount payable by the patient and/or payer to the provider/facility for care in traditional plans or managed care plans
97
condition code
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
coordination of benefits
the payment of insurance benefits when more than one policy is involved to meet the needs of the insured
99
COB
coordination of benefits
100
copayment
a portion of the medical expense the member must pay out of pocked
101
elective admission
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
ELOS
estimated length of stay
103
estimated length of stay
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
exclusion services
services not covered by the patient's insurance plan
105
fee for service
payer reibursement methodology that allows and pays full charges or a percentage of full charges for medical services
106
fee schedule
the max fee an insurance plan will pay for services
107
formulary
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
geographic adjustment factor
GAF; a measure of the effect or geographic location on the cost of a service
109
incident to
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
Medicare beneficiary
an individual who is enrolled for coverage under the Medicare program
111
Medicare eligibility
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)
