CIC Review

Certified Inpatient Coding - AAPC Notes

Bill for facility services are submitted on

UB-04 (CMS 1450) paper or electronically using the 8371 (institutional) claim form

Bill for physician services

CMS-1500 paper claim form or electronically using the 837P (professional) claim form

For medicare patients hospital admission is generally considered appropriate when

The patient is expected to need 2 or more midnights of medically necessary hospital care

Benchmark for physicians to use to determine patient status for inpatient or outpatient care

The 2 midnight rule

Exceptions to the 2 midnight rule

• procedures on the medicare inpatient-only list regardless of length of stay

• admissions involving transfers to another facility

• patient expiration

Is nursing services considered an inpatient service?

Yes

Is use of hospital facilities considered an inpatient service?

yes

Is medical social services considered an inpatient service?

yes

Are drugs, biologicals, supplies, appliances, and equipment considered an inpatient service?

yes

Are certain other diagnostic or therapeutic services considered an inpatient service?

yes

Is medical or surgical services provided by certain interns or residents-in-training considered an inpatient service?

yes

Is transportation services, including transport by ambulance considered an inpatient service?

yes

Is post-hospital SNF care furnished by a hospital or CAH that has a swing-bed approval considered an inpatient service?

no

Is Nursing facility services that may be furnished as a medicaid services under title XIX of the social security Act (the ACT) in a swing-bed hospital that has an approval to furnish nursing facility services considered an inpatient service?

no

Is physician services on a fee schedule basis considered an inpatient service?

no

Is physician assistant services considered an inpatient service?

no

Is nurse practitioner (NP) and clinical nurse specialist (CNS) services considered an inpatient service?

no

Is certified nurse mid-wife services considered an inpatient service?

no

Is qualified psychologist services considered an inpatient service?

no

Is services of an anesthetist considered an inpatient service?

no

Part A medicare payments

for inpatient hospital stays, SNF care, nursing home care (as long as custodial care isn’t the only care needed), hospice, and home health Services

Part A medicare payments are made through

Medicare’s inpatient prospective Payment system (IPPS)

MS-DRG

classification system that groups similar clinical conditions or diagnoses and the procedure furnished by the hospital during the patient’s stay.

To receive covered services in a SNF you must need short-term skilled care (nursing or rehabilitation services) following a hospital stay of at least ___ days.

3

Medicare SNF benefits covered a pre-determined daily rate of up to ___ days.

100

Medicare part A payments are made for inpatient hospital stays through the Medicare’s SNF PPS, utilizing the ______.

Patient Driven Payment model (PDPM)

Graduate Medical Education (GME) is a

residency program approve by the Accreditation Council for Graduate Medical Education (ACGME) of the American Medical Association (AMA) and other accrediting agencies for training physicians in specialties

Teaching hospitals take part in approved GME residency program in _______, _____, _______, or ________.

medicine, osteopathy, dentistry, or podiatry.

Teaching setting receive direct _________ payments for residents services.

Medicare GME payments

Direct medicare GME payments for teaching settings include:

• Resident salaries

• fringe benefits

• teaching physician compensation for services not payable on a fee schedule

Interns

Usually in their 1st year following graduation from medical school and completing a 1 year rotation in various specialty departments of the teaching facility.

Residents

Licensed physicians and (depending on the specialty) have 2-5+ years of training in that specialty

Fellows

Physicians who are obtaining additional training in a sub-specialty after residency training

Critical access Hospital (CAH) are limited service hospitals that recieve cost-based reimbursement which meet the following requirements:

• located in a rural area

• Be located more than a 35 mile drive from a hospital or another health care facility

  • Be certified by the state

CAHS can have _________ inpatient beds used for _________.

no more than 25

either inpatient or swing bed services

CAHs may also operate a distinct part rehabilitation or psychiatric unit, each with up to ____ beds in addition to the 25 maximum.

10

CAHs are reimbursed based on the _____ unless it elects to be paid under the optional payment method.

standard payment method

Long term care hospital (LTCH)

hospital which has an average inpatient length of stay of greater than 25 days

Payments for Long term Care Hospital (LTCH) are made through

LTCH PPS Prospective payment System (PPS). Based on a per discharge system with a DRG-based patient classification

Which payment classification categories is used for skilled nursing facility payments?

PDPM (patient driven payment model)

How many claims are generated for an inpatient stay

2 ; one for the physician and one for the facility

How are payments determined for acute care facilities?

MS-DRGs

Business office

Responsible for claim generation, processing remittance documents, filing incomplete or rejected claim forms, payment posting, appeals, and many other reimbursement issues.

Requires electronic claims filing to standardize reimbursement and reporting processes

HIPAA (Health insurance portability and accountability act of 1996)

Commonly referred to as the patient financial services

Business office

Claims are coded by the _____ department

Health information management department (HIM)

Sometimes referred to as the medical records department

HIM (Health information management department)

HIM department (Health information management)

coding, chart construction or organization, transcription, release of information, birth and death certification, scanning or filing to input information into charts, and other sections required to maintain a consistent flow of patient information throughout the hospital or facility.

ROI

Release of information

Most common outpatient services are ______, __________, _______, and _________.

Same day surgeries, emergency department encounters, outpatient clinic encounters, and therapeutic and diagnostic tesing.

If an outpatient presents for services for multiple departments, how is that billed?

One claim is generated. (UB-04/CMS 1450/837I) for date of service.

Chargemaster / Charge description master (CDM)

Master inventory list of everything that can be reported or performed in the hospital.

PDPM

patient driven payment model

LTCH

Long term care hospital

CAH

Critical access Hospital

PDPM

Patient Driven Payment model

General Supervision

Physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. Not required to be in the room.

Direct Supervision

Procedure or service is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Supervising physician is required to be on campus.

Personal Supervision

physician must be in attendance in the room during the performance of service or procedure

OPPS

Outpatient prospective payment system

OPPS Final Rule (outpatient prospective payment system)

List of surgeries CMS determined is safe to perform in an outpatient hospital and ambulatory surgery center (ASC)

ASC

Ambulatory surgery center

Are nursing personnel included in billing for outpatient procedures / ASC?

Yes

Are Room costs (operating, treatment, cast, etc) included in billing for outpatient procedures / ASC?

yes

Are provider and anesthesiologist fee included in billing for outpatient procedures / ASC?

no

Are DME included in billing for outpatient procedures / ASC?

no

Are prosthetic devices included in billing for outpatient procedures / ASC?

no

Are ambulance included in billing for outpatient procedures / ASC?

no

Are outside laboratory services included in billing for outpatient procedures / ASC?

no

Are certain drugs and biologicals (pass-through payments) included in billing for outpatient procedures / ASC?

no

Type A ED

Open 24/7 for immediate attention, urgent, and emergent care.

Type B ED

Not open 24 hours a day, meets specific licensing requirements.

EMTALA (Emergency Medical Treatment and Active Labor Act)

All Medicare participating hospitals that operate during a hospital emergency department must provide an appropriate medical screening examination to any patient that requests it.

EMTALA

Emergency Medical Treatment and Active Labor Act

IDTF

Independent diagnostic testing facility

Partial hospitalization

Full day programs for psychiatric services. Goal is to help patient’s transition to daily life. Known as a “step down program”

CMHC

Community Mental Health Center

CMS requires ASC services to be billed on

CMS-1500/837P.

CORF

Comprehensive Outpatient Rehabilitation Facility

CORP (comprehensive outpatient rehabilitation) must provide at least _____ , ______, and _________.

physician services, physical therapy, and social/psychological services

All CORF (comprehensive outpatient rehabilitation) services are paid except ______, ______, ________, and ________.

DMEPOS

• durable medical equipment

• Prosthetics

• Orthotics

• supplies

Majority of CORF (comprehensive outpatient rehabilitation) services are paid _____% of the lesser of the actual charge or the PFS amount.

80

CORF (comprehensive outpatient rehabilitation) services are subject to Medicare part ____

B

Covered services for CORF (comprehensive outpatient rehabilitation)

• provider service related to administrative functions

• physical therapy, occupational therapy, speech pathology services, and respiratory therapy

• Nursing care provided under the supervision of a registered professional nurse

• Prosthetic or orthopedic devices, including purchase or rental of DME from the CORF

• Drugs and biologicals that cannot be self administered

• Supplies, appliances, and equipment, including purchase or rental of DME from the CORF

• Single home visit to evaluate the potential impact of the home environment on the rehabilitation goals (occupational / physical therapy and CORFs)

Acute Care Facility (ACF)

healthcare facility providing continuous professional medical care to patients who are in an acute phase of illness

Cost Report (Medicare)

Annual report required of facility contractors participating in the Medicare program. The report details the cost and charges to the provider incurred in rendering services to all patients and the medicare payments received during a specific reporting period.

Critical Access Hospital (CAH)

• no more than 25 inpatient beds

• maintaining an annual average length of stay of no more than 96 hours for acute inpatient care

• Offers 24/7 Emergency care

  • Located in a rural area at least 35 miles from another hospital or CAH

Diagnosis Related Group (DRG)

Patient classification system providing a means of relating the type of patients a hospital treats (i.e. its case mix) to the costs incurred by the hospital

Diagnostic Laboratory Services

Lab services required in the diagnosis of a disease or injury, regardless of where services are rendered. For Medicare, these services are paid under a separate fee schedule.

Long Term Care Hospitals (LTCH)

Facilities that are certified as acute care hospitals, but focus on patients who, on average, stay more than 25 days. Specialize in patients who have one or more serious conditions, but who may improve with time and care, and return home.

Medicare Hospital Manual

Manual containing policies and procedures applicable to the delivery of hospital services, claim process instructions, billing procedures, coverage requirements, and related Medicare matters.

Midlevel Practitioners (MLP)

Professionals (e.g. nurse practitioners, nurse midwives, physician assistants) without physician input or under physician direction. also called NPPs.

MLP

Midlevel practitioners. Also called NPPs.

NPP

Non-physican practitioner

Prospective Payment System (PPS)

Method of reimbursement in which the medicare payment is made based on a predetermine, fixed amount. Derived based on the classification system of that services (for example diagnosis related groups for inpatient hospital services)

Patient Driven Payment Model (PDPM)

Replaces RUG (resource utilization groups). Categories that reflects levels of resources in long term care setting, primarily to facilitate Medicare and Medicaid payment.

Swing-bed

Rural hospitals with fewer than 100 beds can provide post-hospital extended care services to Medicare beneficiaries. Swing-bed facilities can swing their beds from hospital to skilled nursing facility (SNF) levels of care.

Admitting’s office’s responsibilities

Obtaining demographic information, insurance information, recording type of service, establishing an account, and obtaining consent for treatment

Order

Information needed from the physician for a facility to perform a diagnostic test

Non-physician Practitioners

• ______

• ______

• ______

• ______

• ______

• ______

• ______

• PA (physician assistance)

• NP (Nurse practitioner)

• CRNA (Certified Registered Nurse Anesthetists)

• CNS (clinical nurse specialists)

• Certified Nurse-midwives

• Clinical psychologists

• LCSW (Licensed clinical social worker)