Revenue Exam 2

Fee Schedule

A reimbursement methodology where the payer reimburses an amount for each service according to a predetermined list of rates.

Capitation

A reimbursement methodology where the payer pays a set dollar amount for each patient per month.

Global Payment

A reimbursement methodology where the payer reimburses a single amount to cover all applicable services for an established time frame.

Percent of Billed Charges

A reimbursement methodology where the payer pays a negotiated reduced amount instead of the full charge.

Case Rate

A reimbursement methodology where a single payment is made for all care provided during an admission, regardless of service volume.

Bundled Payment

A predetermined payment amount for all services required for a predefined condition and time frame.

Per Diem

A reimbursement methodology where the payer reimburses the provider for each day of care.

Prospective Payment

Type of reimbursement where third-party establishes payment rates for services in advance for a specific period.

CMS-HCC Model

A risk adjustment model predicting healthcare costs based on patient demographics and medical conditions.

Billed Charges vs Allowable Charges

Billed charges are the amounts providers request, while allowable charges are the amounts payers agree to reimburse.

MS-DRG System

A classification system used for Medicare Inpatient hospital services based on diagnosis-related groups.

Major Diagnostic Category (MDC)

The first level of the MS-DRG system representing the body systems treated.

Medical/Surgical Determination

A determination process in the MS-DRG system to classify admissions as surgical or medical based on qualifying procedures.

Federal Register

A publication that contains rules, proposed rules, and notices of federal agencies and organizations.

Hospital Readmission Reduction Program (HRRP)

A program aimed at reducing unnecessary readmissions to hospitals.

Labor Related Share

The portion of a facility's costs attributed to labor in cost reimbursement.

Case Mix Index

A measure of the diversity of patients treated in a healthcare facility.

Transfer Cases

Patient admissions that affect reimbursement depending on the transfer status.

Patient-Driven Payment Model (PDPM)

A reimbursement model for Skilled Nursing Facilities based on patient characteristics.

CMGs (Case-Mix Groups)

Classification system in PDPM placing residents in similar groups based on reason for stay.

Variable Day Adjustment

An adjustment made in SNF reimbursement for certain patient characteristics.

SNF VBP

Skilled Nursing Facility Value-Based Purchasing, a program withholding 2% of payments for incentives.

Bundling

The practice of combining multiple services and charging a single rate.

Packaging

Integrating certain services into another service's payment.

Outpatient Code Editor (OCE)

A system for reviewing outpatient claims for correct coding.

Pass-Through

A provision that allows certain costs to be directly passed through for reimbursement.

Interrupted Services

Outpatient services that are temporarily halted due to specific circumstances.

Comprehensive APCs

Payment classification encompassing multiple related services into one payment.

Payment Status Indicator of Q1

Indicates services are packaged when performed with other specific status indicator services.

Healthcare Common Procedure Coding System (HCPCS)

A set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT) system.

Practice Expense

The costs incurred by healthcare providers for delivering services.

Conversion Factor

A number used to convert relative value units into dollar amounts for reimbursement.

Physician Work

The amount of effort and time spent by a physician to provide care.

Quality Payment Program (QPP)

A program that aims to improve Medicare beneficiaries' care.

Nonphysician Provider (NPP)

Medical practitioners who are not physicians, such as nurse practitioners and physician assistants.

Incident To Services

Services provided by NPPs in a physician's office under the physician's supervision.

Inpatient Psychiatric Facility PPS

Payment system determining Medicare reimbursement for psychiatric facilities.

Emergency Facility Adjustment

An adjustment providing greater per diem rates for IPFs qualifying from emergency departments.

Length of Stay Adjustment

Adjustment considering that costs generally decrease with longer patient stays.

High-Cost Outlier Add-On Payment

An additional payment for facilities with costs significantly higher than the average.

Inpatient Rehabilitation Facility PPS

Payment system for Medicare reimbursement related to rehabilitation facilities.

Impairment Group Code (IGC)

Code reflecting the primary reason for a patient's admission to rehabilitation.

Case Rate Reimbursement Method

Payment method assigning a fixed amount for care regardless of services rendered.

Home Health PPS

Payment system that governs Medicare reimbursement for home health services.

Home Health Resource Groups (HHRGs)

Categorization used by PDGM to calculate reimbursement rates for home health episodes.

Low Utilization Payment Adjustments (LUPA)

Adjustments applied when the number of home health visits falls below a specified threshold.

Admission Source

The origin of a patient’s admission to a healthcare facility, which can affect reimbursement and care planning.

Timing of Admission

The specific period during which a patient is admitted to a healthcare facility, impacting funding and service delivery.

Clinical Grouping

The classification of patients into groups based on similar clinical characteristics or diagnoses for reimbursement purposes.

Functional Impairment Level

A measure of a patient's ability to perform daily activities, important for determining the level of care needed.

Comorbidity Adjustment

An adjustment made to reimbursement rates considering the presence of additional medical conditions in a patient.

Interrupted Services

A situation in which outpatient services are temporarily paused due to defined circumstances affecting care.

Modifier 73

A HCPCS modifier used to indicate that a procedure was terminated prior to administration, typically related to interrupted services.

Non-Case-Mix Component of PDPM

The part of the Patient-Driven Payment Model (PDPM) not based on patient characteristics, focusing on fixed costs and services.

Five Categories of Nursing Component in PDPM

The nursing component categorizes patients based on clinical characteristics, functional status, comorbidities, and needs for rehabilitation.

Benefits of SNF for Medicare Beneficiaries

Skilled Nursing Facilities provide medically necessary services, rehabilitation, and support for recovery post-hospitalization to Medicare beneficiaries.

Third Level of MS-DRG System

Divides Major Diagnostic Categories (MDC) into specific Medicare Severity Diagnosis Related Groups (MS-DRGs) for more precise reimbursement.

Inpatient Services Reimbursed by MS-DRG Payment

Reimburses hospitals for services related to inpatient admissions based on classification of the patient's diagnosis and care.