Comprehensive Guide to Healthcare Documentation, Coding, and Reimbursement

What is the primary goal of Clinical Documentation Improvement (CDI)?

To ensure health records accurately reflect the patient's clinical status for precise coded data.

What are the two types of reviews involved in CDI?

Concurrent (during the stay) and retrospective (after discharge) reviews.

Why do facilities focus on Priority Areas for record reviews in CDI?

Due to the impracticality of reviewing 100% of records, targeting high-impact deficiencies and specific service lines.

What metrics are used to measure the effectiveness of CDI programs?

Review Rate, Physician Response Rate, Physician Agreement Rate, and DRG Match.

What is the target Review Rate for CDI programs?

Over 80% of total discharges reviewed.

What is the importance of accurate documentation in healthcare?

It is essential for appropriate reimbursement and compliance with regulations.

What does coding in healthcare involve?

Managing and validating the accuracy of assigned codes, including ICD-10-CM/PCS and CPT codes.

What is a formal compliance plan in coding?

It includes a commitment to correct code assignment and identification of official guidelines used for coding.

What is the purpose of audits in healthcare?

To ensure compliance and verify that the facility is receiving correct reimbursements.

What is the definition of Health Information System?

A comprehensive collection of components (people, policy, technology) that processes health data into meaningful information.

What does Health Information Technology (HIT) refer to?

The computer systems (hardware and software) used in processing health data.

What is the Prospective Payment System (PPS) used by Medicare?

It determines payment amounts before services are rendered based on diagnosis or service category.

What are the different PPS models used in Medicare?

MS-DRGs for inpatient care, APCs for outpatient services, and RBRVS for physician services.

What is the Front-End phase of the Healthcare Revenue Cycle?

Involves patient registration, insurance verification, pre-authorization, and financial counseling.

What does the Middle phase of the Healthcare Revenue Cycle focus on?

Clinical Documentation Improvement (CDI), charge capture, and coding processes.

What is the role of Medicare Administrative Contractors (MACs)?

They process Medicare claims regionally, ensuring compliance with regulations.

What is the National Correct Coding Initiative (NCCI)?

It prevents unbundling, ensuring that billing practices are compliant and accurate.

What are Hospital-Acquired Conditions (HACs)?

Conditions that may lead to reduced payments for conditions not present on admission.

What is the Best of Fit strategy in system acquisition?

Purchasing all components from a single vendor for seamless integration.

What is the Best of Breed strategy in system acquisition?

Selecting the best individual systems for specific functions and integrating them.

What are Service-Level Agreements (SLAs)?

Legal documents that define expectations and responsibilities between healthcare facilities and vendors.

What are the two main groups of healthcare payers?

Commercial and Government-Sponsored.

What is Commercial Insurance?

Primarily employer-based insurance, with most Americans receiving coverage through their jobs.

What are Government-Sponsored Programs?

Programs like Medicare and Medicaid that provide coverage for specific populations.

Who is Blue Cross Blue Shield?

A historically significant private payer that has played a major role in the development of health insurance in the U.S.

What is Medicare?

A federal program for individuals aged 65 and older or those with certain disabilities, consisting of four parts: A (hospital insurance), B (medical insurance), C (Medicare Advantage), and D (prescription drug coverage).

What is Medicaid?

A joint federal and state program providing healthcare for low-income individuals.

What is TRICARE?

A specialty program providing healthcare for military families.

What does PPO stand for?

Preferred Provider Organization, which offers flexibility in choosing healthcare providers without needing referrals.

What is an HMO?

Health Maintenance Organization, which requires members to choose a primary care physician who acts as a gatekeeper for referrals.

What is capitation in healthcare reimbursement?

A payment model where providers receive a set amount per member per month, regardless of service frequency.

What is Fee-for-Service?

A reimbursement model where providers are paid for each individual service or test performed.

What is a fixed budget?

A budget that remains constant regardless of patient volume.

What is a flexible budget?

A budget that adjusts based on actual activity levels, useful for variable patient loads.

What does Zero-based Budgeting require?

It starts from zero each year, requiring justification for all expenses.

What is budget variance analysis?

The process of comparing actual costs to budgeted costs to assess financial performance.

What factors influence compensation in healthcare?

Legal/external factors (minimum wage laws), internal factors (organizational salary scales), and economic factors (cost of living adjustments).

What are the five key groups in the project management process?

Initiating, Planning, Executing, Monitoring & Controlling, and Closing.

What is the purpose of the AHIMA Code of Ethics?

To govern business practices and professional behavior, particularly in protecting patient privacy.

What is cultural competence in healthcare?

Understanding and respecting diverse beliefs and practices among patients.

What is the first phase of strategic planning?

Assessment & Environmental Scan, which includes conducting SWOT analysis.

What does an income statement display?

Revenue and expenses over a specific period, indicating profit or loss.

What are direct costs in healthcare?

Costs that are easily traceable to specific departments or services, such as medical supplies.

What are indirect costs?

Shared costs not easily linked to one department, such as utilities.

What are variable costs?

Costs that fluctuate directly with patient volume, such as consumables.

What are semi-fixed costs?

Costs that are fixed up to a certain volume, then increase, such as staffing adjustments.