P4P or PFP
1) The BBRA Act of 1999
2) BIPA Act of 2000
Median cost of most expensive item in gorup cannot be more than 2 times greater than median cost of least expensive item in the same group.
(If is more than 2 times greater cost will have to be moved to another APC group)
The number of APCs per encounter for a single patient is limited to 10.
True or False
What services are included in the consolidated billing of the SNF PPS?
(3 of them)
1) Routine Care
2) Ancillary Services
3) Capital Costs
1) Operational costs associated w/ defined aproved educational activities
3) Inpatient Services
4) Extensive Procedures (such as radition therapy)
1) Based on costs
2) Data collected from cost reports
3)Per Diem rates are cost adjusted based on RUG classification
4) Nursing component
5) Therapy component
6) Non-case mix adjusted component
1) Hard Coding: attach CPT code to the item; coded as service is performed.
2) Soft Coding: HIM codes it, which means they drive the process. Use ICD-9 codes.
1) Lost Revenue: undercharging for services, Incorrect HCPCS code or diagnosis code, and Incorrect Revenue Code.
2) Compliance: Overcharging for services.
1) DNFB: days not final billed
2)DNFC: days not final coded
3) AR days: days in accounts receivable
4) % and/or amt. of write offs
5) Percentage of clean claims
6) percentage of denials or returned claims
7) Late charges
1) Incompatible dates of service
2) Nonspecific or inaccurate diagnosis and procedure codes
3) Lack of Medical Necessity
4) Inaccurate revenue code assignment
1) Reimbursment (payment)
1) Prospective Payment - APC
2) Cost Based - Pass thru
3) Fee Schedule - Therapy
Every CPT/HCPCS Code is assigned a PSI = Payment Status Indicators
N-Packaged NOT reimbursed
T-Surgical Procedures APC Payment
C-Inpatient Only NOT reimbursed
Medicare - 80%
Beneficiary - 20%
Packaging: Ancillary services packaged with the payment of significant procedure.
Bundling: mulitple procedures is combined into single unit of payment for the episode of care.
N= packaged imaging NOT reimbursed
T= packaged surgical procedures reimbursed APC
Know what Partial Hospitalization is and how it is paid under HOPPS.
Partial Hospitalizaiton: Intensive outpatient psychiatric program.
Paid APC based: per-diem rate
1)High cost ouliers
3)Pass thru payment Rural Adjustment
1) Maryland Hospital
2) Indian Health Service Hospitals
3) Critical Access Hopsitals
4) Hosptial outside of the 50 states
Similar: payment indicators, Packaging and Bundling, Reimbursement directly related to coding.
Difference: payment differ based on setting, ASCs receive separate payment for some ancillary services.
HOPPS Payment Process:
*APC assigned based on coding
*APC payment rate calculated
*Wage Indexed (regional differences)
-Medicare payments summed up
ASCs Payment Process:
*APC group assigned based on coding
*Multiple/bilater provisions applied
*Payment is then wage-indexed
*Payment is made directly to the ASC facility
1) Skilled Nursing Care
3) Medical Social Work
4) Home Health Aide
-Hospital based units
-Swing beds in an acute care hospital
-Resource Utilization Groups
-53 RUGS based on RW
-No Case Mix Adjustments
-MDS or Minimum Data Set
-Comprehensive Assessment & Treatment Plans
5) Quality Measures
6) Function Modifiers
7) Functional Independence Assessment
8) Medical Information
9) Medical Needs
Know 2 adjustments to IRF PPS. (HLTRW)
1) High Cost Outliers
2) Low Income Patients
3) Teaching Hospital Adjustment
4) Rural Adjustments
5) Wage Related Adjustments
IRF= Inpatient Rehab Facility
PAI=Patient Assessment Instrument
-One payment per discharge
-Electronic Data Submission
What part of Medicare is LTC benefits paid from (A, B, C or D)?
Similar: Both have same components, Both based on RW or resources.
Difference: Principle Diagnosis = diagnosis that occasions the LTC admission/not acute care RWs differ.
Paper: CMS 1500
Participating Physician: 100% of MPFS (which is 80/20)
Non-Participating Physician: 95% of MPFS
-Revenue Cycle: repeating set of events that produce revenue.
-Revenue Cycle Management (RCM): supervision of all administrative and clinical functions that contribute to the capture and manage revenue.
1) Patient present to hospital
2) Patient information collected
3) Services rendered
4) Charge caption
6) Claims submitted to payer
7) Payer processes claim
8) Balance billed to other payers/patient
1) DNFB - days not final billed
2) DNFC - days not final coded
3) AR Days - days in account receivable
4) Percentage and/or amount of write offs
5) Percentage of clean claims
6) Percentage of denials or returned claims
7) Late charges
Know the difference between hard coding and soft coding in the CDM.
*Hard Coding: use of the charge secription master to code repetitive services.
*Soft Coding: external resource (manual coding)
-Paper CMS 1500
What does the acronym OCE stand for?
1) Rewards for Quality Care
2) Directly Control Costs
3) Quality Improvement
4) Indirectly Control Cost
Know what POA and HAC stand for and understand how they relate to P4P.
POA = Present on Admission, used with ICD-9 to identify HAC/poor quality care.
HAC = Hospital Acquired Conditions, identified with POA indicators/result in higher DRG and costs.
*P4P: providers payment system based on performance & incentives.
*VBP: purchasers hold providers accoutnable for both cost & quality
*Similarities: Rewards for quality of care, Direct and indirect cost control.
*Differences: Cost, Settings and Duration
-Rewards for quality care
-Directly control costs
-Indirectly control cost
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