HIM Concepts Chap 7 Questions & Answers 100% Passed
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HIM Concepts Chap 7
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HIM Concepts Chap 7
Acute-care prospective payment system - ANSWERSThe Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare severity, diagnosis-related groups (MS-DRGs) classification system, which determin...
HIM Concepts Chap 7 Questions &
Answers 100% Passed
Acute-care prospective payment system - ANSWERSThe Medicare reimbursement
methodology system referred to as the inpatient prospective payment system (IPPS).
Hospital providers subject to the IPPS utilize the Medicare severity, diagnosis-related
groups (MS-DRGs) classification system, which determines payment rates.
Administrative services only (ASO) contract - ANSWERSAn agreement between an
employer and an insurance organization to administer the employer's self-insured health
plans.
Ambulatory surgery center (ASC) - ANSWERSUnder Medicare, an outpatient surgical
facility that has its own national identifier; is a separate entity with respect to its
licensure, accreditation, governance, professional supervision, administrative functions,
clinical services, recordkeeping and financial and accounting systems; has as its sole
purpose the provision of services in connection with surgical procedures that do not
require inpatient hospitalization; and meets the condiditons and requirements set forth
in the Medicare Conditions.
Balanced Budget Refinement Act (BBRA) of 1999 - ANSWERSMandated the
establishment of a per-discharge, DRG-based PPS for longer-term care hospitals
beginning October 1,2002
Capitation - ANSWERSA specified amount of money paid to a health plan doctor. This
is used to cover the cost of a health plan member's healthcare sercies for a certain
length of time.
Case-mix groups (CMGs) - ANSWERSThe 97 function-related groups into which
inpatient rehabilitation facilities discharges are classified on the basis of the patient's
level of impairment, age, coomorbidities, functional ability, and other factors.
Case-mix group (CMG) relative weight - ANSWERSFactors that account for the
variance in cost per discharge and resource utilization among case-mix groups.
Case-mix index - ANSWERSThe average relative weight of all cases treated at a given
facility or by a given physician, which reflects the resource intensity or clinical severity of
a specific group in relation to the other groups in the classification system; Calculated
by dividing the sum of the weights of diagnosis-related groups for patients discharged
during a given period by the total number of patient discharged.
Categorically needy eligibility group - ANSWERSCategories of individuals to whom
states must provide coverge under the federal Medicaid program.
, Children's Health Insurance Program (CHIP) - ANSWERSThe XXI of social security act.
A program initiated by the BBA that allows states to expand existing insurance
programs to cover children up to age 19; it provides additional federal funds to states so
that Medicaid eligibility can be expanded to include a greater number of children.
Civilian Health & Medical Program -Uniformed Services (CHAMPUS) - ANSWERSRun
by the Department of Defense, provided medical care to active duty members of the
military, military retirees, and their eligible dependents. This program is now called
TRICARE.
Civilian Health and Medical Program-Veterans Administration (CHAMPVA) -
ANSWERSThe federal healthcare benefits program for dependents (Spouse of
widow{er} and children) of veterans rated by the Veterans Administration (VA) as having
a total and permanent disability, for survivors of veterans who died from VA-related
service-connected conditions or who where rated permanetly and totall disabled at the
time of death from a VA-related service-connected condition, and for survivors of
persons who died in the line of duty.
Claim - ANSWERSA request for payment for services, benefits, or cost by a hospital,
physician or other provider that is submitted for reimbursement to the healthcare
insurance plan by either the insured party or by the provider
Comorbidity - ANSWERS1.A medical condition that coexists with the primary cause for
hospitalization and affects the patient's treatment and length of stay.
2. Pre-existing condition that, because of its presence with a specific diagnosis, causes
an increase in length of stay by atleast one day in approximately 75 percent of the
cases.
Complication - ANSWERS1. A medical condition that arises during an inpatient
hospitalization (for example, a postoperative wound infection.
2. Condition that arises during the hospital stay that prolongs the length of stay at lease
one day in approximately 75% of the cases.
Coordination of benefits (COB) transaction - ANSWERSProcess for determining the
respective responsiblites of two or more health plan that have some financial
responsibility for a medical claim.
Cost outlier - ANSWERSExceptioanlly high costs associated with inpatient care when
compared with other cases in the same diagnosis-related group.
Cost outlier adjustment - ANSWERSAdditional reimbursement for certain high-cost
home care cases based on the loss-sharing ratio of costs in excess of a threshold
amount for each home health resource group.
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