Healthcare Reimbursement; Chp. 4
Questions & Answers
Inpatient Prospective Payment System (IPPS) - ANSWERSclassification system used
to reimburse hospitals based on diagnosis-related groups (DRGs) with assigned
payment weights based on average resource utilization for a particular diagnosis
Diagnosis-Related Groups (DRGs) - ANSWERSclassification system that categorizes
patients who are similar in terms of diagnoses and treatments, age, resources used,
and length of stays based on the principal and secondary diagnoses including
comorbidities and complications as well as surgical procedures
Case Mix Group (CMG) - ANSWERSprospective payment system (PPS) used in
inpatient rehabilitation facilities
determines the payment rate per stay
Inpatient Rehabilitation Facilities-Patient Assessment Instrument (IRF-PAI) -
ANSWERSassessment tool that classifies patients into groups bases on clinical
characteristics and expected resource needs in inpatient rehabilitation facilities
Inpatient psychiatric facilities (IPF) - ANSWERSPPS classification is based on a per
diem rate
Outpatient Hospital PPS (OPPS) - ANSWERSuses the ambulatory payment
classification system (APC)
payment rates are based on categories of services that are similar in cost and resource
utilization
hospital-based clinics, Mrs, observations, and ambulatory surgery
Skilled Nursing Facilities - ANSWERSPPS uses Resource Utilization Groups (RUG)
Patient is assessed using the Minimum Data Sets (MDS)
Home Health Agencies - ANSWERSPPS is the Home Health Resource Group (HHRG)
Outcome Assessment Information Set (OASIS) is the assessment tool used to
determine the HHRG
The Inpatient Prospective Payment System (IPPS) applies to Medicare prospective
payment for care provided in which of the following inpatient health care setting?
, a. rehabilitation facilities
b. long-term care hospitals
c. psychiatric facilities
d. acute care hospital - ANSWERSd. acute care hospital
Which statement presents a guiding principle of the Prospective Payment Systems
(PPS) established by the Centers for Medicare and Medicaid Services (CMS), intended
to motivate providers to deliver cost-effective patient care without overuse of services?
a. Payment rates are automatically determined in advance based on the hospital's past
actual cost.
b. Prospective payment rates are established in advance, fixed for the fiscal period, and
considered payment in full.
c. A hospital should suffer no financial loss from a difference between the payment rate
and the actual cost of care.
d. Payment rates are established based on the Medicare patient's length of stay. -
ANSWERSa. Payment rates are automatically determined in advance based on the
hospital's past actual cost
CMS introduced documentation guidelines to Medicare carriers - ANSWERS1. Payment
rates are to be established in advance and fixed for the fiscal period to which they apply
2. payment rates are not automatically determined by hospital's past or current actual
cost
3. prospective payment rates are payment in full
4. the hospital retains the profit or suffers the loss resulting from the difference between
the payment rate and the hospital's cost, creating an incentive for cost control
MDC Hierarchy - ANSWERSMDC
/\
Medical section Surgical sections
Principal diagnosis - ANSWERScondition established after study to be chiefly
responsible for the occasioning the admission the patient to the hospital for care
Secondary diagnosis - ANSWERSdiagnosis that includes all conditions that co-exist at
the time of admission or develop subsequently and that affect the treatment received
and/or the length of stay
complication or comorbidity
Medicare Severity Diagnosis-Related Groups (MS-DRGs) - ANSWERSthis and final
level in the DRG hierarchy divides the surgical and medical section
3 subcategories; CC, MCC, and NonCC/MCC
Questions & Answers
Inpatient Prospective Payment System (IPPS) - ANSWERSclassification system used
to reimburse hospitals based on diagnosis-related groups (DRGs) with assigned
payment weights based on average resource utilization for a particular diagnosis
Diagnosis-Related Groups (DRGs) - ANSWERSclassification system that categorizes
patients who are similar in terms of diagnoses and treatments, age, resources used,
and length of stays based on the principal and secondary diagnoses including
comorbidities and complications as well as surgical procedures
Case Mix Group (CMG) - ANSWERSprospective payment system (PPS) used in
inpatient rehabilitation facilities
determines the payment rate per stay
Inpatient Rehabilitation Facilities-Patient Assessment Instrument (IRF-PAI) -
ANSWERSassessment tool that classifies patients into groups bases on clinical
characteristics and expected resource needs in inpatient rehabilitation facilities
Inpatient psychiatric facilities (IPF) - ANSWERSPPS classification is based on a per
diem rate
Outpatient Hospital PPS (OPPS) - ANSWERSuses the ambulatory payment
classification system (APC)
payment rates are based on categories of services that are similar in cost and resource
utilization
hospital-based clinics, Mrs, observations, and ambulatory surgery
Skilled Nursing Facilities - ANSWERSPPS uses Resource Utilization Groups (RUG)
Patient is assessed using the Minimum Data Sets (MDS)
Home Health Agencies - ANSWERSPPS is the Home Health Resource Group (HHRG)
Outcome Assessment Information Set (OASIS) is the assessment tool used to
determine the HHRG
The Inpatient Prospective Payment System (IPPS) applies to Medicare prospective
payment for care provided in which of the following inpatient health care setting?
, a. rehabilitation facilities
b. long-term care hospitals
c. psychiatric facilities
d. acute care hospital - ANSWERSd. acute care hospital
Which statement presents a guiding principle of the Prospective Payment Systems
(PPS) established by the Centers for Medicare and Medicaid Services (CMS), intended
to motivate providers to deliver cost-effective patient care without overuse of services?
a. Payment rates are automatically determined in advance based on the hospital's past
actual cost.
b. Prospective payment rates are established in advance, fixed for the fiscal period, and
considered payment in full.
c. A hospital should suffer no financial loss from a difference between the payment rate
and the actual cost of care.
d. Payment rates are established based on the Medicare patient's length of stay. -
ANSWERSa. Payment rates are automatically determined in advance based on the
hospital's past actual cost
CMS introduced documentation guidelines to Medicare carriers - ANSWERS1. Payment
rates are to be established in advance and fixed for the fiscal period to which they apply
2. payment rates are not automatically determined by hospital's past or current actual
cost
3. prospective payment rates are payment in full
4. the hospital retains the profit or suffers the loss resulting from the difference between
the payment rate and the hospital's cost, creating an incentive for cost control
MDC Hierarchy - ANSWERSMDC
/\
Medical section Surgical sections
Principal diagnosis - ANSWERScondition established after study to be chiefly
responsible for the occasioning the admission the patient to the hospital for care
Secondary diagnosis - ANSWERSdiagnosis that includes all conditions that co-exist at
the time of admission or develop subsequently and that affect the treatment received
and/or the length of stay
complication or comorbidity
Medicare Severity Diagnosis-Related Groups (MS-DRGs) - ANSWERSthis and final
level in the DRG hierarchy divides the surgical and medical section
3 subcategories; CC, MCC, and NonCC/MCC
