CCA Exam Prep 2024 LATEST UPDATE!!
PPS - ANSWER Prospective Payment System
What is prospective payment system? - ANSWER Payment for all care delivered during an episode of care
based on pre-determined fixed amount (DRGs). Influenced by care setting.
What are the 4 types of Prospective Payment Systems? - ANSWER Capitation, global payment method,
case-rate methodology, and bundled payment.
Capitation - ANSWER System of payment used by managed care plans in which physicians and hospitals
are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type
and number of services provided; reimbursement to the hospital on a per-member/per-month basis to
cover costs for the members of the plan. (PMPM)
Global Payment Method - ANSWER Third-party payer makes one combined payment to cover the
services of multiple providers who are treating a single episode of care.
Case-Rate Method - ANSWER Reimburses provider for all services provided during entire encounter or
visit, regardless of length of stay. Based on typical costs of condition, and is usually used in inpatient
admissions.
Bundled Payment - ANSWER Reimbursement methodology where a predetermined payment amount is
provided for all services required for a single predefined episode-of-care.
Retrospective payment system - ANSWER Type of fee-for-service reimbursement in which providers
receive recompense after health services have been rendered
fee-for-service - ANSWER a system under which doctors and hospitals receive a payment for each service
they provide
, Risk-adjusted payment - ANSWER introduced under ACA, shifts burden of risk for treating high-risk
patients to be shared by all insurers. Meant to make premiums the same.
ACA - ANSWER Affordable Care Act
Risk score - ANSWER indicates how costly an individual may be relative to the average beneficiary
CMS-HCC - ANSWER Centers for Medicare & Medicaid Services-Hierarchical Condition Category
CMS-HCC payment - ANSWER uses patient demographic and medical info to predict cost
HCC - ANSWER Hierarchical Condition Categories
Hierarchical Condition Categories - ANSWER Since 2004, HCCs have been used by the Centers for
Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with
serious acute or chronic conditions.
CMS - ANSWER Centers for Medicare and Medicaid Services
What are the current valid code sets? - ANSWER ICD-10 CM and PCS, CPT, HCPCS, and NDC
!CD-10-CM is maintained by - ANSWER NCHSq
NCHS - ANSWER National Center for Health Statistics
ICD-10-PCS is maintained by - ANSWER CMS
CMS - ANSWER Centers for Medicare and Medicaid Services
PPS - ANSWER Prospective Payment System
What is prospective payment system? - ANSWER Payment for all care delivered during an episode of care
based on pre-determined fixed amount (DRGs). Influenced by care setting.
What are the 4 types of Prospective Payment Systems? - ANSWER Capitation, global payment method,
case-rate methodology, and bundled payment.
Capitation - ANSWER System of payment used by managed care plans in which physicians and hospitals
are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type
and number of services provided; reimbursement to the hospital on a per-member/per-month basis to
cover costs for the members of the plan. (PMPM)
Global Payment Method - ANSWER Third-party payer makes one combined payment to cover the
services of multiple providers who are treating a single episode of care.
Case-Rate Method - ANSWER Reimburses provider for all services provided during entire encounter or
visit, regardless of length of stay. Based on typical costs of condition, and is usually used in inpatient
admissions.
Bundled Payment - ANSWER Reimbursement methodology where a predetermined payment amount is
provided for all services required for a single predefined episode-of-care.
Retrospective payment system - ANSWER Type of fee-for-service reimbursement in which providers
receive recompense after health services have been rendered
fee-for-service - ANSWER a system under which doctors and hospitals receive a payment for each service
they provide
, Risk-adjusted payment - ANSWER introduced under ACA, shifts burden of risk for treating high-risk
patients to be shared by all insurers. Meant to make premiums the same.
ACA - ANSWER Affordable Care Act
Risk score - ANSWER indicates how costly an individual may be relative to the average beneficiary
CMS-HCC - ANSWER Centers for Medicare & Medicaid Services-Hierarchical Condition Category
CMS-HCC payment - ANSWER uses patient demographic and medical info to predict cost
HCC - ANSWER Hierarchical Condition Categories
Hierarchical Condition Categories - ANSWER Since 2004, HCCs have been used by the Centers for
Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with
serious acute or chronic conditions.
CMS - ANSWER Centers for Medicare and Medicaid Services
What are the current valid code sets? - ANSWER ICD-10 CM and PCS, CPT, HCPCS, and NDC
!CD-10-CM is maintained by - ANSWER NCHSq
NCHS - ANSWER National Center for Health Statistics
ICD-10-PCS is maintained by - ANSWER CMS
CMS - ANSWER Centers for Medicare and Medicaid Services
