CCA Exam Prep 2023

PPS - Prospective Payment System What is prospective payment system? - 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? - Capitation, global payment method, case-rate methodology, and bundled payment. Capitation - 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 - 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 - 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 - Reimbursement methodology where a predetermined payment amount is provided for all services required for a single predefined episode-of-care. Retrospective payment system - Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered fee-for-service - a system under which doctors and hospitals receive a payment for each service they provide Risk-adjusted payment - 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 - Affordable Care Act Risk score - indicates how costly an individual may be relative to the average beneficiary CMS-HCC - Centers for Medicare & Medicaid Services-Hierarchical Condition Category CMS-HCC payment - uses patient demographic and medical info to predict cost HCC - Hierarchical Condition Categories Hierarchical Condition Categories - 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 - Centers for Medicare and Medicaid Services What are the current valid code sets? - ICD-10 CM and PCS, CPT, HCPCS, and NDC !CD-10-CM is maintained by - NCHSq NCHS - National Center for Health Statistics ICD-10-PCS is maintained by - CMS CMS - Centers for Medicare and Medicaid Services Official coding guidelines are promulgated by the following 4 parties - AHA, AHIMA, NCHS, and CMS. AHA - American Hospital Association AHIMA - American Health Information Management Association who maintains CPT - American Medical Association (AMA) What are HCPCS Level 1 codes? - CPT codes What are HCPCS Level II codes used for? - They were established to report services, supplies, and procedures not represented in CPT. PDPM - patient driven payment model What is PDPM and where is it used? - Patient driven payment model is used in SNF(skilled nursing facilities) and uses case-mix variables. It focuses more on the patient. Minimum Data Set (MDS) - a report that focuses on the degree of assistance or skilled care that each resident of a long-term care facility needs, required reporting PDGM - patient driven groupings model