PROSPECTIVE PAYMENT SYSTEM PPS
CMS IPF PPS - answer1/inpt psychiatric facility: hospital and units in acute care
hospitals
2/implemented 2005: per diem rate several add-on payments
3/based upon code found in ICD9CM
4/ UHDDS defitions apply
IPF PPS - answer1/federal per fiem amount: reimburses facilities for cost of:
-operations
-ancillary services
-capital
2/adjustments
-pt lv
-facility lv
3/large number of adjustments=complex system: need to adequately reimburse
facilities(adjustment for location, for teaching hospital
timeline - answer1/1900s fee for services
1965smedicare and medicaid
1983 TEFRA/ IPPS
1990 RBRVS resource base relative value system , apply for physicians
2001 APCs for outpt
why move to prospective payment - answer1/incentive for hospital to operate more
efficiently
2/medicare payments had increased approximately 3 times the overall rate of inflation
3/deductible for beneficiaries continued to increase
4/healthcare cost were on rise-draining the medicare trust fund
5/no money available for medicare to fund other programs
6/hospital payment greatly varies from hospital to hospital for same services
7/eliminate burdensome reporting requirements
coding classification overview for IPPS - answerICD 9 CM for diagnosis and procedures
-payment system rely on national guidelines
+UHDDS def
+national coding guidelines
UHDDS UNIFORM HOSPITAL DISCHARGE DATA SET - answer1/ Principle diagnosis:
condition after study, which occasioned the admission to the hospital
2/complication: secondary disease or condition aggravating an already existing one
, 3/principcal procedure: procedure performed for definitive treatment rather than
diagnosis or exploratory purposes, or which is necessary to take care of a complication
4/significant procedure: a procedure that is one, surgical in nature, two, carries a
procedural risk, three, carries an anesthesia risk, or four, requires specialized training.
admitting dianosis - answerTentative or presumptive diagnosis of a patient's condition or
disorder at the time of admission.=> can be changed
primary diagnosis - answerprincipal diagnosis
overview DRGs - answer1/tax equity and fiscal responsibility act of 1982(TEFRA)
2/designed to reflect average resource consumption in medically meaningful groups
3/apply to acute hospital care
4/methodology: utilizes ICD 9CM code sets for coding and reporting
DRG - answer1/assumption: pt with similar illnesses and procedures require similar
care and should cost the same
2/factor in DRG assignment
-principal diagnosis
-surgical procedure performed
-comorbidities&/or complications(CCs)
-pt discharge stt
-pt age: in MS-DRG, pt age not listed as years
org. of DRG - answer1/major diagnostic categories(MDCs)primarily based on body
organ system
-MDC 1-25
+MDC 1, disease and disorders of nervous system
+MDC 23, factors influencing health stt and other contracts with health services
-PRE MDC(DRG 001-017)heart transplant
-uncatergorized DRG 981-999
2/diagnosis related groups-medical and surgical components within MDCs
pre MDC - answerassign based upon procedure code
MS DRG 001-014, 016-017
No MDC for surgical MS-DRG 981-989 - answer-981 extensive or procedure unrealted
to PDX with MCC
-DRG 984, Prostatic OR procedure unrelated to PDX w/ MCC
-DRG 987, Non-extensive OR procedure unrelated to PDX w/ MCC
No MDC for - answer-MS-DRG 998, PDX is invalid as discharge diagnosis
-MS-DRG 999, Ungroupable (Invalid or nonexistent ICD diagnosis code as PDX; sex or
discharge status invalid)
How is MS-DRG assigned?
CMS IPF PPS - answer1/inpt psychiatric facility: hospital and units in acute care
hospitals
2/implemented 2005: per diem rate several add-on payments
3/based upon code found in ICD9CM
4/ UHDDS defitions apply
IPF PPS - answer1/federal per fiem amount: reimburses facilities for cost of:
-operations
-ancillary services
-capital
2/adjustments
-pt lv
-facility lv
3/large number of adjustments=complex system: need to adequately reimburse
facilities(adjustment for location, for teaching hospital
timeline - answer1/1900s fee for services
1965smedicare and medicaid
1983 TEFRA/ IPPS
1990 RBRVS resource base relative value system , apply for physicians
2001 APCs for outpt
why move to prospective payment - answer1/incentive for hospital to operate more
efficiently
2/medicare payments had increased approximately 3 times the overall rate of inflation
3/deductible for beneficiaries continued to increase
4/healthcare cost were on rise-draining the medicare trust fund
5/no money available for medicare to fund other programs
6/hospital payment greatly varies from hospital to hospital for same services
7/eliminate burdensome reporting requirements
coding classification overview for IPPS - answerICD 9 CM for diagnosis and procedures
-payment system rely on national guidelines
+UHDDS def
+national coding guidelines
UHDDS UNIFORM HOSPITAL DISCHARGE DATA SET - answer1/ Principle diagnosis:
condition after study, which occasioned the admission to the hospital
2/complication: secondary disease or condition aggravating an already existing one
, 3/principcal procedure: procedure performed for definitive treatment rather than
diagnosis or exploratory purposes, or which is necessary to take care of a complication
4/significant procedure: a procedure that is one, surgical in nature, two, carries a
procedural risk, three, carries an anesthesia risk, or four, requires specialized training.
admitting dianosis - answerTentative or presumptive diagnosis of a patient's condition or
disorder at the time of admission.=> can be changed
primary diagnosis - answerprincipal diagnosis
overview DRGs - answer1/tax equity and fiscal responsibility act of 1982(TEFRA)
2/designed to reflect average resource consumption in medically meaningful groups
3/apply to acute hospital care
4/methodology: utilizes ICD 9CM code sets for coding and reporting
DRG - answer1/assumption: pt with similar illnesses and procedures require similar
care and should cost the same
2/factor in DRG assignment
-principal diagnosis
-surgical procedure performed
-comorbidities&/or complications(CCs)
-pt discharge stt
-pt age: in MS-DRG, pt age not listed as years
org. of DRG - answer1/major diagnostic categories(MDCs)primarily based on body
organ system
-MDC 1-25
+MDC 1, disease and disorders of nervous system
+MDC 23, factors influencing health stt and other contracts with health services
-PRE MDC(DRG 001-017)heart transplant
-uncatergorized DRG 981-999
2/diagnosis related groups-medical and surgical components within MDCs
pre MDC - answerassign based upon procedure code
MS DRG 001-014, 016-017
No MDC for surgical MS-DRG 981-989 - answer-981 extensive or procedure unrealted
to PDX with MCC
-DRG 984, Prostatic OR procedure unrelated to PDX w/ MCC
-DRG 987, Non-extensive OR procedure unrelated to PDX w/ MCC
No MDC for - answer-MS-DRG 998, PDX is invalid as discharge diagnosis
-MS-DRG 999, Ungroupable (Invalid or nonexistent ICD diagnosis code as PDX; sex or
discharge status invalid)
How is MS-DRG assigned?
