CHAPTER 25 CODING AND
REIMBURSEMENT EXAM ACTUAL UPDATE QUESTIONS
AND VERIFIED ANSWERS
a method of payment undertaken by the Centers for Medicare and Medicaid Services (CMS) to
control the cost of inpatient acute-care hospital services to Medicare recipients
Title VI (6) of the Social Security Amendments of 1983 established the ____ to provide payment
to hospitals for each Medicare case at a set reimbursement rate, rather than on a fee-for-service
or per-day basis
hospital inpatient prospective payment system (IPPS)
under CMS, Medicare recipients must be
- over the age of 65
and / or
- identified with certain disabilities or end-stage renal disease
Medicare coverage includes
Part A: inpatient hospital, skilled nursing, some home health
Part B: medical insurance premium, physician services, outpatient hospital services, some home
health, durable medical equipment
Part C: Medicare + Choice (Medicare as an HMO product), or Medicare Advantage Plan
Part D: Prescription drug coverage
____ is another type of coverage administered by the state governments under CMS
based on
,- income
- resource shortfalls
Medicaid
both Medicare and Medicaid include
quality and medical necessity provisions
third-party payers and private insurance companies follow CMS's lead in reimbursement;
however major difference is
using negotiated versus set base rates for hospitals
inpatient hospital payment rates are established before services are rendered and are based on
_____
diagnosis-related groups (DRGs)
for fiscal year 2008, Medicare adopted a severity-adjusted diagnosis related group system called
______
- most drastic change to system in 24 years
- goal to significantly improve Medicare's ability to recognize severity of illness in its inpatient
hospital payments
- intended to increase payment to hospitals for services provided to the sicker patient and
decrease payments for treating less severely ill patients
Medicare Severity Diagnosis-Related Groups (MS-DRGs)
3 levels of severity in MS-DRGs reflecting the differences in the patient's condition based on
additional diagnosis codes assigned:
- both medical and surgical MS-DRGs may be influenced by secondary diagnosis code
ex:
principal diagnosis of heart failure, but presence or absence of secondary diagnosis determines
MS-DRG assigned
1. MS-DRGs with major complication or comorbidity (MCC)
- reflects highest severity level
- reflects sickest patient with highest severity level requiring a significant amount of resources to
treat both the principal diagnosis and additional conditions the patient has
, 2. MS-DRG with complication or comorbidity (CC)
- mid level severity
- based on secondary diagnoses
- requires additional resources for treating the principal and additional diagnoses
3. MS-DRGs with no complication or comorbidity (non-CC)
- does not affect severity of illness and resource use
- patient did not have additional condition requiring significant additional resources than what
was needed to treat the condition the patient had
____ represent an inpatient classification system designed to categorize patients who are
medically related with respect to diagnoses and treatment and who are statistically similar in
their lengths of stay
each ___ has preset reimbursement amount the hospital receives whenever the ____ is
assigned
acute care hospitals receive Medicare IPPS payments on a per discharge basis for Medicare
beneficiaries (one payment per hospital stay)
all outpatient diagnostic services and admission related therapeutic services provided by the
same hospital on the day of the patient's admission or within 3 days preceding the date of the
inpatient admission must be included on the inpatient hospital claim to Medicare and are paid
as pay of ____ payment
- no separate payment for these outpatient services
MS-DRGS
the Medicare patient's principal diagnosis and up to 24 additional diagnoses including those
diagnoses recognizes as major or other complication or comorbidity will determine the MS-DRG
*** The Medicare patient's principal diagnosis and up to 24 additional diagnoses that include
diagnoses that are recognized as major or other complication or comorbidity will determine the
MS-DRG assignment
patients having surgery or significant procedures will affect MS-DRG assignment
REIMBURSEMENT EXAM ACTUAL UPDATE QUESTIONS
AND VERIFIED ANSWERS
a method of payment undertaken by the Centers for Medicare and Medicaid Services (CMS) to
control the cost of inpatient acute-care hospital services to Medicare recipients
Title VI (6) of the Social Security Amendments of 1983 established the ____ to provide payment
to hospitals for each Medicare case at a set reimbursement rate, rather than on a fee-for-service
or per-day basis
hospital inpatient prospective payment system (IPPS)
under CMS, Medicare recipients must be
- over the age of 65
and / or
- identified with certain disabilities or end-stage renal disease
Medicare coverage includes
Part A: inpatient hospital, skilled nursing, some home health
Part B: medical insurance premium, physician services, outpatient hospital services, some home
health, durable medical equipment
Part C: Medicare + Choice (Medicare as an HMO product), or Medicare Advantage Plan
Part D: Prescription drug coverage
____ is another type of coverage administered by the state governments under CMS
based on
,- income
- resource shortfalls
Medicaid
both Medicare and Medicaid include
quality and medical necessity provisions
third-party payers and private insurance companies follow CMS's lead in reimbursement;
however major difference is
using negotiated versus set base rates for hospitals
inpatient hospital payment rates are established before services are rendered and are based on
_____
diagnosis-related groups (DRGs)
for fiscal year 2008, Medicare adopted a severity-adjusted diagnosis related group system called
______
- most drastic change to system in 24 years
- goal to significantly improve Medicare's ability to recognize severity of illness in its inpatient
hospital payments
- intended to increase payment to hospitals for services provided to the sicker patient and
decrease payments for treating less severely ill patients
Medicare Severity Diagnosis-Related Groups (MS-DRGs)
3 levels of severity in MS-DRGs reflecting the differences in the patient's condition based on
additional diagnosis codes assigned:
- both medical and surgical MS-DRGs may be influenced by secondary diagnosis code
ex:
principal diagnosis of heart failure, but presence or absence of secondary diagnosis determines
MS-DRG assigned
1. MS-DRGs with major complication or comorbidity (MCC)
- reflects highest severity level
- reflects sickest patient with highest severity level requiring a significant amount of resources to
treat both the principal diagnosis and additional conditions the patient has
, 2. MS-DRG with complication or comorbidity (CC)
- mid level severity
- based on secondary diagnoses
- requires additional resources for treating the principal and additional diagnoses
3. MS-DRGs with no complication or comorbidity (non-CC)
- does not affect severity of illness and resource use
- patient did not have additional condition requiring significant additional resources than what
was needed to treat the condition the patient had
____ represent an inpatient classification system designed to categorize patients who are
medically related with respect to diagnoses and treatment and who are statistically similar in
their lengths of stay
each ___ has preset reimbursement amount the hospital receives whenever the ____ is
assigned
acute care hospitals receive Medicare IPPS payments on a per discharge basis for Medicare
beneficiaries (one payment per hospital stay)
all outpatient diagnostic services and admission related therapeutic services provided by the
same hospital on the day of the patient's admission or within 3 days preceding the date of the
inpatient admission must be included on the inpatient hospital claim to Medicare and are paid
as pay of ____ payment
- no separate payment for these outpatient services
MS-DRGS
the Medicare patient's principal diagnosis and up to 24 additional diagnoses including those
diagnoses recognizes as major or other complication or comorbidity will determine the MS-DRG
*** The Medicare patient's principal diagnosis and up to 24 additional diagnoses that include
diagnoses that are recognized as major or other complication or comorbidity will determine the
MS-DRG assignment
patients having surgery or significant procedures will affect MS-DRG assignment
