Which of the following does not impact the CMG used in the SNF services payment system quizlet?

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Terms in this set (44)

What is the reimbursement methodology used in acute care inpatient setting payment system (IPPS)?

Case rate

Rhonda saw her nurse practitioner Ms. Jones for a sinus infection. Ms. Jones practices at Sunnyside Clinic incident to Dr. Howard. Dr. Howard is a Medicare participating physician. The MPFS amount is $38.00 for the clinic visit. How much will Sunnyside Clinic be reimbursed for Rhonda's encounter?

$38.00

Rhonda saw her nurse practitioner Ms. Jones for a sinus infection. Ms. Jones practices at Sunnyside Clinic incident to Dr. Howard. Dr. Howard is a Medicare participating physician. The MPFS amount is $38.00 for the clinic visit. What is the coinsurance amount that Rhonda must pay?

$7.60

Which RBRVS RVU accounts for the skill of the physician, mental effort and judgement, and psychological stress?

Work

Which if the following does not impact the CMG used in the SNF services payment system?

Amount of therapy provided to resident
Function score
Clinical condition

Amount of therapy provided to resident

Lixin is an inpatient coder at Community Hospital. He is determine the MS-DRG for a hip replacement surgery. He has determined that the encounter is surgical. What is the next step in the MS-DRG assignment process.
Refinement Questions
Pre-MDC assignment
MDC for the admission

Refinement Questions

Which classification system is used for the Hospital Outpatient system (OPPS)?
CMG
APCs
MS-DRGs

APCs

What is the VBP program for physicians that links payment to quality measures and cost-saving goals?
Readmission Reduction Program
HAC POA
Quality Payment Program (QPP)

Quality Payment Program (QPP)

In MS-DRGs, _____________ is a proxy for resource consumption.
the secondary diagnoses
the length of stay
the relative weight

the relative weight

Lizbeth is a Medicare beneficiary enrolled at A+ Medicare Advantage plan. Her risk score is 1.56. That means _____________.
A+ Medicare Advantage receives the same capitated payment amount for all beneficiaries.
A+ Medicare Advantage will receive a higher monthly capitated payment amount for Lizbeth than the average Medicare beneficiary.
A+ Medicare Advantage will receive a lower monthly capitated payment amount for Lizbeth than the average Medicare beneficiary.

A+ Medicare Advantage will receive a higher monthly capitated payment amount for Lizbeth than the average Medicare beneficiary.

Use Table 6.1 in your textbook for this question.
Linda is a Medicare resident in a SNF. She is recovering from a knee replacement. Her function score is 4. What is the PT CMG for this resident stay?
TC
TB
TA

TA

Use Table 6.5 in your textbook for this question.
Jose is a Medicare resident in a SNF. He has a serious infection. His function score is 7. What is the Nursing CMG for this resident stay?
ES1
ES3
CDE2

ES1

When a third-party payer negotiates reduced fees for their beneficiaries they are using a ________________ reimbursement methodology.
fee schedule
per diem
percent of billed charges

percent of billed charges

When a third-party payer reimburses the provider a fixed, per capita amount for a specified period of time they are using a __________ reimbursement methodology.
case rate
fee schedule
capitated payment

capitated payment

In the PDPM the two components adjusted for residents living with HIV/AIDs are _________ and ______________.
nursing and non-case mix
physical therapy and occupational therapy
nursing and NTA

nursing and NTA

Fee schedule

a predetermined list of fees that the third party payer allows for payment for a set of healthcare services.
(retrospective)

Capitation

the third-party payer reimburses providers a fixed, per capita amount for a period. per capita means per head or per person
(prospective)

Global payment

the third-party payer makes one combined payment to cover the services of multiple providers, typically physicians, who are treating a single episode of care
(prospective)

Percent of billed charges

the contracting unit is the claim. third party payers negotiate reduced fees for their members or beneficiaries to control their costs.
(retrospective)

Case Rate

the third-party payer reimburses the provider one amount for the entire visit or encounter regardless of the number of services or length of the encounter
(prospective)

Per diem

a type of retrospective payment method that is commonly used in the hospital inpatient setting. the third party payer reimburses the provider a fixed rate for each day a beneficiary is hospitalized
(retrospective)

Describe the difference between ACO models that have a 1-sided risk versus a 2-sided risk.

The one-sided model allows the organization to share in cost savings. The two-sided model allows the organization to share in cost savings, but the organization must also share in the losses if the costs are greater than the benchmark amount.

CMS uses the CMS-HCC model when contracting with Medicare Advantage payers. (see figure 4.4 in your textbook). Why does CMS use the CMS-HCC model to adjust capitation rates for their beneficiaries rather than using a standard capitation rate for every beneficiary?

To predict which beneficiaries will be most costly to treat during the following year and then to increase capitated payments for those individuals. this allows CMS to redirect payments from managed care payers that may target healthy populations to managed care payers that provide insurance for the most ill patients.

List the four steps for MS-DRG assignment.

1. Pre-MDC assignment
2. Major Diagnostic Category Determination
3. Medical/Surgical Determination
4. Refinement

Which reimbursement methodology is used for the SNF PPS

Per diem

What are the six components of care used in the PDPM model

· Physical Therapy
· Occupational Therapy
· Speech Language Pathology
· Nursing
· Non-Therapy Ancillary
· Fixed non-case mix rate

Which of these components have a variable day adjustment?

PT, OT and NTA.

Which of these components are adjusted for residents with HIV/AIDS?

·Nursing Classification
NTA

packaging

occurs when reimbursement for minor ancillary services associated with a significant procedure is combined into a single payment for the procedure.

bundling

occurs when payment for multiple significant procedures or multiple units of the same procedure related to an outpatient encounter or to an episode of care is combined into a single unit of payment.

What are the reimbursement methodologies used in OPPS?

APC, Per diem, Comprehensive APC (C-APC), Conditional APC, Composite, Packaged, fee schedule, reasonable cost, services not reimbursed under OPPS

What is the classification system of OPPS?

APC

List the provisions of the OPPS

Interrupted services
High cost outlier
rural hospital adjustment
cancer hospital adjustment
pass through payment policy

Interrupted Services

Reported with modifiers

High Cost Outlier

Cost of providing service is 1.75 times higher than APC payment and Cost must exceed APC payment plus a fixed dollar thresholdAdd on- 50% of the difference between the cost and 1.75 times the APC payment

Rural Hospital adjustment

- rural hospitals costs are 7.1 percent greater than urban costs

cancer hospital adjustment

Aggregate payment is made to facilities at cost report settlement rather than an adjustment on each claim- this allows facilities to receive an adjustment without negatively impacting co-payments

Pass through payment policy

Provide hospital with additional payments for high cost drugs, biologicals, and devices -Total payment cannot exceed 2% of total OPPS payments for any given year-specific criteria such as device is different than others and shows substantial clinical improvement

What are the 3 components of physician payment?

RVU, geographic adjustment, and a conversion factor

What are the 3 types of RVUs in RBRVS?

Physician work (WORK)
Practice expense (PE)
Malpractice (MP)

Physician work (WORK)

at 51 percent the total RVU weight

Practice expense (PE)

at 45 percent of the total RVU weight

Malpractice (MP)

at 4 percent of the total RVU weight

List the steps for determining the MPFS amount (review figure 8.3)

Determine the procedure code for the service,
Use the Medicare Fee Schedule to find the three RVUs - work, practice expense, and malpractice- for the procedure,
Use the Medicare GPCI list to find three geographic practice cost indices,
Multiply each RVU by its GPCI to calculate the adjusted value,
Add the three adjusted totals, and multiply the sum by the conversion factor to determine the payment

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