The Medicare OPPS is designed to pay acute hospitals for most outpatient services. Hospitals must bill on a UB-92 or successor claim forms using CPT or HCPCS codes for all services, supplies and pharmaceuticals. Each line on a claim is evaluated for payment or non payment using various criteria. The outcome of the evaluation results in a Status Indicator assigned to each line. These Status Indicators determine the payment mechanism to be applied [referenceAppendix 1].
What is the primary outpatient hospital reimbursement method used by Medicare?
However, the primary outpatient hospital reimbursement method used is the OPPS. The Outpatient Prospective Payment System (OPPS) is a Medicare reimbursement methodology used to determine fees for Part B outpatient services.
What is the HCPCS code for Medicare claims?
Medicare Claims Processing Manual, Chapter 25, for general instructions for completing the hospital claim data set. The HCPCS code is used to describe services where payment is under the Hospital OPPS or where payment is under a fee schedule or other outpatient payment methodology.
How are other services reported on a hospital outpatient claim?
With few exceptions, all other services reported on a hospital outpatient claim in combination with the primary service are considered to be related to the delivery of the primary service and packaged into the single payment for the primary service.
What is the billing form for outpatient hospital procedures and services?
The billing form used to bill for outpatient hospital procedures and services is the UB-04 claim form, shown above in Figure 1, which is maintained by the National Uniform Billing Committee (NUBC). 1. Patient is registered by the admitting office, clinic, or hospital outpatient department.
Which provision provides additional reimbursement for new technologies that enhance beneficiary outcomes quizlet?
Which provision provides additional reimbursement for new technologies that enhance beneficiary outcomes? The prospective payment system or PPS.
What perform quality control and utilization review of healthcare furnished to Medicare beneficiaries?
Quality Improvement Organization (QIO): CMS announced that peers review organizations (PROs) will be known as quality improvement organizations, and that they will continue to perform quality control and utilization review of health care furnished to Medicare beneficiaries.
Which act provided federal grants for modernizing hospitals?
Hill-BurtonAbout Hill-Burton, Titles VI & XVI It was designed to provide Federal grants to modernize hospitals that had become obsolete due to lack of capital investment throughout the period of the Great Depression and World War II (1929 to 1945).
Which was an indirect result of the Taft Hartley Act?
And indirect result was the creation of third-party administrators (TPAs), which administer healthcare plans and process claims, thus serving as a system of checks and balances for labor and management.
What is Kepro used for?
KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for more than 30 states. KEPRO offers information and assistance to providers, patients and families regarding beneficiary complaints, discharge appeals and immediate advocacy in states.
What is CMS QIO?
A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare.
What is the Hill-Burton Act of 1946?
On August 13, 1946, the Hill-Burton Act was signed into law by President Harry S. Truman. The bill, known formally as the Hospital Survey and Construction Act, was a Truman initiative that provided construction grants and loans to build hospitals where they were needed and would be sustainable.
What was the purpose of the Hill-Burton Act?
Hill-Burton provided construction grants and loans to communities that could demonstrate viability — based on their population and per capita income — in the building of health care facilities. The idea was to build hospitals where they were needed and where they would be sustainable once their doors were open.
Does the Hill-Burton Act still exist?
The program stopped providing funds in 1997, but about 140 health care facilities nationwide are still obligated to provide free or reduced-cost care.
Which act resulted in a prospective payment system PPS that issues a predetermined payment for inpatient services?
TEFRATEFRA also enacted a prospective payment system (PPS), which issues a predetermined payment for inpatient services. Previously, reimbursement was generated on a per diem basis, which issued payment based on daily rates.
Which act signed by President Theodore Roosevelt in 1908 protects and compensates railroad workers who are injured on the job?
President Theodore Roosevelt signed Federal Employers' Liability Act (FELA) legislation that protects and compensates railroad workers who are injured on the job.
Which was implemented as a result of the BBA of 1997?
Skilled Nursing Facility Prospective Payment System (SNF PPS) is implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries.
What is a per diem in healthcare?
For inpatient services, per-diems and defined or relative weight case-rates are used by the payer to promote shared cost/care management. Providers often negotiate stop-loss provisions, carve-outs for high-cost items as a means of balancing out the risk.
What is bundled payment?
With bundled payments, healthcare providers are reimbursed for specific episodes of care. It is much broader in the coordination of care than the traditional case-rate reimbursement. CMS’ Comprehensive Joint Replacement (CJR) program is an example where the inpatient stay and all related providers are bundled under a single payment. This method encourages greater coordination of care and can prevent redundant or medically unnecessary services.
What is CDM billing?
This offers the provider the lowest level of risk with the payer agreeing to reimburse at a negotiated discount using the provider’s standard Charge Description Master (CDM) which serves to track activity/usage and billing . Conceptually, this is the easiest to calculate, but payers often scrutinize the billed charges and there can be higher denial rates which can lead to additional audit/recovery work.
What is the primary outpatient hospital reimbursement method?
However, the primary outpatient hospital reimbursement method used is the OPPS.
What is a C code in Medicare?
Medicare created C codes for use by Outpatient Prospective Payment System (OPPS) hospitals. OPPS hospitals are not limited to reporting C codes, but they use these codes to report drugs, biologicals, devices, and new technology procedures that do not have other specific HCPCS Level II codes that apply.
What is an outpatient facility?
Outpatient facility coding is the assignment of ICD-10-CM, CPT ®, and HCPCS Level II codes to outpatient facility procedures or services for billing and tracking purposes. Examples of outpatient settings include outpatient hospital clinics, emergency departments (EDs), ambulatory surgery centers (ASCs), and outpatient diagnostic and testing departments (such as laboratory, radiology, and cardiology).
What is CPT code?
The CPT ® code set, developed and maintained by the American Medical Association (AMA), is used to capture medical services and procedures performed in the outpatient hospital setting or to capture pro-fee services, meaning the work of the physician or other qualified healthcare provider.
What is an ambulatory surgery center?
An ambulatory surgery center (ASC) is a distinct entity that operates to provide same-day surgical care for patients who do not require inpatient hospitalization. An ASC is a type of outpatient facility that can be an extension of a hospital or an independent freestanding ASC.
What is the official coding guidelines?
Official coding guidelines provide detailed instructions on how to code correctly; however, it is important for facility coders to understand that guidelines may differ based on who is billing (inpatient facility, outpatient facility, or physician office).
What is a patient registered?
1. Patient is registered by the admitting office, clinic, or hospital outpatient department. This includes validating the patient’s demographic and insurance information, type of service, and any preauthorization for procedures required by the insurance company, if not already completed prior to the visit. 2.
What is the purpose of CMS-1500?
legislation protects and compensates railroad workers who are injured on the job. consumer driven health plans. introduced in 2000 as a way to encourage individuals to locate the best health care at the lowest possible price with the goal of holding down health care costs. CMS-1500.
What is single payer health care?
third-party payer. provides health insurance coverage. help physicians, hospitals, and other health care providers work together to improve care for people with Medicare.
What is BIPA in healthcare?
Which is the abbreviation for the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 that required implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (former ly called Medicare+Choice) benefits, required faster Medicare appeals decisions, and more.
When was the Affordable Care Act created?
The Patient Protection and Affordable Care Act (PPACA) was signed into federal law on March 23, 2010, and resulted in the creation of a Health Insurance Marketplace to. reduce provider costs & cycle time.
What is the Federal Employees Compensation Act?
Federal Employees' Compensation Act. legislation provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages. meaningful use objectives and measurements.