Term
| coc credential recognizes expertise in |
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Definition
| outpatient hospital and ambulatory surgical center coding |
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Term
| a list of surgeries safe to perform in an outpatient hospital and ASC is released |
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Definition
| Yearly by CMS in the Outpatient Prospective Payment System (OPPS) final rule |
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Term
| Under General Supervision, the physician must be |
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Definition
|
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Term
| which facility must have no more than 25 inpatient beds? |
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Definition
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Term
| the department responsible for coding procedures and services in the hospital facility is |
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Definition
|
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Term
| all of the following are examples of outpatient facilities except |
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Definition
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Term
| differences between coding surgical and diagnostic procedures for the outpatient facility and the provider |
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Definition
| modifiers and payment methodology are different for the outpatient facility and the provider. the code selection will be the same. |
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Term
| hospital outpatient services include |
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Definition
| all services rendered in a hospital not requiring an inpatient admission |
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Term
| the most common outpatient services are |
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Definition
| same-day surgeries, emergency department encounters, outpatient clinic encounters, therapeutic and diagnostic testing |
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Term
| when a patient presents to different departments for services at the hospital how many claims are generated |
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Definition
| One claim is generated for each date of service. all departments report the services performed and all charges are consolidated on one claim form. UB-04 for the date of service |
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Term
| for each department to receive credit for services rendered |
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Definition
| the services must be reported by them |
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Term
| the different methods for code selection |
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Definition
| in some departments the charge for the service is selected by the technician. or it is selected by the secretary for the department by using the hospitals chargemaster |
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Term
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Definition
| a master inventory list of everything that can be reported or performed in the hospital. |
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Term
| what are some other names for the chargemaster |
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Definition
| charge description master (CDM) or service master |
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Term
| codes for surgical procedures and emergency department encounters are selected by |
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Definition
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Term
| What is general supervison |
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Definition
| the physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. (not required to be present in the room or within any other physical boundary. |
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Term
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Definition
| the procedure or service is furnished under the physician's or NPPs overall direction and control, but the provider's presence is not required during the performance of the procedure. must be prepared to step in and perform the service, not just respond. |
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Term
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Definition
| the provider must be in attendance in the room during the performance of the services or procedure |
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Term
| who determines what surgeries are safe to perform in an outpatient hospital and ASC |
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Definition
| CMS and the information is released in the Outpatient Prospective Payment System (OPPS) final rule |
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Term
| what items are not included in the facility ambulatory payment classifications(APC) reimbursement and may be billed separately if supplied by the hospital |
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Definition
provider and anesthesiologist professional fees
durable medical equipment (DME)
prosthetic devices (except intraocular lenses)
ambulance services
outside laboratory services
certain drugs and biological(pass-through payments) |
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Term
| reimbursement for surgeries is based on |
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Definition
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Term
| payment for surgeries in a hospital outpatient facility is based on |
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Definition
|
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Term
| teaching physicians oversee |
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Definition
| residents providing patient care |
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Term
| an outpatient is defined by CMS as |
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Definition
| a person who has not been admitted by the hospital as an inpatient but is registered in the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH |
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Term
| partial hospitalization services are |
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Definition
| full-day programs for psychiatric services. also known as a step down program. can be in an outpatient hospital department or community mental health center.(cmhc) |
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Term
| outpatient services are covered under |
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Definition
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Term
| CAHs have how many beds for inpatient |
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Definition
| no more than 25 inpatient beds used for either inpatients or swing bed services |
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Term
| the privacy rule under HIPAA is managed by |
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Definition
| Medical records department |
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Term
| the department that is not open 24 hours a day but provides emergent care is called |
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Definition
| emergency department type b |
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Term
| A critical access hospital is |
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Definition
| a facility in a rural area used for hospital inpatient stays, inpatient rehabilitation and psychiatric services, which also offers emergency services |
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Term
| what constitutes a consultation |
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Definition
| a qualified provider seeks advice from another qualified provider |
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Term
| in the hospital outpatient facility, all facility services must be billed on |
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Definition
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Term
| what services must be provided in a CORF |
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Definition
| physician services, physical therapy, social or psychological services |
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Term
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Definition
| a hospital emergency department |
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Term
| how are codes selected for claim submission |
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Definition
| coders review the medical documentation to assign codes or putpatient department personnel select codes using the facility chargemaster |
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Term
| the admitting office is responsible for |
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Definition
| obtaining demographic information, insurance information, recording the type of service the patient requires, establishing an account, and obtaining consent for treatment |
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Term
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Definition
| a listing of everything that can be reported if performed in the hospital |
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Term
| where can additional requirements to be certified as a CAH be found |
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Definition
|
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Term
| what is the department that registers patients for outpatient services called |
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Definition
|
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Term
| we refer to both hospitals and ASC as |
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Definition
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Term
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Definition
| outpatient surgical services to patients not requiring hospitalization |
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Term
| services provided by the facility |
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Definition
| use of surgical suites, medical monitoring devices, recovery room time, and nursing services associated with the procedure or service provided |
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Term
| when providers perform procedures in the outpatient facility how many bills are generated and what are they |
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Definition
| two bills are generated. One claim is for the physician which are submitted on CMS-1500, and the other is for the facility which is submitted on a UB-04 claim form |
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Term
| name the two types of emergency departments defined by cms |
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Definition
|
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Term
| define type A emergency department |
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Definition
facility open 24 hrs day
open 7 days week
for immediate attention and emergent and urgent care |
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Term
| define type b emergency department |
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Definition
facility meet specific licensing requirements for emergent or urgent care patients
not open 24 hours day |
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Term
| when a patient is treated in the ed |
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Definition
additional charges for diagnostic testing and therapeutic services may result from the encounter
professional charges for patient care, interpretation of diagnostic studies, etc are billed separately by the professional rendering the services. |
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Term
| What are services provided by hospital clinic |
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Definition
outpatient visits
consults
minor office procedures
services are performed by physicians and NPPs
can be scheduled or non scheduled |
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Term
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Definition
| emergency medical treatment and labor act |
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Term
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Definition
a federal law that requires anyone coming to the emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. enacted in 1986 and remains an unfunded mandate.
but if it is determined the patients condition is not an emergency, the patient then can be seen in the outpatient clinic instead. |
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Term
| what is a teaching hospital |
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Definition
| they are affiliated with medical schools to train physicians. take part in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry. |
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Term
| what is a graduate medical education |
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Definition
| GME. a residency program approved by the accreditation council for graduate medical education. (ACGME) of the american medical association and other accrediting agencies for training physicians in specialties. |
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Term
| How do the teaching hospitals get paid for resident's services |
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Definition
| receive direct medicare GME payments |
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Term
| what do the direct GME payments include |
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Definition
| resident salaries, fringe benefits, and teaching physician compensation for services not payable on a fee schedule. Made on per resident basis and are hospital specific. |
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Term
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Definition
| are made for inpatient hospital stays through PPS better known as medicare severity diagnosis-related group payments. MS_DRG |
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Term
| additional payments to a teaching facility include |
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Definition
| for higher indirect costs incurred with MS-DRG payments. this includes administrative and supervisory services by a provider unrelated to the GME program or other approved educational activities. |
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Term
| Intern as defined for medicare purposes |
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Definition
| usually in their first year following graduation from medical school and are completing a one-year rotation in various departments of the teaching facility departments of the hospital that depend on specialities. |
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Term
| residents as defined for medicare purposes |
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Definition
| licensed physicians and , depending on the speciality, have two to five (possibly more) years of training in that speciality. |
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Term
| Fellows as defined for medicare purposes |
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Definition
| are physicians who are obtaining additional training in a subspeciality after residency training. |
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Term
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Definition
| independent or affiliated with a hospital. both perform similar services |
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Term
| where do independent asc get their money |
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Definition
| they are privately funded and are not part of a provider of services or any other facility. |
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Term
| Hospital outpatient surgery centers have option to be |
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Definition
| considered a provider-based department of the hospital or an ASC. |
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Term
| provider based departments of the hospital reimbursement is based on |
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Definition
| outpatient hospital reimbursement OPPS, addendum B. |
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Term
| if facility choses to participate in medicare as hospital owned ASC reimbursement is |
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Definition
| based on the ASC payment system OPPS addendum aa,bb |
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Term
| to be considered an ASC the hospital owned ASC must |
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Definition
be a separately identifiable entity, physically, administratively, and financially independent and distinct from other operations of the hospital. (costs are treated on the hospital cost report as non reimbursable cost center).
meet all of the requirements with regard to health and safety and agrees to the same regulations applied to independent ASC and
be surveyed and approved as complying with conditions for coverage in an ASC |
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Term
| Outpatient diagnostic testing |
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Definition
hospital facility must have order from the physician to perform test.
can be done independent or with other facility services.
hospital bills for the tc and patient get bill from physician for the professional interpretation.
if specimen sent in considered non-patient service (lab samples like blood, tissue, etc). |
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Term
| how are asc services billed |
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Definition
| cms requires it to be billed on cms-1500 and some private payers will require a ub-04 claim form |
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Term
| in addition to the 25 bed maximum in a CAH they may also operate |
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Definition
| a distinct rehabilitation and psychiatric unit, each with up to 10 beds to be used exclusively for the inpatient rehab and psyc. |
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Term
| In a CAH a physician must certify |
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Definition
| that an individual may resonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH. |
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Term
| CAH are reimbursed based on what method? (receive cost-based reimbursement) |
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Definition
| Standard payment method, unless the facility elects to be paid under the Optional Payment Method. |
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Term
| under the standard payment method for CAH |
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Definition
The cah bills only for the facility fees and is reimbursed:
80% of the 101% of reasonable costs for outpatient CAH services; or
101% of the reasonable costs of the CAH in furnishing outpatient CAH services, less the applicable part b deductible and coinsurance amounts. |
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Term
| Under the optional payment method , the cah bills for |
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Definition
| facility fees and professional fees |
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Term
| reimbursement under the optional payment method is based on the sum of |
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Definition
for facility services 101% of reasonable costs, after applicable deductions, regardless of whether the physician has reassigned their billing rights over to the cah; and
for physician services 115& of the allowable amount, after applicable deductions, under medicare physician fee schedule .payments for npp is 115% of the amount that otherwise would be paid for the practitioner's professional services under medicare pfs. |
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Term
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Definition
24 hour emergency services 7 days a week
hospital inpatient stays
inpatient rehab
psychiatric services |
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Term
| to be certified by medicare as a CAH, a facility must (among other requirements): |
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Definition
be located in a rural area or an area treated as rural
those in rural-turned urban areas have 2 yr transition period(sept 2016) to seek rural classification status
be located more than 35 miles from any hospital or other cah;or in a area with mountains or secondary roads only be located 15 miles; or
be certified by the state as being necessary provider of healthcare services to residents in the area. |
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Term
| CORF must supply at least |
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Definition
| physician services, physical therapy and social or psychological services. |
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Term
| a corf may cover other areas such as |
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Definition
| oncology, transplants, aids therapy, and renal dialysis |
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Term
| facility requirements for corf |
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Definition
| must have adequate space and equipment to provide services required by the patient as established in the treatment plan. |
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Term
| all corf services are paid under |
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Definition
| the medicare PFS except drugs and biologicals, and dme, prosthetics, orthotics, and supplies(dmepos) |
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Term
| the majority of corf services are paid |
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Definition
80% of the lesser of the actual charge or the PFS. subject to medicare part b deductibles and coinsurance provisions.
facility pays the provider. |
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Term
| under corf the patient may be billed |
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Definition
| the unmet portion of the deductible and 20 percent of the fee schedule amount for covered services. |
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Term
| covered services in a corf |
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Definition
provider service related to administrative functions;
physical therapy, occupational therapy, speech pathology services, and respiratory therapy;social and psychological services;nursing care directly related and provided by rn;prosthetic/orthopedic devices including fitting, training;supplies, appliances and equipment, including purchase or rental of dme from corf;drugs/biological that can't be self admin;single home visit to eval home environment on the rehab goals. |
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Term
| the admitting office does |
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Definition
| registers the patient for services. collects demographics, insurance information, type of service and insurance card copied, obtaining consent for treatment, collecting copays. An account is created that transfers patient information hospital wide or mr is transferred if small place. |
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Term
| business office is responsible for |
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Definition
| claim generation(claims come from the coding department), processing of remittance documents, filing incomplete/rejected claims, payment posting, appeals and the efficiency of the information systems may also fall here. |
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Term
| transactions provisions of HIPAA |
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Definition
| requires electronic claims filing to standardize the reimbursement and reporting processes |
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Term
| business office is referred to as |
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Definition
| patient financial services |
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Term
| Health Information Management Department |
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Definition
| HIM department is also called the Medical Records Department. |
|
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Term
| what are the duties of the HIM department |
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Definition
| organizes and stores the patients medical information in a medical record. paper or electronic. sections for coding, chart construction(organization), transcriptions, roi(requests of information), birth and death certifications, scanning or filing to input into charts. other sections that maintain consistent flow of patient info throughout the hospital. Manage the privacy rule under HIPAA. |
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Term
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Definition
notifying patients about their privacy rights and how their information can be used
adopting and implementing privacy procedures for its practice, hospital, or plan
training employees so they understand the privacy procedures
designating an individual to be responsible for seeing that the privacy procedures are adopted and followed. |
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