Insurance Ch. 17

Admitted patients for services require overnight stay

Skilled Nursing Facility (SNF)
Provides skilled nursing or rehabilitation services to help with recovery after hospital stay

A delay in patient treatment would lead to significant increase threat to life or body part

Ambulatory Care
Outpatient care that doesn’t require an overnight stay

Ambulatory Surgical Unit (ASU)
Hospital department that provides outpatient surgery

Ambulatory Surgical Center (ASC)
Clinic that provides outpatient surgery

Home Healthcare (HHA)
Care given to patients in their homes

Home Health Agency
Organization that provides home care services

At-Home Recovery Care
Assistance with daily living activities provided in home

Hospice Care
Care for terminally ill people provided by public or private organization

Health Information Management (HIM)
Hospital department that organizes and maintains patient medical records
3 major steps:
– Admission
– Treatment
– discharge

Process of gathering PHI from patient prior to admission to hospital

Pre-admission Process
Gives staff members time to verify insurance, calculate patient’s responsibility, work out payment plans (if necessary), and handle ordered pre-admission tests

Master Patient Index (MPI)
Hospital’s main patient database
(ex: full name, birth date (8-digits), address, sex)

Attending Physician
Primary responsible for care of patient from beginning of hospital episode

Consent For Medical Treatment
Acceptance of responsibility for payment, and EOB

Hospital-Issued notice of non-coverage (HINN)
Form used for inpatient hospital services

Limited Liability For Inpatient Services
Not considered reasonable and necessary
May be safely provided in lover-acuity setting
Custodial in nature

Pre-treatment Patient Payment Collection
Facilitates set up pre-treatment payment plans to collect at least a deposit before admission and treatment, may be collected in advance

The Joint Comission
Sets stands for hospital patient medical records

Joint Commission on the Accreditation of Hospitals Organization

Joint Accreditation Committee Organization

Medicare Lifetime Reserve (LTR)
Medicare pays for 60 days over a person’s lifetime, if a patient exceeds 60 days medicare pays all covered costs except for daily coinsurance

Treatments and Charges During Hospital Stay
Patient is charged for everything, as well as type of accommodations and services they recieve

Observation Services
Assistance provided in a hospital room but billed as outpatient service

Charge Master
Hospital list of codes and charges for services

Hospital Diagnosis Coding
Inpatient coders do the coding asap after patient is discharged

Uniform Hospital Discharge Data Set (UHDDS)
Classification system for inpatient health data

Principal Diagnosis (PDX)
Condition established after study to be chiefly responsible for admission

Admitting Diagnosis (ADX)
Patient’s condition determined at admission to an inpatient facility

Listing correct order of principal diagnosis according to guidelines

Admitted patient’s coexisting condition that affect length of hospital stay or course of treatment

Patient develops a condition after surgery or treatment that affect the length of hospital stay or course of treatment

Hospital Procedure Coding
Significant procedures have these characteristics:
Involve surgery,
Anesthesia/Topical administered,
procedure involving risk to pt,
procedure requires specialized training

International Classification of Diseases, 10th Edition, Procedure Coding System

Principal Procedure
Process most closely related to treatment of the principal diagnosis

Diagnosis-Related Groups (DRGs)
System analyzing conditions and treatments for similar groups of patients

Case Mix Index
Measure of clinical severity of resource requirements

DRG Grouper
Computer program called a grouper calculates DRG to be paid based on codes assigned to patient’s stay

Major Diagnostic Categories (MDCs)
Categories by which MS-DRGs are grouped

Medicare-Severity DRGs (MS-DRGs)
New type of DRG designed to reflect different severity of illness among patients that have same basic diagnosis

Present On Admission (POA)
Code used when condition existed at the time the order for inpatient admission occured

Hospital-Acquired Condition (HAC)
Condition a hospital causes or allows to develop

Never Events
Preventable medical errors resulting in serious consequence for the patient

Outpatient Prospective Payment System (OPPS)
Payment system for medicare part B service that facilities provide on an outpatient basis

Ambulatory Patient Classification (APO)
Medicare payment classification for outpatient services

Ambulatory care is provided in an outpatient facility or setting An ambulatory surgery center is a clinic that provides outpatient surgery WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample …

Ambulatory care is provided in a(n): Outpatient facility or setting An ambulatory surgery center is a clinic that provides: Outpatient surgery WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample …

Hospitals provide different services, for example inpatient and outpatient. Although both services are provided within the hospital and have obvious similarities there are also major differences. The codes used within each service are affected by the differences between the services. …

UHDDS is the abbreviation for: uniform hospital discharge data set Which of these are used for outpatient billing by CMS? APCs WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample …

When an insurance carrier makes a payment to the patient/insured (or the provider) for a covered expense, it is referred to as reimbursement A payment system whereby the healthcare provider is paid a fee for each service or supply provided …

For this project I choose to talk about CHAMPVA insurance. In 1973, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) was established as a health benefits program for dependents of permanently and totally disabled veterans, …

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