Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
99 Cards in this Set
- Front
- Back
Hospital Inpatient Settings
|
–Hospital Inpatient Unit
–Intensive Care Unit |
|
True or False According to the American Hospital Association (AHA), a hospital must maintain at least six (6) inpatient beds and care must be readily available for the patients who stay an average of 24 hours or more per admission.
|
True |
|
Hospital Outpatient Settings |
-Hospital Outpatient Unit
-Hospital Outpatient Clinic -Hospital Emergency Unit -Hospital Observation Services -Hospital Ambulatory Surgery Unit -Partial hospitalization program (PHP) |
|
What is a Long-Term Care Hospital (LTCH)? |
Provides hospital-level care for medically complex patients. Has an average inpatient length of stay of greater than 25 days.
|
|
What has been the trend in the utilization on hospital-based services?
|
Hospital based-service utilization has expanded from providing short term acute care to providing many different types of care ranging from ambulatory care to long term care. The advances in medical technology and changes in reimbursement have also changed the way that hospital based services are utilized. The role of hospitalists in caring for inpatients has expanded greatly. The number of long term acute care hospitals has grown significantly.
|
|
What factors help account for this trend in the utilization of hospital-based services?
|
Federal regulations and private accrediting organizations have placed a renewed focus on quality improvement initiatives within health care organizations. Documentation, coding, reimbursement,and revenue cycle management is increasingly scrutinized due to auditing initiatives such as the Recovery Audit Contractor and Medicaid Integrity Program. Also,the implementation of EHR’s, hospitals merging with other health care facilities, third party payers, a wide variety of patient’s needs, services rendered, and care givers.
|
|
Hospital Outpatient Unit
|
– An outpatient facility where a patient can receive diagnostic or therapeutic services such as lab and/or radiology screening.
|
|
Hospital Outpatient Clinic
|
– an outpatient clinic within the hospital where low income patients receive care and evaluation and also provides education for physicians in training
|
|
Hospital Emergency Unit
|
– An organizational unit staffed as a trauma center providing medical services needed on an urgent or emergency basis
|
|
Hospital Observation Services
|
– observation of an outpatient at the hospital facility (provided with use of a bed) to determine if the patient needs to be admitted as an inpatient.
|
|
True or False
Hospital observation services may be billed to all payers as outpatient services for observation stays up to 72 hours |
False |
|
Hospital Ambulatory Surgery Unit
|
– surgeries performed and patient discharged to home on the same day
|
|
True or False Acute and chronic illnesses can both be treated on an ambulatory basis.
|
True |
|
Clinic Outpatient
|
– a clinic within the hospital where patients receive care and evaluation
|
|
True or False
Hospital clinics are rarely organized by medical specialty. |
False |
|
Referred Hospital Outpatient
|
– an outpatient receives diagnostic or therapeutic services such as lab and/or radiology screening
|
|
True or False
For referred outpatients, the hospital provides diagnostic or therapeutic services, but it does not take responsibility for evaluating or managing the patient's care. |
True |
|
Emergency Outpatient
|
- an outpatient is evaluated and receives care and treatment
|
|
True or False
According to the Joint Commission, the records of patients receiving continuing ambulatory care services must contain a summary list of known significant diagnoses, conditions, procedures, drug allergies, and medications. |
True |
|
Ambulatory Surgery
|
(also called "same-day" surgery) surgery in which it is planned that the patient will arrive at the facility, have surgery, recover from any anesthesia, and be ready for discharge in a single day, thus avoiding an overnight stay in the health care facility
|
|
Hospital Inpatient
|
an individual receiving health care services as well as room and board and continuous nursing care in a hospital and where patients generally stay overnight
|
|
Referred Hospital Outpatient
|
an outpatient who is referred to the hospital for specific services, such as laboratory or radiology examinations; the hospital is responsible only for providing the diagnostic or therapeutic services requested, while the referring physician is responsible for evaluating and managing the patient's care
|
|
Hospital Outpatient
|
a hospital patient who receives care at the hospital but who is not admitted as a patient
|
|
Partial Hospitalization Program (PHP)
|
an intensive treatment program in which patients receive services for part of each day; these patients would otherwise require inpatient psychiatric care
|
|
True or False
A partial hospitalization program is considered to be a type of inpatient psychiatric program. |
False |
|
Resident
|
primarily a licensed physician, dentist, or podiatrist who participates in an approved graduate medical education program
|
|
Hospitalist
|
a physician who specializes in inpatient medicine
|
|
True or False
A hospitalist is a physician who provides comprehensive care to hospitalized patients, as well as seeing patients outside of the hospital setting. |
False |
|
Types of Caregivers
|
physicians, nurses, physical therapists, occupational therapists, clinical laboratory scientists, pharmacists, and others
|
|
True or False
Hospitals that meet the standards of the Joint Commission, HFAP, or DNV are deemed to meet the Conditions of Participation. |
True |
|
What organization accredits the majority of hospitals in the United States?
|
The Joint Commission
|
|
Which accrediting organization most recently received “deeming authority” for its hospital accreditation program from CMS?
|
National Integrated accreditation of Healthcare Organizations (NIAHO), a program of DNV Healthcare, Inc., an international organization originating in Norway.
|
|
Licensure:
|
Each state determines requirements
|
|
Federal Regulations:
|
Medicare’s Conditions of Participation for Hospitals or “deemed” status by virtue of accreditation
|
|
Accreditation:
|
Voluntary program through:
–The Joint Commission –Healthcare Facilities Accreditation Program (HFAP), American Osteopathic Association –NIAHO program of DNV Healthcare, Inc. |
|
Good documentation is important to the hospital to…
|
Meet accrediting and regulatory guidelines Provide high-quality care
Demonstrate appropriateness of payments |
|
Type and extent of documentation depends on -
|
nature of services performed, e.g., surgery, critical care, outpatient care
|
|
What are the key components that both inpatient and outpatient records must contain in the documentation of surgery?
|
History and physical examination report, Operation report,
Anesthesia record, Operation recovery notes, Pathology reports (when appropriate) |
|
What are the key issues with regard to documentation of services rendered by teaching physicians?
|
Except for services furnished as set forth in (the exceptions) the medical records must document the teaching physician was present at the time the service is furnished. The presence of the teaching physician during procedures may be demonstrated by the notes in the medical records made by a physician, resident, or nurse. In the case of evaluation and management procedures, the teaching physician must personally document his or her participation in the service in the medical records
|
|
Joint Commission and Documentation
|
•Standards affecting health information services are found in various sections, e.g. –Information Management –Record of Care, Treatment, and Services –Provision of Care, Treatment, and Services •Elements of performance (EPs) address specific issues |
|
True or False
The level of service provided determines the selection and reporting of an appropriate code, which in turn determines the amount of physician reimbursement. |
True |
|
Physician Reimbursement and Documentation
|
Level of service billed by physician determined by documentation in record
|
|
Physician Reimbursement and Documentation
|
•Level of service billed by physician determined by documentation in record
•Resident’s services not billed to Medicare (Indirect medical education allowances fund resident’s Medicare services.) •Teaching physician may bill Medicare when documentation indicates his or her presence and participation |
|
Charge Description Master (CDM) or Chargemaster
|
•is a data file containing codes for hospital services with charges for those services
•automatically assigns codes for billing when the charge is entered •maintenance is important to hospital’s financial health |
|
What is the hospital charge master or description master?
|
A computerized data file which lists appropriate codes for the service and the hospitals charge for that service. It is used for ancillary services like laboratory and radiology charges. Charges are automatically charged by the charge master when those codes are entered into that system.
|
|
What are DRG’s/APC’s, and what is their impact on hospital reimbursement?
|
-Diagnosis-related group (DRG) are used determine how much Medicare pays the hospital for inpatient stays. (1 DRG per stay)
-APCs or Ambulatory Payment Classifications are Medicare’s method of determining payment for facility outpatient services. (Multiple APCs per stay) |
|
Ambulatory Payment Classifications (APCs)
|
groupings of outpatient services (based on the HCPCS code assigned) that determine the payment the hospital receives under the Hospital Outpatient Prospective Payment Systems (HOPPS)
|
|
Medicare Severity Diagnosis Related Groups (MS-DRGs)
|
groupings of inpatient services (based on the diagnosis, expected resource consumption, and other characteristics) that determine the payment the hospital receives under the Hospital Inpatient Prospective Payment System (HIPPS)
|
|
Hospital Outpatient Prospective Payment System (HOPPS or OPPS)
|
Medicare's payment system for hospital outpatient services; the basic unit of payment in the OPPS is the ambulatory payment classification (APC) of each service provided
|
|
Hospital Inpatient Prospective Payment System (HIPPS or IPPS)
|
Medicare's payment system for hospital inpatient services; the basic unit of payment in the IPPS is the Medicare Severity Diagnosis Related Group (MS-DRG)
|
|
Hospital Reimbursement - Medicare
|
•Medicare Administrative Contractor (MACs) replaced
-Part A: Fiscal Intermediary -Part B: Medicare carrier –Hospital Inpatient Prospective Payment System (IPPS) –Hospital Outpatient Prospective Payment System (OPPS) |
|
Hospital Reimbursement - Discounting
|
reducing the payment for additional procedures or ambulatory patient groups so that these other items are not paid at the full rate, as they would be if they had been the only services performed in a given encounter
|
|
Hospital IPPS
|
•Medicare-Severity Diagnosis RelatedGroups (MS-DRGs) are the basis for Medicare payment •Each MS-DRG has a relative weight that determines the payment amount for the patient stay
|
|
Seventy-Two-Hour Window
|
•Outpatient services related to inpatient admission within subsequent 72 hours must be billed with inpatient charges, resulting in a single DRG payment for both outpatient and inpatient services
•Failure to bundle outpatient and inpatient codes on same bill can result in financial penalties for the hospital |
|
True or False
Charges for ancillary services, such a laboratory and radiology charges, are usually captured through the hospital chargemaster. |
True |
|
True or False
The PATH audit demonstrated that teaching physician documentation almost always supported the level of service billed to Medicare; therefore, these audits did not result in significant reimbursement of funds to Medicare. |
False |
|
True or False
To meet federal requirements that permit participation in Medicare/Medicaid, the federal government surveys and certifies non-accredited hospitals. |
False |
|
True or False
When a resident, as part of his or her medical education, participates with a teaching physician in providing a service, the resident is usually paid a salary by the hospital , and the teaching physician is reimbursed by Medicare. |
True |
|
True or False
With regard to Medicare, hospitals should bill separately any charges for ancillary services provided on an outpatient basis within 72 hours prior to hospital admission. |
False |
|
Common Working File
|
a file maintained on each Medicare beneficiary in one of the 9 regional databases; this file contains claims history information from both Part A and Part B claims and data on utilization patterns of Medicare beneficiaries
|
|
What coding systems are used in hospital-based care?
|
ICD-10-CM, ICD-10-PCS, HCPCS, CPT, Revenue Codes
|
|
Fiscal Intermediary (FI)
|
before the implementation of MACs, an organization with a contract with CMS to process and pay Part A Medicare claims
|
|
Medicare Administrate Contractor (MAC)
|
an organization that has contacted with CMS to process Medicare claims; MACs have replaced fiscal intermediaries and Medicare carriers
|
|
Medicare Carrier
|
before the implementation of MACs, an organization having a contract with the CMS to process and pay Part B Medicare claims
|
|
Potentially Compensable Event (PCE)
|
an occurrence that may result in litigation against the health care provider or that may require health care provider to financially compensate an injured party
|
|
Revenue Codes
|
used on the UB-04 to indicate the general nature of the services provided
|
|
Status Indicator
|
an alphabetic character that indicates the type of each APC and whether or how that APC is paid under the Hospital Outpatient Prospective Payment System (OPPS)
|
|
Uniform Ambulatory Care Data Set (UACDS)
|
a 16-item data set approved by the National Committee on Vital and Health Statistics (NCVHS); one of the first attempts to standardize ambulatory data collection efforts
|
|
Uniform Hospital Discharge Data Set (UHDDS)
|
standard data elements to be collected from individual inpatient records; the UHDDS data definitions are important for correct reporting of inpatient data
|
|
HFAP
|
Healthcare facilities accreditation program (of the AOA American osteopathic organization)
|
|
NIAHO
|
National integrated accreditation of healthcare organizations
|
|
Emergency Medical Treatment and Active Labor Act (EMTALA)
|
a federal law that imposes a legal duty on hospitals to screen and stabilize, if necessary, any patient who arrives in the emergency department; the purpose of EMTALA is to prevent the "dumping" of patients who may not be able to pay for emergency department services
|
|
American Recovery and Reinvestment Act (ARRA)
|
a federal law that, among other things, created an incentive program for health care providers to utilize EHRs for improved patient care
|
|
Hospital OPPS
|
•Ambulatory Payment Classifications (APCs) are the basis for Medicare payment under hospital OPPS •Multiple APCs per visit are possible for outpatients. In contrast, only one DRG per stay is paid for inpatients. • Status indicators •Composite APCs •Observation services •Pass-through payments •Provider-based clinics |
|
Long-Term Care Hospital PPS
|
Long Term Care Hospital Prospective Payment System
|
|
Long-Term Care Hospital PPS
|
•Medicare severity long-term care diagnosis related groups (MS-LTC-DRGs) –Similar in structure to MS-DRGs –Different relative weights –Different lengths of stay •Other Medicare payment mechanisms for interrupted stays and certain types of transfers |
|
Other Reimbursement Issues
|
•Other payers
•Billing forms –UB-04 (or HCFA 1450) used by hospitals –HCFA 1500 used by physicians •Electronic claims submission is the norm |
|
Coding and Classification
|
ICD -Diagnosis coding for inpatients and outpatients -Procedure coding for inpatients only |
|
Coding and Classification
|
HCPCS Procedure coding for hospital outpatients |
|
Coding and Classification
|
Revenue codes - used on the UB-04 to indicate the general nature of the services provided
|
|
Coding and Classification
|
Coding edits (MCE, OCE, NCCI)
|
|
Data and Information Flow
|
•Registration
•Master patient index •Documentation of assessments, diagnostic procedures, treatments, etc., added to record as completed •Record must be readily available when patient presents for care in any location of the hospital |
|
Electronic Health Records and Computer Systems
|
•Early systems related to billing functions •Clinical information systems began to receive more attention in the 1990's
•Electronic health records –ARRA’s financial incentives for meaningful use of electronic health records –Advantages to patients and clinicians |
|
Data Sets
|
•Uniform Hospital Discharge Data Set
•Uniform Ambulatory Care Data Set •Data Elements for Emergency Department Systems •HIPAA designated standards maintenance organizations •Medicare common working file (CWF) combines claims data from Part A and Part B claims |
|
Quality Assessment and Performance Improvement
|
•Joint Commission
•DNV Healthcare •CMS –Hospital Inpatient Quality Reporting –Hospital Outpatient Quality Data Reporting |
|
Utilization Management (UM)
|
•Appropriateness, efficiency, and cost-effectiveness of health care
•PPS and managed care provide incentive for effective UM programs •Team effort required to operate efficiently, reduce repetitive testing, etc. |
|
Risk Management & Legal Issues
|
•Potentially compensable events (PCEs) – may result in litigation or payments to an injured party
•Occurrence (or incident) reporting systems may be paper-based or electronic •Legible, complete documentation •Documentation of telephone contacts •Telephone calls should be HIPAA compliant |
|
EMTALA - Emergency Medical Treatment and Active Labor Act
|
•“Anti-dumping” legislation
•Legal duty to screen and stabilize •Cannot delay screening to check insurance status •Must stabilize before transfer •Stabilization for woman in labor generally means delivery of infant before transfer |
|
Role of Health Information Management Professional
|
•Health Information Services
•Compliance Officer •Revenue Cycle •Other Roles |
|
Trends
|
•Increasing complexity of services
•Increasing numbers of hospitalists •Long-term acute care •Quality and reimbursement linkage •Electronic health records •Auditing initiatives |
|
Summary of Hospital-based care
|
•Broad range of services and many types of caregivers
•Licensure and accreditation •Documentation issues •Reimbursement issues •Coding and classification •Data and information flow |
|
Summary of Hospital-based care (continued)
|
•Data sets
•Quality assessment and improvement •Utilization management •Risk management •Role of the health information professional •Trends |
|
WebActivity
|
•Health Care Compliance Associationhttp://www.hcca-info.org
•CHC certification –HCCB handbook content outline –Content areas and health information management training |
|
What is EMTALA?
|
Emergency Medical Treatment and Active Labor Act. A federal law that imposes a legal duty on hospitals to screen and stabilize, if necessary, any patient who arrives in the emergency department. The purpose of EMTALA is to prevent the “dumping” of patients who may not be able to pay for emergency department services.
|
|
What is ARRA?
|
American Recovery and Reinvestment Act. A federal law that, among other things, created an incentive program for health care providers to utilize EHR’s for improves patient care.
|
|
What factors should be considered to avoid legal risk in hospital-based care?
|
*Quality Assessment and Performance Improvement Risk Management Department, providing high-quality documentation of all patient encounters and services. Providers must ensure that all documentation is both legible and complete and ensuring that all providers have properly timed, dated, and signed an order or entry. Incident reporting systems whereas risk management tracks PCE’s (potentially compensable events) as to identify risk areas within the organization that can be targeted for improvement.
*Telephone contact of outpatients after procedures because of the limited amount of time the outpatient spends at the hospital. Proper Documentation of all phone calls including what the caregiver tells the patient and what the patient tells the caregiver. *Emergency Medical Treatment and Active Labor Act (EMTALA) following this rule will limit potential legal issues. |
|
Various roles of the HIM professional in
hospital-based care. |
-Traditional Role
-Compliance officer -Compliance Departments (Promote -compliance with both billing and HIPAA regulations) -Coding specialist – Inpatient and Outpatient specialties -Chargemaster coordinators -Performance improvement -Cancer registry -Trauma registry -Information systems -Financial services -Supervisors that deal with accuracy, completeness, and legal acceptability of the electronic record -In paper based systems – filing and retrieval -Release of information -Data collection and analysis -Privacy officer -Work with revenue cycle management ---Performance improvement |
|
PCE
|
Potentially Compensable Event
|
|
What is a PCE? |
A Potentially Compensable Event - Any event that can pose the risk of financial loss to a health care institution. |