Alternate Care Systems Chapter 2

Front 1

Hospital Inpatient Settings

Back 1

–Hospital Inpatient Unit

–Intensive Care Unit

Front 2

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.

Back 2

True

Front 3

Hospital Outpatient Settings

Back 3

-Hospital Outpatient Unit

-Hospital Outpatient Clinic

-Hospital Emergency Unit

-Hospital Observation Services

-Hospital Ambulatory Surgery Unit

-Partial hospitalization program (PHP)

Front 4

What is a Long-Term Care Hospital (LTCH)?

Back 4

Provides hospital-level care for medically complex patients. Has an average inpatient length of stay of greater than 25 days.

Front 5

What has been the trend in the utilization on hospital-based services?

Back 5

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.

Front 6

What factors help account for this trend in the utilization of hospital-based services?

Back 6

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.

Front 7

Hospital Outpatient Unit

Back 7

– An outpatient facility where a patient can receive diagnostic or therapeutic services such as lab and/or radiology screening.

Front 8

Hospital Outpatient Clinic

Back 8

– an outpatient clinic within the hospital where low income patients receive care and evaluation and also provides education for physicians in training

Front 9

Hospital Emergency Unit

Back 9

– An organizational unit staffed as a trauma center providing medical services needed on an urgent or emergency basis

Front 10

Hospital Observation Services

Back 10

– 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.

Front 11

True or False

Hospital observation services may be billed to all payers as outpatient services for observation stays up to 72 hours

Back 11

False

Front 12

Hospital Ambulatory Surgery Unit

Back 12

– surgeries performed and patient discharged to home on the same day

Front 13

True or False Acute and chronic illnesses can both be treated on an ambulatory basis.

Back 13

True

Front 14

Clinic Outpatient

Back 14

– a clinic within the hospital where patients receive care and evaluation

Front 15

True or False

Hospital clinics are rarely organized by medical specialty.

Back 15

False

Front 16

Referred Hospital Outpatient

Back 16

– an outpatient receives diagnostic or therapeutic services such as lab and/or radiology screening

Front 17

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.

Back 17

True

Front 18

Emergency Outpatient

Back 18

- an outpatient is evaluated and receives care and treatment

Front 19

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.

Back 19

True

Front 20

Ambulatory Surgery

Back 20

(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

Front 21

Hospital Inpatient

Back 21

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

Front 22

Referred Hospital Outpatient

Back 22

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

Front 23

Hospital Outpatient

Back 23

a hospital patient who receives care at the hospital but who is not admitted as a patient

Front 24

Partial Hospitalization Program (PHP)

Back 24

an intensive treatment program in which patients receive services for part of each day; these patients would otherwise require inpatient psychiatric care

Front 25

True or False

A partial hospitalization program is considered to be a type of inpatient psychiatric program.

Back 25

False

Front 26

Resident

Back 26

primarily a licensed physician, dentist, or podiatrist who participates in an approved graduate medical education program

Front 27

Hospitalist

Back 27

a physician who specializes in inpatient medicine

Front 28

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.

Back 28

False

Front 29

Types of Caregivers

Back 29

physicians, nurses, physical therapists, occupational therapists, clinical laboratory scientists, pharmacists, and others

Front 30

True or False

Hospitals that meet the standards of the Joint Commission, HFAP, or DNV are deemed to meet the Conditions of Participation.

Back 30

True

Front 31

What organization accredits the majority of hospitals in the United States?

Back 31

The Joint Commission

Front 32

Which accrediting organization most recently received “deeming authority” for its hospital accreditation program from CMS?

Back 32

National Integrated accreditation of Healthcare Organizations (NIAHO), a program of DNV Healthcare, Inc., an international organization originating in Norway.

Front 33

Licensure:

Back 33

Each state determines requirements

Front 34

Federal Regulations:

Back 34

Medicare’s Conditions of Participation for Hospitals or “deemed” status by virtue of accreditation

Front 35

Accreditation:

Back 35

Voluntary program through:

–The Joint Commission

–Healthcare Facilities Accreditation Program (HFAP), American Osteopathic Association

–NIAHO program of DNV Healthcare, Inc.

Front 36

Good documentation is important to the hospital to…

Back 36

Meet accrediting and regulatory guidelines Provide high-quality care

Demonstrate appropriateness of payments

Front 37

Type and extent of documentation depends on -

Back 37

nature of services performed, e.g., surgery, critical care, outpatient care

Front 38

What are the key components that both inpatient and outpatient records must contain in the documentation of surgery?

Back 38

History and physical examination report, Operation report,

Anesthesia record,

Operation recovery notes,

Pathology reports (when appropriate)

Front 39

What are the key issues with regard to documentation of services rendered by teaching physicians?

Back 39

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

Front 40

Joint Commission and Documentation

Back 40

•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

Front 41

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.

Back 41

True

Front 42

Physician Reimbursement and Documentation

Back 42

Level of service billed by physician determined by documentation in record

Front 43

Physician Reimbursement and Documentation

Back 43

•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

Front 44

Charge Description Master (CDM) or Chargemaster

Back 44

•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

Front 45

What is the hospital charge master or description master?

Back 45

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.

Front 46

What are DRG’s/APC’s, and what is their impact on hospital reimbursement?

Back 46

-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)

Front 47

Ambulatory Payment Classifications (APCs)

Back 47

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)

Front 48

Medicare Severity Diagnosis Related Groups (MS-DRGs)

Back 48

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)

Front 49

Hospital Outpatient Prospective Payment System (HOPPS or OPPS)

Back 49

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

Front 50

Hospital Inpatient Prospective Payment System (HIPPS or IPPS)

Back 50

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)

Front 51

Hospital Reimbursement - Medicare

Back 51

•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)

Front 52

Hospital Reimbursement - Discounting

Back 52

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

Front 53

Hospital IPPS

Back 53

•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

Front 54

Seventy-Two-Hour Window

Back 54

•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

Front 55

True or False

Charges for ancillary services, such a laboratory and radiology charges, are usually captured through the hospital chargemaster.

Back 55

True

Front 56

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.

Back 56

False

Front 57

True or False

To meet federal requirements that permit participation in Medicare/Medicaid, the federal government surveys and certifies non-accredited hospitals.

Back 57

False

Front 58

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.

Back 58

True

Front 59

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.

Back 59

False

Front 60

Common Working File

Back 60

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

Front 61

What coding systems are used in hospital-based care?

Back 61

ICD-10-CM, ICD-10-PCS, HCPCS, CPT, Revenue Codes

Front 62

Fiscal Intermediary (FI)

Back 62

before the implementation of MACs, an organization with a contract with CMS to process and pay Part A Medicare claims

Front 63

Medicare Administrate Contractor (MAC)

Back 63

an organization that has contacted with CMS to process Medicare claims; MACs have replaced fiscal intermediaries and Medicare carriers

Front 64

Medicare Carrier

Back 64

before the implementation of MACs, an organization having a contract with the CMS to process and pay Part B Medicare claims

Front 65

Potentially Compensable Event (PCE)

Back 65

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

Front 66

Revenue Codes

Back 66

used on the UB-04 to indicate the general nature of the services provided

Front 67

Status Indicator

Back 67

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)

Front 68

Uniform Ambulatory Care Data Set (UACDS)

Back 68

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

Front 69

Uniform Hospital Discharge Data Set (UHDDS)

Back 69

standard data elements to be collected from individual inpatient records; the UHDDS data definitions are important for correct reporting of inpatient data

Front 70

HFAP

Back 70

Healthcare facilities accreditation program (of the AOA American osteopathic organization)

Front 71

NIAHO

Back 71

National integrated accreditation of healthcare organizations

Front 72

Emergency Medical Treatment and Active Labor Act (EMTALA)

Back 72

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

Front 73

American Recovery and Reinvestment Act (ARRA)

Back 73

a federal law that, among other things, created an incentive program for health care providers to utilize EHRs for improved patient care

Front 74

Hospital OPPS

Back 74

•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

Front 75

Long-Term Care Hospital PPS

Back 75

Long Term Care Hospital Prospective Payment System

Front 76

Long-Term Care Hospital PPS

Back 76

•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

Front 77

Other Reimbursement Issues

Back 77

•Other payers

•Billing forms

–UB-04 (or HCFA 1450) used by hospitals

–HCFA 1500 used by physicians

•Electronic claims submission is the norm

Front 78

Coding and Classification

Back 78

ICD

-Diagnosis coding for inpatients and outpatients -Procedure coding for inpatients only

Front 79

Coding and Classification

Back 79

HCPCS

Procedure coding for hospital outpatients

Front 80

Coding and Classification

Back 80

Revenue codes - used on the UB-04 to indicate the general nature of the services provided

Front 81

Coding and Classification

Back 81

Coding edits (MCE, OCE, NCCI)

Front 82

Data and Information Flow

Back 82

•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

Front 83

Electronic Health Records and Computer Systems

Back 83

•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

Front 84

Data Sets

Back 84

•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

Front 85

Quality Assessment and Performance Improvement

Back 85

•Joint Commission

•DNV Healthcare

•CMS

–Hospital Inpatient Quality Reporting

–Hospital Outpatient Quality Data Reporting

Front 86

Utilization Management (UM)

Back 86

•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.

Front 87

Risk Management & Legal Issues

Back 87

•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

Front 88

EMTALA - Emergency Medical Treatment and Active Labor Act

Back 88

•“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

Front 89

Role of Health Information Management Professional

Back 89

•Health Information Services

•Compliance Officer

•Revenue Cycle

•Other Roles

Front 90

Trends

Back 90

•Increasing complexity of services

•Increasing numbers of hospitalists

•Long-term acute care

•Quality and reimbursement linkage

•Electronic health records

•Auditing initiatives

Front 91

Summary of Hospital-based care

Back 91

•Broad range of services and many types of caregivers

•Licensure and accreditation

•Documentation issues

•Reimbursement issues

•Coding and classification

•Data and information flow

Front 92

Summary of Hospital-based care (continued)

Back 92

•Data sets

•Quality assessment and improvement •Utilization management

•Risk management

•Role of the health information professional •Trends

Front 93

WebActivity

Back 93

•Health Care Compliance Associationhttp://www.hcca-info.org

•CHC certification

–HCCB handbook content outline

–Content areas and health information management training

Front 94

What is EMTALA?

Back 94

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.

Front 95

What is ARRA?

Back 95

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.

Front 96

What factors should be considered to avoid legal risk in hospital-based care?

Back 96

*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.

Front 97

Various roles of the HIM professional in

hospital-based care.

Back 97

-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

Front 98

PCE

Back 98

Potentially Compensable Event

Front 99

What is a PCE?

Back 99

A Potentially Compensable Event - Any event that can pose the risk of financial loss to a health care institution.