Chapter 9

Differences between a diagnosis of comorbidity and complication?

- Comorbidity is a condition that is present at admission, but is not inherant to the principle diagnosis. - Complications, however, as condition as you are in the hospital, like a staph infection.

What is the difference between a staff model HMO and an IDN model HMO?

- Staff Model: HMO owns the facilities and employs the doctors. - IDN Model (Integrated Delivery Network)- facilities and physicians form a business arrangement (IND) for the purpose of contracting with the HMO to provide both hospitals and physician services. Doctors work in their own offices

What does it mean when a facility payment is calculated per diem?

"per day" or "by the day", so a facility get paid by the day.

APC

Ambulatory Payment Classification

What is the standard method between a staff model HMO and an IDN model HMO?

Capitation- Payment based on the number of members who select a certain PCP or participating group as their HMO provider. The PCP, IPA, or IDN is paid a flat rate per member per month by the HMO

EOB

Explanation of Benefits

When should you use ICD-10 codes to code insurance claims?

ICD-10 did go into effect for billing on October 1, 2015

Under what conditions will a complication not results in payment of a higher DRG?

If the secondary diagnosis is a hospital acquired condition because it could have been prevented.

PCP

Primary Care Physician

RVU

Relative Value Unit

Give an example of a type of hospital exempt from IPPS.

An example is a Children's hospital.

DRG

Diagnosis-Related Group

A participating provider's usual and customary fee for a service is %120, the Medicare allowed amount is $78. What is the amount of write-down adjustment?

Write - down adjustment : $42

Which Medicare plan pays for doctor's services?

Part B

Two patients have the same insurance plan and the same DRG. Patient Jone's inpatient stay lasted 1 day. Patient Smith's inpatient stay lasted 2.5 days. How much more will the PPS pat for Smith's claim?

The PPS for both patients would be the same because they have same insurance plan and DRG. Only when a secondary diagnosis on the claim is in the CC list and is not an inherent part of the principal diagnosis, the result may be a different DRG code with a higher reimbursement. (CC= complication/comorbidity)