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Survey of Medical Insurance pp ch18
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Survey of Medical Insurance pp ch18

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 18.1 Distinguish between inpatient and outpatient hospital services. Pages: 646-647 Teaching Notes:   Have your students explain the differences between inpatient and outpatient care.
  • Learning Outcome: 18.1 Distinguish between inpatient and outpatient hospital services. Pages: 646-647 Teaching Notes:   Have your students explain the differences between inpatient and outpatient care.
  • Learning Outcome: 18.1 Distinguish between inpatient and outpatient hospital services. Pages: 646-647 Teaching Notes:   Have your students explain the differences between inpatient and outpatient care.
  • Learning Outcome: 18.2 List the major steps relating to hospital billing and reimbursement. Pages: 647-658 Teaching Notes:   Ask your students to explain some of the differences between the billing cycle for hospital claims and the medical billing cycle.
  • Learning Outcome: 18.2 List the major steps relating to hospital billing and reimbursement. Pages: 647-658 Teaching Notes:   Ask your students to explain some of the differences between the billing cycle for hospital claims and the medical billing cycle.
  • Learning Outcome: 18.2 List the major steps relating to hospital billing and reimbursement. Pages: 647-658 Teaching Notes:   Have your students name the three major steps in a patient’s hospital stay from the insurance perspective. (Refer to the numbered list on page 648.) Ask your students to list the information about a patient that is contained in the master patient index. (Full name; birth date; sex; address; admission and/or treatment date; admitting physician; attending physician; health record number.)
  • Learning Outcome: 18.2 List the major steps relating to hospital billing and reimbursement. Pages: 647-658 Teaching Notes:   Have your students explain the difference between an admitting physician and an attending physician.
  • Learning Outcome: 18.3 Describe two differences in coding diagnoses for hospital inpatient cases and physician services. Pages: 659-660 Teaching Notes:   Review the Coding Examples on page 660 with your students, and create additional examples to discuss.
  • Learning Outcome: 18.3 Describe two differences in coding diagnoses for hospital inpatient cases and physician services. Pages: 659-660 Teaching Notes:   Have your students explain the difference between the PDX and the ADX, in their own words.
  • Learning Outcome: 18.3 Describe two differences in coding diagnoses for hospital inpatient cases and physician services. Pages: 659-660 Teaching Notes:   Have your students explain the differences between comorbidities and complications, in their own words.
  • Learning Outcome: 18.4 Describe the classification system used for coding hospital procedures. Pages: 661-662 Teaching Notes:   Ask your students to name some of the characteristics that make procedures significant. (They involve surgery; anesthesia is administered; the procedure involves a risk to the patient; the procedure requires specialized training.)
  • Learning Outcome: 18.5 Describe the factors that affect the rate that Medicare pays for inpatient services. Pages: 662-667 Teaching Notes:   Ask your students to name the groups that hospital admissions are based on. (Principal diagnosis; surgical procedure(s); age; sex; complications; comorbidities; signs and symptoms; discharge disposition.)
  • Learning Outcome: 18.5 Describe the factors that affect the rate that Medicare pays for inpatient services. Pages: 662-667 Teaching Notes:   Examine the list of MDCs on pages 663 and 664 with your students.
  • Learning Outcome: 18.5 Describe the factors that affect the rate that Medicare pays for inpatient services. Pages: 662-667 Teaching Notes:   Review the five codes that are used for POA indicator reporting with your students. (See page 664; Y, N, W, U, .1.)
  • Learning Outcome: 18.5 Describe the factors that affect the rate that Medicare pays for inpatient services. Pages: 662-667 Teaching Notes:   Ask your students to explain how reimbursement is made for patients in an APC group, in their own words.
  • Learning Outcome: 18.6 Discuss the important items that are reported on the hospital health care claim. Pages: 667-678 Teaching Notes:   Review the UB-04 form in Figure 18.4, and its description in Table 18.2, with your students.
  • Learning Outcome: 18.6 Discuss the important items that are reported on the hospital health care claim. Pages: 667-678 Teaching Notes:   Review the UB-04 form in Figure 18.4, and its description in Table 18.2, with your students.

Survey of Medical Insurance pp ch18 Survey of Medical Insurance pp ch18 Presentation Transcript

  • 18 Hospital Billing and Reimbursement
  • Learning Outcomes
    • When you finish this chapter, you will be able to:
    • 18.1 Distinguish between inpatient and outpatient hospital
    • services.
    • 18.2 List the major steps relating to hospital billing and
    • reimbursement.
    • 18.3 Describe two differences in coding diagnoses for hospital inpatient cases and physician services.
    • 18.4 Describe the classification system used for coding hospital procedures.
    18-2
  • Learning Outcomes (Continued)
    • When you finish this chapter, you will be able to:
    • 18.5 Describe the factors that affect the rate that Medicare pays for inpatient services.
    • 18.6 Discuss the important items that are reported on the
    • hospital health care claim.
    18-3
  • Key Terms
    • admitting diagnosis (ADX)
    • ambulatory care
    • ambulatory patient classification (APC)
    • ambulatory surgical center (ASC)
    • ambulatory surgical unit (ASU)
    • at-home recovery care
    • attending physician
    • case mix index
    18-4
    • charge master
    • CMS-1450
    • comorbidities
    • complications
    • diagnosis-related groups (DRGs)
    • 837I
    • emergency
    • grouper
    • health information management (HIM)
  • Key Terms (Continued)
    • home health agency (HHA)
    • home health care
    • hospice care
    • hospital-acquired condition (HAC)
    • hospital-issued notice of noncoverage (HINN)
    • inpatient
    • Inpatient Prospective Payment System (IPPS)
    18-5
    • major diagnostic categories (MDCs)
    • master patient index (MPI)
    • Medicare-severity DRGs (MS-DRGs)
    • never events
    • observation services
    • Outpatient Prospective Payment System (OPPS)
  • Key Terms (Continued)
    • present on admission (POA)
    • principal diagnosis (PDX)
    • principal procedure
    • registration
    • sequencing
    • skilled nursing facility (SNF)
    • UB-92
    • UB-04
    18-6
    • Uniform Hospital Discharge Data Set (UHDDS)
  • 18.1 Health Care Facilities: Inpatient Versus Outpatient
    • Inpatient— person admitted for services that require an overnight stay
    • Inpatient services:
      • Those involving an overnight stay
      • Provided by general and specialized hospitals, skilled nursing facilities, and long-term care facilities
    • Skilled nursing facility (SNF)— facility in which licensed nurses provide services under a physician’s direction
    18-7
  • 18.1 Health Care Facilities: Inpatient Versus Outpatient (Continued)
    • Emergency— situation where a delay in patient treatment would lead to a significant increase in the threat to life or body part
    • Outpatient services:
      • Provided by ambulatory surgical centers or units, by home health agencies, and by hospice staff
      • Ambulatory care— outpatient care that does not require an overnight hospital stay
      • Ambulatory surgical unit (ASU)— hospital department that provides outpatient surgery
      • Ambulatory surgical center (ASC)— clinic that provides outpatient surgery
    18-8
  • 18.1 Health Care Facilities: Inpatient Versus Outpatient (Continued)
    • Outpatient services are also provided in patients’ home settings:
      • Home health care— care given to patients in their homes
      • Home health agency (HHA)— organization that provides home care services
      • At-home recovery care— assistance with daily living provided in the home
      • Hospice care— public or private organization that provides services for terminally ill people
    18-9
  • 18.2 Billing Cycle
    • The first major step in the hospital claims processing sequence:
      • Patient is admitted and registered
      • Personal and financial information is entered in the hospital’s health record system
      • Insurance coverage is verified
      • Consent forms are signed by the patient
      • A notice of the hospital’s privacy policy is presented to the patient
      • Some pretreatment payments are collected
    18-10
  • 18.2 Billing Cycle (Continued)
    • The second step:
      • The patient’s treatments and transfers among the various departments in the hospital are tracked and recorded
    • The third step:
      • Discharge and billing
      • Follows the discharge of the patient from the facility and the completion of the patient’s record
    18-11
  • 18.2 Billing Cycle (Continued)
    • Health information management (HIM)— hospital department that organizes and maintains patient medical records
    • Registration— process of gathering information about a patient during admission to a hospital
    • Master patient index (MPI)— hospital’s main patient database
    18-12
  • 18.2 Billing Cycle (Continued)
    • Attending physician— clinician primarily responsible for a patient’s care from the beginning of a hospitalization
    • Hospital-issued notice of noncoverage (HINN)— form used for inpatient hospital services
    • Observation services— service provided in a hospital room but billed as an outpatient service
    • Charge master— hospital’s list of the codes and charges for its services
    18-13
  • 18.3 Hospital Diagnostic Coding
    • Diagnostic coding for inpatient services follows the rules of the Uniform Hospital Discharge Data Set (UHDDS)— classification system for inpatient health data
    • Inpatient coding differs from physician and outpatient diagnostic coding in two ways:
      • The main diagnosis, called the principal rather than the primary diagnosis, is established after study in the hospital setting
      • Coding an unconfirmed condition (rule-out) as the admitting diagnosis is permitted
    18-14
  • 18.3 Hospital Diagnostic Coding (Continued)
    • 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
    • Sequencing— guideline for listing the correct order of a principal diagnosis
    18-15
  • 18.3 Hospital Diagnostic Coding (Continued)
    • Comorbidities— admitted patient’s coexisting conditions that affect the length of hospital stay or course of treatment
    • Complications— conditions an admitted patient develops after surgery or treatment that affect length of hospital stay or course of treatment
    18-16
  • 18.4 Hospital Procedure Coding
    • Volume 3 of the ICD-9-CM, Procedures , is used to report the procedures for inpatient services
      • Organized by surgical procedures divided into body systems, followed by diagnostic and therapeutic procedures
      • The three- or four-digit codes are assigned based on the principal diagnosis
    • Principal procedure— procedure most closely related to treatment of the principal diagnosis
    18-17
  • 18.5 Payers and Payment Methods
    • Medicare pays for inpatient services under its Inpatient Prospective Payment System (IPPS)— Medicare payment system for hospital services
      • Uses diagnosis-related groups (DRGs) to classify patients into similar treatment and length-of-hospital-stay units and sets prices for each classification group
      • Diagnosis-related groups (DRG)— system of analyzing conditions and treatments for similar groups of patients
      • Grouper— Software used to assign DRGs
    18-18
  • 18.5 Payers and Payment Methods (Continued)
      • Each hospital’s case mix index is an average of the DRG weights handled for a specific period of time
    • Other factors affect the pay rate a hospital negotiates with CMS:
      • Geographic location, labor and supply costs, and teaching costs
      • MS-DRGs— new type of DRG designed to better reflect the differing severity of illness among patients who have the same basic diagnosis
    • Major diagnostic categories (MDC)— categories where MS-DRGs are grouped
    18-19
  • 18.5 Payers and Payment Methods (Continued)
    • Present on admission (POA)— code used when a condition exists at the time the order for inpatient admission occurs
    • Hospital-acquired condition (HAC)— condition a hospital causes or allows to develop
    • Never events— preventable medical errors resulting in serious consequences for the patient
    18-20
  • 18.5 Payers and Payment Methods (Continued)
    • Outpatient Prospective Payment System (OPPS)— payment system for Medicare Part B services that facilities provide on an outpatient basis
    • Ambulatory patient classification (APC)— Medicare payment classification for outpatient services
    18-21
  • 18.6 Claims and Follow-up
    • 837I— HIPAA-mandated electronic transaction for hospital claims
    • UB-04— Current paper claim form for hospital billing
      • CMS-1450— another name for the UB-04 paper claim form
      • UB-92— former hospital paper claim form
    • The UB-04 reports:
      • Patient data
      • Information on the insured
      • Facility and patient type
    18-22
  • 18.6 Claims and Follow-up (Continued)
    • The UB-04 reports (continued):
      • The source of the admission
      • Various conditions that affect payment
      • Whether Medicare is the primary payer (for Medicare claims)
      • The principal and other diagnosis codes
      • The admitting diagnosis
      • The principal procedure code
      • The attending physician
      • Other key physicians
      • Charges
    18-23