Prospective Payment Systems (Paperback)

Introduction to Prospective Payment SystemsPreliminary CommentsOverview of Healthcare Payment SystemsClaims Filing and PaymentDeductibles and CopaymentsOverview of Medicare Prospective Payment SystemsPrivate Third-Party Payer and Prospective Payment SystemsPayment System InterfacesHealthcare Provider Use of Prospective Payment Systems to Set ChargesSummary and Conclusion Healthcare Provider ConceptsIntroduction Physicians Non-Physician Practitioners and ProvidersClinicsHospitalsSpecial Hospitals with Specialized Prospective Payment SystemsHospitals and Integrated Delivery SystemsSpecial Provider Organizations DME Suppliers Skilled Nursing Facilities Home Health Agencies Independent Diagnostic Testing Facilities Comprehensive Outpatient Rehabilitation Facilities Clinical Laboratories Ambulatory Surgical CentersSummary and Conclusion Anatomy of a Prospective Payment SystemIntroductionNecessary Elements PPS Coverage PPS Unit of Service PPS Classification Systems Developing Categories or Groups Determining Payment Amounts Unusual Circumstances for Additional Payments Special Incentives/ConstraintsCoding for PPSsCost ReportsHospital ChargemastersRelative WeightsConversion FactorChapter Summary Medicare Severity Diagnosis Related Groups (MS-DRGs)IntroductionTerminologyHistorical BackgroundMS-DRG Design Features Coverage Unit of Service Classification System MS-DRG Categories MS-DRG Grouping MS-DRG Relative Weights Case-Mix Index (CMI) ICD-10 Coding: The Key for Optimizing MS-DRG ReimbursementConversion of M-DRGs to MS-DRGsPayment Process Transfers Cost Outliers Special Types and Designations of HospitalsDocumentation FeaturesAdditional Features for MS-DRGs 3-Day Preadmission Window Post-Acute Care Transfer Present on Admission (POA)Updating Process for MS-DRGsVariations of DRGsCompliance ConsiderationsQuality Initiatives and Electronic Health RecordsSummary and Conclusion Ambulatory Payment Classifications (APCs)IntroductionHistorical BackgroundChallenges for Hospital Outpatient Prospective PaymentAmbulatory Patient Groups (APGs) Three-Day Window of Service Significant Procedure Consolidation E/M Service BundlingAPC Design and Implementation Parameters Medicare APC Coverage Encounter Driven APC Classification Systems: CPT and HCPCS CPT Codes and Modifiers HCPCS Codes and Modifiers National Correct Coding Initiative (NCCI) Edits APC Status Indicators (Sis) Packaging Composite APCs Discounting Global Surgical Package (GSP) Payment under APCs Special Payment Considerations APC Grouper/Pricer Deductibles and CopaymentsThe Provider-Based Rule Provider-Based Clinics Split Billing: 1500 plus UB-04 Establishing Fee Schedules Billing Privileges Special SituationsAmbulatory Surgical CentersPayment System Interfaces for APCsAPCs and the Federal Register ProcessQuality Reporting and Compliance for APCsSummary and Conclusion Other Prospective Payment SystemsIntroductionSkilled Nursing Facilities (SNFs) Coverage Classification and Grouping SNF Payment SNF IssuesHome Health Coverage Unit of Service/Unit of Payment Classification/Grouping Home Health PaymentLong-Term Care Hospitals (LTCHs) Coverage Classification and Grouping for LTCHs MS-LTC-DRG Pricer Other Features for the LTCH-PPSInpatient Rehabilitation FacilitiesInpatient Psychiatric Facilities (IPFs)End-Stage Renal Dialysis (ESRD)Private Third-Party Payer Utilization of PPSsSummary and Conclusion Conclusion and Endnote Appendix A: Case Studies Chapter 1 Case Studies Chapter 2 Case Studies Chapter 3 Case Studies Chapter 4 Case Studies Chapter 5 Case Studies Chapter 6 Case Studies Appendix B: Acronyms