medicare code edits: - ️️A method to identify various situations based upon
assigned ICD-10-CM codes. For example, the sex conflict edit identifies situations when
a female only diagnosis code is on a claim indicating the patient is a male.
hospital wage index: - ️️A numeric factor defin...
MS-DRG's
medicare code edits: - ✔️✔️A method to identify various situations based upon
assigned ICD-10-CM codes. For example, the sex conflict edit identifies situations when
a female only diagnosis code is on a claim indicating the patient is a male.
hospital wage index: - ✔️✔️A numeric factor defined by Medicare that considers the
geographic location of hospitals. This factor is used in the reimbursement calculations
for facilities to account for geographic differences.
DRGs - ✔️✔️In 1983, the government enacted the system using diagnosis related
groups (DRGs) as the payment methodology. The theory is based upon patients with
similar characteristics consuming similar resources. Determining how patients are
similar is a key factor for the system, which defines the similarities by the DRGs.
The system was created by Medicare; however many other larger payers have
implemented a DRG system, such as Tricare, Medicaid, and Blue Cross. The other
commercial payers are not required by regulation to follow Medicare's system exactly
but many choose to follow their system. A billing professional working in a hospital
should learn if their payers are using a DRG system in addition to knowing if they follow
Medicare's logic.
against medical advice: - ✔️✔️A type of discharge status in which a patient chooses to
leave the facility even though all medical personnel recommend the patient stays for
treatment.
discharge status: - ✔️✔️When patients who were considered inpatients at healthcare
facilities leave the facility to go to another location. The status indicates the new location
of the patient. For example, a patient returns home to his/her house after being treated
at their local community hospital.
IPPS - ✔️✔️inpatient prospective payment system
MS-DRGs - ✔️✔️Medicare severity diagnosis groups (MS-DRGs).
case mix index (CMI): - ✔️✔️The sum of all MS-DRG weights, divided by the total
number of Medicare discharges for the same time period. Slight increases or decreases
impact a hospitals overall reimbursement amount. Facilities routinely monitor the CMI.
CC: - ✔️✔️Abbreviation for complications and comorbid conditions.
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