IPPS
→ inpatient prospective payment system
MS-DRGs
→ Medicare severity diagnosis groups (MS-DRGs).
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 consu...
→ 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.
→ 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.
comorbid condition:
→ A pre-existing condition which, because of its presence, causes an increase in length of
stay by at least one day in approximately 75% of the cases.
complication:
→ A condition that arises during the hospital stay which prolongs the length of stay by at
least one day in approximately 75% of the cases.
grouper:
→ A software program designed to determine MS-DRGs and typically contains Medicare
code edits.
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.
major complication/comorbid condition (MCC):
→ Complications and comorbid conditions defined by Medicare to have a higher severity
of illness impact on a patient.
major diagnostic category (MDC):
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