Drgs - Study guides, Class notes & Summaries

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, ...

Chapter 01: The Past, Present, and Future MULTIPLE CHOICE 1. A patient chooses to have the certified nurse midwife (CNM) provide care during her pregnancy. What does the CNMs scope of practice include? a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Cesarean sections ANS: B The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures that a backup physician is availab...

Retrospective Pay v. Prospective Pay & Define DRGs - ANSWER*Retrospective*: - paid all bills sent to them without looking at them until they were already paid - paid for unnecessary charges & doctor's errors - hospitals were reimbursed for all costs *Prospective*: - payment for hospital services to Medicare pts was based on a flat fee per admission based on the Diagnostic Related Groups (DRGs) - "you can bill us for this service but we have a flat fee per service and we won't ...

Reimbursement Methodologies » Healthcare Reimbursement Questions and Answers Already Passed How does reimbursement methodology affect healthcare provider behavior? Reimbursement methodologies incentivize healthcare providers to manage costs, deliver efficient care, and focus on patient outcomes, depending on the specific model in place. What is the impact of diagnosis-related groups (DRGs) on hospital reimbursement? DRGs determine the amount hospitals will be reimbursed based on ...

CNML Test Exam Questions Revised With Correct Answers < Updated & Already Passed > DRGs - ANSWER : Diagnostic-Related Groups: payment rate based on specific diagnoses Prospective Payment System - ANSWER : Used by Medicare-participating hospitals: pretreatment diagnosis billings based on DRGs; rate decided ahead of time between insurance companies and hospitals Exclusive Provider - ANSWER : Used by HMO's: insurance coverage for contracted providers or institutions ...

Healthcare Reimbursement Methodologies Chapter 1: Questions and Answers 100% Pass What is healthcare reimbursement? Healthcare reimbursement is the process by which healthcare providers receive payment for the medical services they provide to patients. How do healthcare reimbursement methodologies affect patient care? Reimbursement methodologies influence how providers deliver care by creating incentives for specific types of services or treatments and by affecting the cost t...

Healthcare Reimbursement Final Exam Questions and Answers Already Passed What is the difference between direct and indirect costs in healthcare? Direct costs are expenses directly tied to patient care, such as salaries and medical supplies, while indirect costs are overhead expenses, like administrative salaries and utilities. What role do diagnosis-related groups (DRGs) play in reimbursement? DRGs categorize hospital cases into groups that determine the fixed payment amount for i...

The _________ diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital a.Secondary b.DRG diagnosis c.Most resource intensive d.Principal - d The Principal diagnosis should be assigned as the first-listed diagnosis for the hospital admission as the cause of the hospital stay after study and evaluation by the responsible physician (ICD-10-CM Official Coding Guidelines 2016b, 88). In 1...

Healthcare Reimbursement Chapters 8+ Latest Version Already Passed How do insurance plans typically categorize services for reimbursement? Insurance plans categorize services based on various criteria such as type of care, urgency, and medical necessity, influencing the coverage and reimbursement rates. What role does the Medicare Severity Diagnosis Related Groups (MS-DRGs) play in reimbursement? MS-DRGs classify hospital cases into groups that are expected to have similar hospi...

MANAGING DRGS FOR REIMBURSEMENT QUESTIONS AND ANSWERS 2024/2025