hospital insurance chapter 15. 2 hospital insurance learning objectives inpatientoutpatient compare...
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HOSPITAL INSURANCE
Chapter 15
Chapter 15 2
HOSPITAL INSURANCE
Learning Objectives Compare inpatientinpatient and outpatient outpatient hospital services. List the major steps relating to hospital claims hospital claims
processing.processing. Describe two differences in coding diagnosescoding diagnoses for hospital hospital
inpatient casesinpatient cases and physician office services.physician office services. Describe the procedure codesprocedure codes used in hospital coding. Discuss the important items that are reported on the
HIPAA hospital claimHIPAA hospital claim, the 837I.837I.
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Key Terms Admitting diagnosis Ambulatory care Attending physician Charge master or
Charge ticket CMS-1450 Emergency care Health information
management (HIM)(HIM)
Inpatient Master patient index Principal diagnosis Principal procedure Prospective Payment
System (PPS)(PPS) Registration 837I837I
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Inpatient Care Patient stays overnight or longer Includes:
Inpatient hospital care Skilled nursing facilities Long-term care facilities Hospital emergency departments
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Outpatient or AmbulatoryAmbulatory Care Care
No overnight stay Includes:
Same-day surgery Care provided in patients’ homes
Home Health Agencies Skilled nursing care, physical therapy, etc.
Assistance with Activities of Daily Living (ADLs)(ADLs)
Home health aides Hospice care
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HIM Department HHealth IInformation MManagement
Organizes and maintains patient medical records Three Major Steps in a Patient’s Hospital
Stay: Admission Treatment and Charges Discharge and Billing
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Admission
Registration Process Create/update patient’s medical record Verify insurance coverage Secure consent for release of information Collect advance payments, as appropriate Emergency departments usually have separate
registration/admission
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Admission (cont’d)
Registration Process Medicare patients receive one-page printout
Entitled “An Important Message from Medicare”“An Important Message from Medicare” Explains rights as hospital patient
All patients receive copy of hospital’s privacy practices
Based on the HIPAA Privacy Rule Receipt is acknowledged with signature
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Treatment and Charges Medical record contains
Notes, ancillary documents, and correspondence from attending physician and all other physicians/providers
Patient data, including insurance information Charges for all treatments and tests; supplies
and equipment used; medication; room and board; and time spent in special facilities
Confidentiality is important - Confidentiality is important - WhyWhy
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Goal is to file a claim within 7 days of discharge
Items recorded on charge mastercharge master Similar to practice’s encounter formencounter form Hospital’s computer system tracks patient’s system tracks patient’s
servicesservices
Discharge and Billing
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Inpatient (Hospital) Coding
HIM HIM (Health information Management) Responsible for diagnostic & procedural
of patient’s medical records. Coding is done as soon as the patient is
discharged. Inpatient Coders:Inpatient Coders:
Generalists Maybe skilled as surgical coderssurgical coders or or
Medicare CodersMedicare Coders..
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Inpatient (Hospital) CodingCont. ICD-9 Volumes 1 and 2Volumes 1 and 2 used for
inpatient diagnosesdiagnoses codes codes
ICD-9 Volume 3Volume 3 used for inpatient procedureprocedure codes codes
HCPCS may be used for some claims
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HospitalDiagnosis Coding
Admitting Diagnosis Condition identified at time of admission
Principal Diagnosis Condition responsible for this admission
established after study Listed first in medical record and insurance billing
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HospitalDiagnosis Coding (cont’d)
Suspected or unconfirmed diagnosis Usually used as an admitting diagnosis Often referred to as “rule outs”“rule outs” The admitting diagnosis admitting diagnosis may not match the
principal diagnosis principal diagnosis once the patient has been treated
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HospitalDiagnosis Coding (cont’d)
ComorbiditiesComorbidities and ComplicationsComplications ComorbiditiesComorbidities (co-existing conditions) are other
conditions that affect a patient’s stay or course of treatment
ComplicationsComplications are conditions that develop as a result of surgery or treatment
Shown in patient medical record as “CC”“CC” May list up to 8 on claim
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Hospital Procedural CodingProcedural Coding
ICD-9 Volume 3 used Includes an Alphabetic IndexAlphabetic Index and a Tabular Tabular
ListList similar to those in Volumes 1 and 2
Codes are 3 or 4 digits3 or 4 digits Principal Procedure
Most closely related to the treatment of the principal diagnosis
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Medicare InpatientInpatientPayment System
Diagnosis Related GroupsDiagnosis Related Groups (DRGs) – Cost reimbursement method developed by MedicareMedicare for its prospective payment system (PPS)(PPS) for reimbursement of medical fees for a patient. DRGDRG system analyze conditions and treatment for
similar groups of patients used to establish Medical Medical feesfees for hospital inpatient services.
Under the DRGDRG classification system: GroupingsGroupings were created based on relative value of
the resources that physicians and hospitals nationally used for patients with similar conditions.
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Medicare InpatientInpatientPayment System
Cont. The Calculations
Each DRG category is based on patient characteristics (e.g., age, sex), diagnosis, and medical procedures all of which are condensed into a single DRG that applies to a specific patient.
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Medicare InpatientInpatientPayment System
Cont. Prospective Payment System (PPS)(PPS)
At the same time the DRG system was created, At the same time the DRG system was created, Medicare changed the way hospitals were paid.
Payment changed from a Payment changed from a fee-for-servicefee-for-service approach approach to to Medicare Prospective Payment System (PPS).Medicare Prospective Payment System (PPS).
Payment set ahead of time based on DRG.DRG.
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Medicare InpatientInpatientPayment System
Cont. Quality Improvement OrganizationQuality Improvement Organization
Made up of practicing physiciansphysicians and other health care health care expertsexperts contracted by CMS in each state to review Medicare & Medicaid claims for appropriateness of hospitalization and clinical care.
QIO’s QIO’s goal is to ensure that payment is made only for medically necessary services.
Set up when DRG was established, The program replaced the “Peer Review Organization”. MonitorMonitor and improve improve the usageusage and quality of carequality of care for
Medicare beneficiaries.
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Medicare OutpatientOutpatientPayment System
DRGs (Diagnosis Related Groups)
Implemented for outpatient hospital services, previously were paid on a fee-for-servicefee-for-service basis
Hospital Outpatient Prospective Payment System (PPS)Prospective Payment System (PPS) is used to pay for hospital outpatient services.
In place of DRGs, patients are grouped under an Ambulatory Patient ClassificationAmbulatory Patient Classification
Reimbursement made according to preset amounts based on the value of each APC APC (ambulatory Patient Classification).
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Private Insurers Often use standardized number of days
allowed for condition
Many private insurers have adapted the DRGDRG system for their billing
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Filing Claims Medicare Medicare Part APart A
HIPAA 837IHIPAA 837I claim is mandated by CMS Electronic claim I I in 837I stands for InstitutionalInstitutional
Paper claimPaper claim, UB-92,UB-92, is accepted under some circumstances
Uniform Billing 1992 (UB-92) form Also known as CMS-1450 CMS-1450
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The HIPAA 837I and the UB-92 Contain:
Patient data Information on insured Facility/patient type Source of admission Various conditions that
affect payment Whether Medicare is
primary payer
Principal and other diagnosis codes
Admitting diagnosis Principal procedure
code Attending and other
physician Charges
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Remittance Advice Received when paymentpayment is transmitted
to account HIM HIM (Health Information Management)(Health Information Management)
Department coordinates with Patient Patient Accounting DepartmentAccounting Department
Remittance AdviceRemittance Advice reviewed to assure payment received matches payment anticipated
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Quiz
hospital coders
comorbidities and complicationsPart A
institutional
Medicare ___________ pays for inpatient and outpatient hospital costs.
In the hospital medical record, CC refers to
_____________________________.
ICD-9 Volume 3 is used by ______________.
The II in 837I stands for ____________. An encounter form is created for hospital
services. (T/F)False, the charge master is used in
hospitals.
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Critical Thinking What is the difference between the
admitting diagnosisadmitting diagnosis and the principal principal diagnosis?diagnosis?
The admitting diagnosisadmitting diagnosis is usually the reason identified at the time of admission.
The principal diagnosisprincipal diagnosis is determined after study and is listed first in the medical record and insurance claim.