Prospective payment systems

Content: Introduction to Prospective Payment Systems Preliminary Comments Overview of Healthcare Payment Systems Claims Filing and Payment Deductibles and Copayments Overview of Medicare Prospective Payment Systems Private Third-Party Payer and Prospective Payment Systems Payment System Interfaces Healthcare Provider Use of Prospective Payment Systems to Set Charges Summary and Conclusion    Healthcare Provider Concepts Introduction      Physicians           Non-Physician Practitioners and Providers Clinics Hospitals Special Hospitals with Specialized Prospective Payment Systems Hospitals and Integrated Delivery Systems Special Provider Organizations      DME Suppliers      Skilled Nursing Facilities      Home Health Agencies      Independent Diagnostic Testing Facilities      Comprehensive Outpatient Rehabilitation Facilities      Clinical Laboratories      Ambulatory Surgical Centers Summary and Conclusion    Anatomy of a Prospective Payment System Introduction Necessary Elements      PPS Coverage      PPS Unit of Service      PPS Classification Systems      Developing Categories or Groups      Determining Payment Amounts      Unusual Circumstances for Additional Payments      Special Incentives/Constraints Coding for PPSs Cost Reports Hospital Chargemasters Relative Weights Conversion Factor Chapter Summary    Medicare Severity Diagnosis Related Groups (MS-DRGs) Introduction Terminology Historical Background MS-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 Reimbursement Conversion of M-DRGs to MS-DRGs Payment Process      Transfers      Cost Outliers      Special Types and Designations of Hospitals Documentation Features Additional Features for MS-DRGs      3-Day Preadmission Window      Post-Acute Care Transfer      Present on Admission (POA) Updating Process for MS-DRGs Variations of DRGs Compliance Considerations Quality Initiatives and Electronic Health Records Summary and Conclusion    Ambulatory Payment Classifications (APCs) Introduction Historical Background Challenges for Hospital Outpatient Prospective Payment Ambulatory Patient Groups (APGs)      Three-Day Window of Service      Significant Procedure Consolidation      E/M Service Bundling APC 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 Copayments The Provider-Based Rule      Provider-Based Clinics           Split Billing: 1500 plus UB-04           Establishing Fee Schedules           Billing Privileges           Special Situations Ambulatory Surgical Centers Payment System Interfaces for APCs APCs and the Federal Register Process Quality Reporting and Compliance for APCs Summary and Conclusion    Other Prospective Payment Systems Introduction Skilled Nursing Facilities (SNFs)      Coverage      Classification and Grouping      SNF Payment      SNF Issues Home Health      Coverage      Unit of Service/Unit of Payment      Classification/Grouping      Home Health Payment Long-Term Care Hospitals (LTCHs)      Coverage      Classification and Grouping for LTCHs      MS-LTC-DRG Pricer      Other Features for the LTCH-PPS Inpatient Rehabilitation Facilities Inpatient Psychiatric Facilities (IPFs) End-Stage Renal Dialysis (ESRD) Private Third-Party Payer Utilization of PPSs Summary 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