Common Terms and Definitions Used in Case …

1 Common Terms and Definitions used in case management October 2013 Providing technologically supported physician advisory and case management services to healthcare providers and payors 1 Update: 10-09-13 Common CMS Terms Alphabetical order list TermDefinitionAdmission Order(n) a document used in a hospital to define the order to admit a patient to the hospital. As specified in CMS 42 CFR , no specific procedures or forms are required for certification and recertification statements. The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.

2 Except as provided for delayed certifications, there must be a separate signed statement for each certification or recertification. This is also called a "practitioner order" by Limits(acronym) Additional Document Request limits with regard to how many records can be audited by a RAC vendor during a specified periodCAH(acronym) Critical Access Hospital or also called a Skilled Nursing Facility (SNF)CERT(acronym) Comprehensive Error Rate Testing reporting process within CMS for tracking fraud and errors in billingCMS(org) Center for Medicare & Medicaid ServicesCMS-1599-F(rule notice) revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems including the new "two-midnight" rule change and other changes.

3 In addition, CMS is making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments CMS is updating policies relating to the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Update: 10-09-13 Common CMS Terms Alphabetical order list TermDefinitionCMS-1599-CN2(rule notice) This document corrects technical and typographical errors in the final rules that appeared in the August 19, 2013 Federal Register titled "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status.

4 "CMS-1599-IFC(rule notice) Medicare Program; FY 2014 Inpatient Prospective Payment System: Changes to Certain Cost Reporting Procedures Related to Disproportionate Share Hospital Uncompensated Care PaymentsDescription: In this interim final rule with comment period, we revise certain policies for Medicare disproportionate share hospital (DSH) payments and the uncompensated care payments under subsection(r) of the Act, established under Section 3133 of the Affordable Care Act. In the FY 2014 IPPS/LTCH PPS Final Rule, we had established the methodology for determining the amount of uncompensated care payments made to hospitals eligible for the DSH payment adjustment in FY 2014 and a process for making interim and final (rule notice) Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2014 (Display Date: July 31, 2013)CMS-1447-N(rule notice) FY 2014 Inpatient Psychiatric Facilities Prospective Payment System - Rate Update (Publication Date: August 1, 2013)CMS-1601-P(rule notice) Hospital Outpatient Payment System (OPPS) and CY 2014 Payment Rates (Display Date: July 8, 2013.)

5 Publication Date: July 19, 2013)3 Update: 10-09-13 Common CMS Terms Alphabetical order list TermDefinitionDAB(acronym) Departmental Appeals Board, CMS level 4 appeal processDischarge(verb) Discharge from the hospital is the point at which the patient leaves the hospital and either returns home or is transferred to another facilityED(acronym) Emergency Department or Emergency Room (ER)ER(acronym) Emergency Room (ER)FFS(acronym) Fee For Service programHHS(acronym) Health and Human Services, department in the US government that is responsible for CMSI npatient(n) a patient who stays in a hospital while under (acronym) Improper Payments Information Act of 2002 IPERIA(acronym) Improper Payments Elimination and Recovery Improvement Act of 2012 IPPS(acronym) Hospital Inpatient Prospective Payment SystemIRF(acronym) Inpatient Rehabilitation FacilityOIG(acronym) Office of the Inspector General, department of US Health and Human ServicesOPPS(acronym) Hospital Outpatient Prospective Payment SystemLTCH(acronym) Long Term Care HospitalMAC(acronym) Medicare Administrative Contractor defined by CMS granted jurisdiction4 Update.

6 10-09-13 Common CMS Terms Alphabetical order list TermDefinitionMedical Necessity(n) Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in Terms of type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient, physician, or other health care ( ) a federal insurance program enacted as Title XVIII of the Social Security Amendments that provides certain inpatient and outpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals.

7 The program is administered by the Health Care Financing Part A(n) provides hospital insurance to all qualified beneficiaries under the Medicare criteria. Medicare Part A provides payments for in-patient hospital services excluding those of physicians and Part B(n) provides medical insurance coverage for services such as physician' s services, outpatient services, and home health care. Participation under Part B is voluntary, and beneficiaries pay monthly premiums. Part B is also called Supplementary Medical Insurance. Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, x-rays and diagnostic tests) and certain durable medical equipment and suppliesMedicare Part C(n) (Medicare Advantage, or Medicare Part C), where the federal government pays for private health coverageMedicare Part D(n) Part D prescription drug benefit plan, and are known as a Medicare Advantage Prescription Drug plan or "MAPD.

8 "5 Update: 10-09-13 Common CMS Terms Alphabetical order list TermDefinitionOutpatient(n) a patient who receives medical treatment without being admitted to a hospital such as "attending a clinic or physician's office as an outpatient."Practioner Order(n) a document used in a hospital to define the order to admit a patient to the hospital. As specified in CMS 42 CFR , no specific procedures or forms are required for certification and recertification statements. The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form. Except as provided for delayed certifications, there must be a separate signed statement for each certification or recertification.

9 This is also called an "admission order" by (acronym) Recovery Audit Contractor programSNF(acronym) a Skilled Nursing Facility or also called a Critical Access Hospital6 Update: 10-09-13 Questions? 6 CMC Physicians 2950 W. Square Lake Rd, Ste. 200 Troy, MI 48098 (248) 641-3300