Glossary/Terms/Abbreviations. Glossary/Terms/Abbreviations
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1 AHA: American Hospital Association AHIMA: American Health Information Management Association APR-DRGs: sophisticated risk adjustment software program that refines Hospital Coding Data to more accurately capture true severity. All Patient Refined - Diagnostic Related Groups (3M proprietary software) AMLOS: Arithmetic mean length of stay Base Rate: A # assigned to a hospital used to calculate DRG reimbursement. Base rates vary from hospital to hospital. Base rates are adjusted for the individual characteristics of the hospital: Geographic location, Urban vs Rural Status Local labor costs CMI: Case Mix Index - The sum of all DRG relative weights (RW s), divided by the number of Medicare cases. 1
2 CC: Complication or comorbid condition CMS: Centers for Medicare & Medicaid Services Comorbidity: Preexisting condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by a least one day in 75% of the cases. Complication: A condition that arises during the hospital stay that prolongs the length of stay by one day in 75% of the cases. CS-DRG: Consolidated Severity diagnostic related groups Glossary /Terms/Abbreviations Discharge: A situation in which the patient leaves an acute care hospital (PPS) after receiving care and treatment. Discharge status: Disposition of the patient at discharge, for example, AMA, home, transfer to another acute care facility, SNF, Rehab and Home health. DRG: Diagnosis Related Group FY: Fiscal year GMLOS: Geometric mean length of stay Grouper: The software program that assigns DRGs. HPMP: Hospital Payment Monitoring Program 2
3 Glossary /Terms/Abbreviations InterQual: InterQual Criteria are set of measurable, clinical indicators, as well as diagnostic and therapeutic services reflecting the need for hospitalization. Rather than being based on diagnosis, they consider the level of illness of the patient and the services required; thus they serve as the criteria for all acute hospital care, regardless of location or size of the hospital. The criteria are grouped into 14 body systems, and there are 3 sets of criteria for each body system: Intensity of Service Severity of Illness Discharge Screens ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-CM & PCS: International Classification of Diseases, Tenth Edition and Procedure Coding System IS: Intensity of Service JCAHO: Joint Commission on Accreditation of Hospital Organizations. JCAHO is the national accrediting body for hospitals and other health care delivery organizations. Hospitals request to have JCAHO evaluate their facility and are charged a fee. Because accreditation is not automatically renewed, a full accreditation survey is required at least every three years. MCC: Major Complication/Comorbidity MDC: Major Diagnostic Category, broad classification of Dx, grouped by body system. 3
4 MEDPAC: Medicare Payment Advisory Commission to CMS for changes in IPPS MEDPAR: Medicare Provider Analysis and Review file which holds all the claims data used to analyze costs, length of stay and utilization (this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights.) MCV: Major cardiovascular condition MMA: Medicare Modernization Act, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 into law on December 8th. The longawaited and historic changes to the Medicare system have supporters claiming it will "allow the biggest improvements in senior health care in nearly 40 years, and provide seniors with prescription drug benefits and more choices in health care". OIG: Office of the Inspector General Other Diagnosis: All secondary diagnoses that exist at the time of admission or develop subsequently, affect treatment and/or length of stay and meet UHDDS guidelines as a secondary diagnosis. Principal Diagnosis: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. PEPPER: Payment Error Prevention Program Electronic Report. 4
5 QIO: Quality Improvement Organization, formerly known as PRO (Peer Review Organization) Relative Weight: An assigned weight to reflect the resource consumption associated with each DRG. The higher the RW the higher the PPS payment to the hospital. SOI: Severity of Illness Transfer: When a patient is transferred to another acute care PPS hospital for related care. UHDDS: Uniform Hospital Discharge Data Set Volume: The number of patients in each DRG. 5
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