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Revenue Management and Reimbursement (Key Terms)
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CMS identified eight hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection—mediastinitis after coronary artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/ pulmonary embolism (PE) following certain orthopedic procedures.
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This type of medical insurance is an optional and supplemental portion of Medicare for which beneficiaries pay a monthly premium. This assists with coverage for physicians' services and outpatient care. It also insures other medical services not covered under Part A, such as some physical and occupational therapists' services, and some home healthcare. It pays for these covered services and supplies when they are medically necessary. To be medically necessary, the services or supplies required to diagnose or treat a medical condition meet accepted standards of medical practice. Services covered may include physicians' services, outpatient care, home health, durable medical equipment, ambulance, and preventive services. Preventive services include healthcare services to prevent illness (for example, vaccinations to prevent diseases like polio) or early detection tests and diagnostic tools, when treatment is most likely to be effective
is collaboration between healthcare and service providers to aid in the process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet the comprehensive health needs of an individual or family. This is accomplished through communication and coordination of available resources to promote quality and cost-effective outcomes. The primary reason for this is the facilitation of care across the continuum of care for the patient. For example, a patient newly diagnosed with cancer may require surgery, laboratory services, chemotherapy, radiation, and counseling services. Case management helps navigate all the services and providers for the patient.
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