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Case mix groups are used as the basis for the Health Insurance Prospective Payment System (HIPPS) rate codes used by Medicare in its prospective payment systems. [ 1 ] Case mix groups are designed to aggregate acute care inpatients that are similar clinically and in terms of resource use.
Patients are assigned their SOI based on their specific diagnoses and procedures performed during their medical encounter, which is generally an inpatient hospital stay. Patients with higher SOI (e.g. major or extreme) are more likely to consume greater healthcare resources and stay longer in hospitals than patients with lower SOI in the same ...
The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget. [11] In 1982 the US Congress passed Tax Equity and Fiscal Responsibility Act with provisions to reform Medicare payment, and in 1983, an amendment was passed to use DRGs for Medicare, [ 7 ] : 16 ...
The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas.MDC codes, like diagnosis-related group (DRG) codes, are primarily a claims and administrative data element unique to the United States medical care reimbursement system.
Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4] The payor returns the claim back to the medical biller and the biller evaluates how much of the bill the patient owes, after insurance is taken out.
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