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Group Topics
DRG
This Medicare prospective payment system reimburses most hospitals for inpatient hospital services at a predetermined rate based upon one Diagnostic Related Group classification for each discharge. This system is designed to motivate hospitals to manage operations more efficiently.

APC
This Medicare prospective payment system reimburses most hospital outpatient services based upon Ambulatory Payment Classification groups that are similar both clinically and in terms of resources required. Depending upon the services provided, hospitals may be reimbursed for more than one APC for an encounter.

HHRG
This Medicare prospective payment system reimburses home health agencies for each covered 60-day episode of care. The reimbursement will be adjusted for the health condition and care needs of the patient. Payments cover skilled nursing and home-health aide visits, covered therapy, medical social services and supplies.

RUG
This Medicare prospective payment system reimburses skilled nursing facilities on a per diem basis adjusted using a resident classification system developed from data contained in resident assessments (MDS 2.0) and relative weights of staff time. The resident classification system is referred to as Resource Utilization Groups III and the payment associated with each RUG covers all costs related to services furnished.

Compliance
Because coding determines reimbursement, coding is at the heart of health care compliance. Discuss specific coding compliance issues, settlements, auditing and monitoring activities.

ICD-9
This classification system has been designated as the "official code set" for diagnostic coding for Medicare and all payors. We need to keep a close eye on this system as it continues to evolve and as the government decides whether or not to adopt ICD-10.

Credentialing

The government wants all coders of Medicare claims to be credentialed. Yet, the National Inpatient Coder Survey (1999) showed that only 74% of inpatient coders are credentialed. Is it difficult to find credentialed coders? Maintain the credential?

CPT-4
This classification system has been designated as the "official code set" for procedure coding for Medicare Part B and ambulatory claims for all payors. As these requirements are phased in, health care providers and coders alike will face new challenges with correct code submission.

Nomenclature
The future of coding will most likely find coders applying computerized nomenclature to health care records. Nomenclature is the standardization of medical terminology and will make coding clinical data more reliable and valid. Will SNOMED be the nomenclature of choice?

HCPCS
This classification system has been designated as the "official code set" for level two coding for DME, supplies, and some ancillary services. Coding compliance concerns will continue to make this topic a hot one.

CDT
This classification system has been designated as the "official code set" for dental procedures not covered by CPT-4. NDC
This classification system has been designated as the "official code set" for drugs. As physicians and other providers begin to be more aware of all "extras' that they can bill for, these codes will gain increased focus.

Physician Fee Schedule
This Medicare payment system is used to price Part B professional services. Payment amounts under this system are the product of a uniform relative value, a geographic adjustment factor and a uniform conversion factor.

Laboratory Fee Schedule
This Medicare payment system is used to price clinical laboratory services. This fee schedule contains pricing amounts and national limitation amounts for all procedure codes subject to this payment methodology.