CCM (The Commission CCM & CDMS Exams) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

DRG

Diagnosis-related group; a prospective payment system that pays hospitals a fixed amount based on the patient's principal diagnosis, procedures, age, and comorbidities.

Capitation

A payment model that pays a provider a fixed per-member-per-month amount for each enrolled person regardless of how many services that person uses.

Bundled payment

A single payment covering all services for a defined episode of care, such as a joint replacement, shared among providers to encourage coordination and reduce costs.

Medicare Part A

Hospital insurance covering inpatient hospital stays, skilled nursing facility care after a qualifying stay, hospice, and some home health services.

Medicare Part B

Medical insurance covering physician services, outpatient care, durable medical equipment, and some preventive services; case management may be billed under specific conditions.

Observation status

A hospital status for patients receiving monitoring without inpatient admission; it can disqualify Medicare coverage of subsequent skilled nursing facility care.

Value-based purchasing

A payment approach that adjusts reimbursement based on quality, outcomes, and cost performance rather than volume of services delivered.

Kübler-Ross stages

Five stages of grief: denial, anger, bargaining, depression, and acceptance; they are not necessarily linear and may overlap or recur.

Transtheoretical model

Behavior-change model with stages: precontemplation, contemplation, preparation, action, maintenance, and sometimes termination; interventions are matched to the person's stage.

PHQ-9

A nine-item depression screening and severity tool scoring each item 0 to 3; total scores of 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression.

CAGE questionnaire

Four yes/no questions screening for alcohol misuse: Cut down, Annoyed by criticism, Guilty feelings, and Eye-opener use; two or more positive answers suggest a problem.

Maslow hierarchy

A five-level model of human needs ordered from physiologic and safety through belonging, esteem, and self-actualization; lower needs generally must be met before higher ones.

Motivational interviewing

A collaborative, person-centered counseling style using open questions, affirmations, reflections, and summaries to strengthen a person's own motivation and commitment to change.

Donabedian model

A framework evaluating quality through structure (resources), process (what is done), and outcomes (results), commonly used to design quality measurement in health care.

HEDIS

Healthcare Effectiveness Data and Information Set; a set of standardized performance measures used by health plans to compare quality of care across many clinical domains.

PDSA cycle

Plan-Do-Study-Act; a rapid-cycle quality improvement method for testing small changes, studying results, and then adopting, adapting, or abandoning the change.

Root cause analysis

A structured retrospective method to identify underlying system causes of an adverse event and to develop actions that prevent recurrence.

Sensitivity

The proportion of people who truly have a condition and are correctly identified by a test; it reflects the test's ability to detect disease.

Reliability vs validity

Reliability is consistency or reproducibility of a measure; validity is whether the measure actually captures the concept it is intended to measure.

Benchmarking

Comparing an organization's performance measures with internal targets or external best-practice standards to identify gaps and guide improvement.

FIM score

Functional Independence Measure; an 18-item scale rating self-care, mobility, and cognition from 1 (total assistance) to 7 (complete independence), with a maximum total of 126.

Inpatient rehab 3-hour rule

Medicare requires IRF patients to receive at least three hours of therapy per day, five days per week, or 15 hours per week, generally.

60 percent rule

Medicare rule requiring that at least 60 percent of an inpatient rehabilitation facility's admissions have one of 13 qualifying conditions, such as stroke or spinal cord injury.

Transfer training

Teaching a patient safe techniques for moving between surfaces such as bed, chair, and toilet, often using assistive devices and stand-by assistance graded to ability.

Durable medical equipment

Reusable medical equipment ordered for home use, such as walkers or wheelchairs, that serves a medical purpose and is not useful in the absence of illness.

Vocational rehabilitation

Services helping people with disabilities prepare for, obtain, or retain employment, including assessment, training, worksite modification, and job placement support.

HIPAA minimum necessary

A rule requiring covered entities to limit protected health information disclosed or used to the minimum amount needed for the intended purpose.

Informed consent

A process of disclosing diagnosis, proposed treatment, risks, benefits, and alternatives so a patient with capacity can voluntarily agree; it must be documented.

Tarasoff duty

A legal duty in many jurisdictions to warn or protect an identifiable third party when a patient poses a serious threat of violence.

Negligence elements

Four elements must be proven: duty owed, breach of that duty, causation, and damages; all four are required for a malpractice claim.

Advance directive

A legal document stating a person's health care wishes or naming a surrogate decision maker, used when the person lacks decision-making capacity.

Mandated reporting

A legal obligation of certain professionals, including case managers in many states, to report suspected child abuse, elder abuse, or neglect to designated authorities.