Reimbursement Methodology

Reimbursement Methodology

Order Description

1.IPPS: High cost devices are used in many inpatient surgery cases. The Safe-Cross®, radio frequency total occlusion crossing system, is such a device.

The Safe-Cross® guidewire is present on the following claim. Complete an outlier payment calculation to determine whether this claim would qualify for a high cost outlier payment. If the claim qualifies for outlier payment, calculate the total reimbursement for this claim, including the aIDitional amount that the facility would receive for the high cost outlier. Formulas are provided for you

2.IPPS: The top 25 MS-DRGs for Hospital A are provided in the table below. Calculate the case mix index for this MS-DRG set

Assignment #3

1.    IPPS: High cost devices are used in many inpatient surgery cases. The Safe-Cross®, radio     frequency total occlusion crossing system, is such a device.

The Safe-Cross® guidewire is present on the following claim. Complete an outlier payment calculation to determine whether this claim would qualify for a high cost outlier payment. If the claim qualifies for outlier payment, calculate the total reimbursement for this claim, including the aIDitional amount that the facility would receive for the high cost outlier. Formulas are provided for you

The 2013 IPPS high-cost outlier threshold is $21,821; the hospital specific CCR is: 0.329; the hospital base rate is $5,200.00.

Inpatient Claim

Admit Date:    January 12, 2013    Discharge Date:    January 10, 2013    Length of Stay:    9 days

Principal Diagnosis:    410.71     Subendocardial infarction, initial episode of care

Secondary Diagnosis:    414.01    Coronary atherosclerosis of native coronary artery

Secondary Diagnosis:    427.1    Paroxysmal ventricular tachycardia

Secondary Diagnosis:    272.0    Pure hypercholesterolemia

Principal Procedure:    00.66

Percutaneous transluminal coronary angioplasty

Secondary Procedure:    36.07    Insertion of drug-eluting coronary artery stent

Secondary Procedure:    39.29    Other vascular shunt or bypass

Secondary Procedure:    37.22    Left heart cardiac catheterization

MS-DRG: 246

RW: 3.1566    Percutaneous cardiovascular procedure with drug-eluting stent with major complication/comorbidity or 4+vessels/stents

Claim Detail

Revenue Code    Revenue Code Description    Charge

110    Room & board – private    $4,375.00

120    Room & board – semi private    $1,700.00

200    Intensive care – general    $2,910.00

206    Intensive care – intermediate ICU    $1,780.00

250    Pharmacy –  general    $1,486.66

255    Pharmacy – drugs incident to radiology    $728.13

258    Pharmacy – IV solutions    $1,583.60

259    Pharmacy – other pharmacy    $7,766.18

270    Medical/surgical supplies – general    $8,256.00

272    Medical/surgical supplies – sterile supply    $8,366.25

272    The Safe-Cross® guidewire    $12,000.00

278    Medical/surgical supplies – other implants    $28,623.00

301    Laboratory –chemistry    $2,739.00

302    Laboratory – Immunology    $648.00

305    Laboratory – Hematology    $2,335.00

323    Laboratory – Arteriography    $2,491.00

360    Operating room – general    $13,875.00

361    Operating room – minor surgery    $517.00

370    Anesthesia – general    $209.00

390    Blood and blood component admin, process, storage – gen    $668.00

410    Respiratory services – general    $21.00

420    Physical therapy – general    $314.00

430    Occupational therapy – general    $441.00

480    Cardiology – general    $5,629.00

481    Cardiology – cardiac cath lab    $6,249.00

483    Cardiology – echocardiology    $1,786.00

710    Recovery room – general    $1,648.00

730    EKG/ECG – general    $1,098.00

921    Other diagnostic services – peripheral vascular lab    $359.00

TOTAL CHARGE:    $120,601.80

Outlier = cost of claim > reimbursement of claim + threshold

Cost = charge * hospital specific cost to charge ratio

Claim reimbursement = MS-DRG relative weight * hospital base rate

HC outlier payment = 80% * (cost – (claim reimbursement + threshold))

TOTAL reimbursement for claim = claim reimbursement + HC outlier payment

2.    IPPS: The top 25 MS-DRGs for Hospital A are provided in the table below. Calculate the case mix index for this MS-DRG set.

MS-DRG    MS-DRG Title     Volume     MDC    TYPE    RW    Weighted Average

470    Major joint replacement or reattachment of lower extremity w/o MCC     420     08    SURG    2.0953

392    Esophagitis, gastroent & misc digest disorders w/o MCC     332     06    MED    0.7375

194    Simple pneumonia & pleurisy w CC     295     04    MED    0.9996

247    Perc cardiovasc proc w drug-eluting stent w/o MCC     280     05    SURG    1.9911

293    Heart failure & shock w/o CC/MCC     246     05    MED    0.6751

313    Chest pain     233     05    MED    0.5617

292    Heart failure & shock w CC     232     05    MED    1.0034

690    Kidney & urinary tract infections w/o MCC     219     11    MED    0.781

192    Chronic obstructive pulmonary disease w/o CC/MCC     218     04    MED    0.7072

871    Septicemia w/o MV 96+ hours w MCC     213     18    MED    1.8803

641    Nutritional & misc metabolic disorders w/o MCC     209     10    MED    0.692

291    Heart failure & shock w MCC     193     05    MED    1.5174

885    Psychoses     188     19    MED    0.9539

312    Syncope & collapse     177     05    MED    0.7339

287    Circulatory disorders except AMI, w card cath w/o MCC     173     05    MED    1.0709

195    Simple pneumonia & pleurisy w/o CC/MCC     172     04    MED    0.7078

310    Cardiac arrhythmia & conduction disorders w/o CC/MCC     171     05    MED    0.5541

603    Cellulitis w/o MCC     143     09    MED    0.8392

379    G.I. hemorrhage w/o CC/MCC     137     06    MED    0.7015

191    Chronic obstructive pulmonary disease w CC     131     04    MED    0.9521

065    Intracranial hemorrhage or cerebral infarction w CC     128     01    MED    1.1345

683    Renal failure w CC     116     11    MED    0.9958

189    Pulmonary edema & respiratory failure     114     04    MED    1.2461

069    Transient ischemia     110     01    MED    0.7449

066    Intracranial hemorrhage or cerebral infarction w/o CC/MCC     102     01    MED    0.8135

Totals

CMI                1.0682

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