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 additional 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 additional 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 1, 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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