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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