1. After adding diagnoses and procedures, evaluate the differences in MS-DRG and reimbursement by comparing the before and aftereffects of your inputted data.
Added by Michael D.
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This involves reviewing the current medical record and any associated billing information. Show more…
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Examine the relationship between medical documentation, severity of illness, hospital-acquired conditions, present on admission indicators, and case mix. Provide examples to support your examination, based on POA and case mix information for Independence Hospital. Make recommendations that may impact revenue and reimbursement, based on your assessment of the information. Also, provide recommendations to educate physicians on documentation standards and educate coders on how to work with physicians during the documentation process. Present on Admission: Under the Hospital-Acquired Conditions provision, the Secretary of Health and Human Services has designated several conditions that, when acquired during a hospital admission, have the potential to reduce payment. One of these conditions is Pressure Ulcers (ICD-10-CM L89.X) codes. To determine if the pressure ulcer was present when the patient was admitted or acquired during the hospital stay, the hospital must report a present on admission code for each diagnosis on the billing form. You are working with the coding manager at Independence Hospital. The coders have been asked to apply the present on admission indicator code. The coding manager has collected data over the past six months, and it is clear from the data that there is an issue with either the documentation of pressure ulcers, assignment of the POA indicator, or the quality of care. POA Report for Pressure Ulcers (L89.X) October - March POA Code Description Volume Y Yes, present on admission 15 N No, not present on admission 30 U Unknown, insufficient documentation 45 W Clinically undetermined 3 1 Exempt from POA reporting 0 Case Mix: The Case Mix Index (CMI) is the average weight of a healthcare facility's diagnosis-related groups (MS-DRG). The higher a facility's CMI, the greater the number of high-cost services the facility performs. The more high-cost services performed, the more revenue. Steps to Calculate CMI: 1. Multiply the relative weight of each MS-DRG by the number of discharges for each MS-DRG. 2. Sum all weights to calculate the case mix. 3. Divide the case mix by the total number of patients. MS-DRG MS-DRG WEIGHT # OF DISCHARGES Renal failure w MCC 682 2.0 10 Renal failure w CC 683 1.5 10 Renal failure w/o CC/MCC 684 1.0 10
Sri K.
DPOS Assignment Worksheet Resource Surgeon ASR RN CA Weeks per year 52 52 52 52 Less: Vacation & Holidays 6 4 4 4 Less: Training and Leave 2 2 2 2 Available weeks per year 44 46 46 46 Hours per day 10 8 8 8 Less: Breaks, training, meetings 1.2 1.5 1.5 1.5 Available hours 8.8 6.5 6.5 6.5 Less: Estimate of Research & Education time (%) 25% 0% 0% 0% Clinical Hours per day 6.6 6.5 6.5 6.5 Clinical minutes available per day $ 396.00 $ 390.00 $ 390.00 $ 390.00 Clinical minutes available per year 87,120 89,700 89,700 89,700 Annual Cost per person $ 522,720 $ 89,700 $ 134,550 $ 71,760 Capacity cost rate ($ per minute) $ 6.00 $ 1.00 $ 1.50 $ 0.80 Personnel process times (minutes) Plagiocephaly 18 8 23 5 Neoplasm skin excision 22 55.5 20 5 Craniosynostosis 40 10.5 23 10 Medical Diagnosis Cost per patient visit Surgeon ASR RN CA Total cost Charge Average reimbursement TDABC Profit RCC Cost RCC Profit Plagiocephaly $ 108.00 $ 8.00 $ 34.50 $ 4.00 $ 154.50 $ 350 $ - Neoplasm skin excision $ 132.00 $ 55.50 $ 30.00 $ 4.00 $ 221.50 $ 350 $ - Craniosynostosis $ 240.00 $ 10.50 $ 34.50 $ 8.00 $ 293.00 $ 350 $ - Plastic Surgery Dept. Charges $ 12,449,500 Costs 7,469,700 Reimbursement 7,967,680 RCC: Ratio of costs-to-charges 60% Average DPOS reimbursement rate 64%
Akash M.
Assess the activities within each department in a healthcare organization for how they may impact reimbursement. What specific data would you review in the reimbursement area to know whether changes were necessary?
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