Applied Sciences Health Information Technology Homework

Example

Assumption	ED Visit
MCR CCR	0.35
WI	1.0105
DOS	2023
DX	M54.9	M51.86
Claim Information
RC	CPT	Mod-1	Mod-2	Unit	Charge	Service Description
250				4	$ 156.00	General pharmacy
258				1	$ 62.00	IV Drugs
270				2	$ 58.00	General supplies
450	99284			1	$ 568.00	Emergency level IV
450	96374			1	$ 215.00	Initial IV injection
450	96375			1	$ 120.00	Sequencial IV injection
450	96376			1	$ 47.00	Additional sequencial IV inj
			TOTAL Charge		$ 1,226.00
			Cost		$ 429.10
MCR Payment
RC	CPT	APC	SI	Unadjusted Payment	WI adjusted Payment
250		0000	N	$ - 0
258		0000	N	$ - 0
270		0000	N	$ - 0
450	99284	5024	J2	$ 381.61	$ 384.01
450	96374	5693	S	$ 206.57	$ 207.87
450	96375	5691	S	$ 42.37	$ 42.64
450	96376	0000	N	$ - 0
					$ 634.52	Total Reimbursement

The national amount is before wage index adjustment; only APC rates are WI adjusted—fee schedule and reasonable cost are not!

The WI adjusted payment amount is the reimbursement amount (unless any other add-ons are applicable). This amount is the total amount (Medicare portion plus the beneficiary cost-sharing portion).

APC and SI information are from the OCE/Pricer. The SI here is different from Addendeum B because the Pricer has executed the packaging and bundling logic. Use Addendum B, to identify reimbursement rates for payable lines. See table 7.1, Payment status indicators for 2023, for a refresher on SI descriptions.

Information about the claim. CCR = cost to charge ratio. WI = wage index.

Claim information represents the data that the hospital submits to the MAC. Use the total charge from this section to calculate cost.

Helpful Tip: If WI value is less than 1.0 then the payment rate will decrease. If the WI value is greater than 1.0 then the payment rate will increase.

ED Visit

Assumption	ED Visit
MCR CCR	0.227
WI	0.8934
DOS	2023
DX	S61.409A	Z23
Claim Information
RC	CPT	Mod-1	Mod-2	Unit	Charge
361	29130			1	$ 157.50
450	99285	25		1	$ 654.42
363	90714			1	$ 140.60
940	90471			1	$ 29.99
			TOTAL Charge
			Cost
Medicare Payment
RC	CPT	APC	SI	Unadjusted Payment	WI adjusted Payment
361	29130	0000	N
450	99285	5023	V
363	90714	0000	N
940	90471	0000	N
						Total Reimbursement
						Profit or Loss?

Rural SCH

Assumption	Rural SCH
CCR	0.42
WI	0.9663
DOS	2023
DX	S69.80XA	S62.523A
Claim Information
RC	CPT	Mod-1	Mod-2	Unit	Charge	Service Description
250				3	$ 96.50	General pharmacy
258				1	$ 4.25	IV Drugs
272				2	$ 7.25	Sterile supplies
320	73130			1	$ 168.25	X-ray, hand
450	90471			1	$ 31.50	Immunization administration
450	96372			1	$ 61.25	Therapeutic injection
450	99283	25		1	$ 402.50	Emergency, level IV
			TOTAL Charge
			Cost
MCR Payment
RC	CPT	APC	SI	Unadjusted Payment	WI-Adj MCR Pre-Add-on	Add-on	Total Medicare Payment
250
258
272
320	73130	0000	N
450	90471	0000	N
450	96372	0000	N
450	99283	5023	V
								Total Reimbursement
								Profit or Loss?

Surgery

Assumption	1-day Surgery
MCR CCR	0.32
WI	0.8934
DOS	2023
DX	S83.289A	M22.40	I10
Claim Information
RC	CPT	Mod-1	Mod-2	Unit	Charge	Service Description
250				1	$ 15.20	General pharmacy
250	J2250			4	$ 19.40	Versed
250	J3010			3	$ 9.70	Fentanyl
250				4	$ 80.20	General pharmacy
300	36415			1	$ 16.00	Venipuncture
301	80053			1	$ 192.00	Comprehensive meta panel
305	85025			1	$ 80.00	CBC complete
307	81003			1	$ 44.00	Urinalysis
307	81025			1	$ 72.00	Urine pregnancy test
324	71021			1	$ 283.00	Chest x-ray
360	29881			1	$ 3,866.00	Arthorscopy, ankle
370	01400			1	$ 756.00	Anesthesia
710				1	$ 1,121.76	Recovery room
730	93005			1	$ 185.00	EKG
			TOTAL Charge
			Cost
MCR Payment
RC	CPT	APC	SI	Unadjusted Payment	WI adjusted Payment
250
250	J2250	0000	N
250	J3010	0000	N
250
300	36415	0000	N
301	80053	0000	N
305	85025	0000	N
307	81003	0000	N
307	81025	0000	N
324	71021	0000	N
360	29881	5113	J1
370	01400	0000	N
710
730	93005	0000	N
						Total Reimbursement
						Profit or Loss?