Medical Reimbursement Unit 4 Discussion
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medical_reimbursement_unit_4_discussion.docxMedical Reimbursement Unit 4 Discussion
There are two categories of adjustments in the IPF PPS system, Patient Level Adjustments and Facility Level Adjustments. Review this information below along with the accompanied Tables 6.7–6.10.
Review the types of adjustments under either category and discuss the following:
What are the reasons for the adjustments and the impact of the adjustments on payment? Give an example. Does the adjustment and how it is applied make sense? Why or why not?
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Length-of-Stay Adjustment
Cost regression, first based on 1999 claims data and then updated with 2002 data, showed that the per diem cost for psychiatric cases decreased as the LOS increased (DHHS 2004b, 66949). Therefore, the IPF PPS provides an LOS adjustment factor for each day of the patient encounter. Table 6.7 shows the adjustment schedule by day.
Table 6.7. Length-of-stay adjustment schedule
|
Day of Stay |
Variable Per Diem Payment Adjustment |
|
Day 1 |
1.31/1.19 * |
|
Day 2 |
1.12 |
|
Day 3 |
1.08 |
|
Day 4 |
1.05 |
|
Day 5 |
1.04 |
|
Day 6 |
1.02 |
|
Day 7 |
1.01 |
|
Day 8 |
1.01 |
|
Day 9 |
1.00 |
|
Day 10 |
1.00 |
|
Day 11 |
0.99 |
|
Day 12 |
0.99 |
|
Day 13 |
0.99 |
|
Day 14 |
0.99 |
|
Day 15 |
0.98 |
|
Day 16 |
0.97 |
|
Day 17 |
0.97 |
|
Day 18 |
0.96 |
|
Day 19 |
0.95 |
|
Day 20 |
0.95 |
|
Day 21 |
0.95 |
|
Over 21 |
0.92 |
The adjustment for day 1 would be 1.31 or 1.19, depending on whether the IPF has or is a psychiatric unit in an acute-care hospital with a qualifying emergency department.
Source: Department of Health and Human Services. 2011. Federal Register 76 (88):26452–26453.
Medicare-Severity Diagnosis-Related Group Adjustment
The IPF PPS will provide reimbursement for MS-DRGs that contain a psychiatric ICD-9-CM code as identified in chapter 5 of the codebook as principal diagnosis. However, a payment adjustment will be made only for 17 designated psychiatric MS-DRGs. Table 6.8 provides a listing of the 17 psychiatric MS-DRGs.
Table 6.8. Psychiatric MS-DRGs that qualify for payment adjustment
|
DRG Title |
MS-DRG Code |
Adjustment Factor |
|
Degenerative nervous system disorders w MCC |
MS-DRG 056 |
1.05 |
|
Degenerative nervous system disorders w/o MCC |
MS-DRG 057 |
1.05 |
|
Nontraumatic stupor & coma w MCC |
MS-DRG 080 |
1.07 |
|
Nontraumatic stupor & coma w/o MCC |
MS-DRG 081 |
1.07 |
|
O.R. procedure w principal diagnoses of mental illness |
MS-DRG 876 |
1.22 |
|
Acute adjustment reaction & psychosocial dysfunction |
MS-DRG 880 |
1.05 |
|
Depressive neuroses |
MS-DRG 881 |
0.99 |
|
Neuroses except depressive |
MS-DRG 882 |
1.02 |
|
Disorders of personality & impulse control |
MS-DRG 883 |
1.02 |
|
Organic disturbances & mental retardation |
MS-DRG 884 |
1.03 |
|
Psychoses |
MS-DRG 885 |
1.00 |
|
Behavioral & developmental disorders |
MS-DRG 886 |
0.99 |
|
Other mental disorder diagnoses |
MS-DRG 887 |
0.92 |
|
Alcohol/drug abuse or dependence, left AMA |
MS-DRG 894 |
0.97 |
|
Alcohol/drug abuse or dependence w rehabilitation therapy |
MS-DRG 895 |
1.02 |
|
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC |
MS-DRG 896 |
0.88 |
|
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC |
MS-DRG 897 |
0.88 |
|
Source: Department of Health and Human Services. 2011. Federal Register 76(88):26450–26451. |
Comorbid Conditions
The regression analysis of 2002 cost data identified a need to provide a payment adjustment for some comorbid conditions. Table 6.9 provides a listing of the comorbidity groupings that warrant a payment adjustment in the IPF PPS system. This is not a complete list of comorbidities as used in the IPPS; rather, it is a listing of the conditions that were found to be more costly to treat for psychiatric patients in IPFs.
Table 6.9. Comorbidity adjustment categories
|
Comorbidity Category |
Applicable ICD-9-CM Codes |
Adjustment Factor |
|
Developmental disabilities |
317, 318.0, 318.1, 318.2, and 319 |
1.04 |
|
Coagulation factor deficits |
286.0 through 286.4 |
1.13 |
|
Tracheotomy |
519.00 through 519.09 and V44.0 |
1.06 |
|
Renal failure, acute |
584.5 through 584.9, 636.30, 636.31, 636.32, 637.30, 637.31, 637.32, 638.3, 639.3, 669.32, 669.34, and 958.5 |
1.11 |
|
Renal failure, chronic |
403.01, 403.11, 403.91, 404.02, 404.12, 404.13, 404.92, 404.93, 585.3, 585.4, 585.5, 585.6, 585.9, 586, V45.1, V56.0, V56.1, and V56.2 |
1.11 |
|
Oncology treatment |
140.0 through 239.9 with either 92.21 through 92.29 or 99.25 |
1.07 |
|
Uncontrolled diabetes mellitus with or without complications |
250.02, 250.03, 250.12, 250.13, 250.22, 250.23, 250.32, 250.33, 250.42, 250.43, 250.52, 250.53, 250.62, 250.63, 250.72, 250.73, 250.82, 250.83, 250.92, and 250.93 |
1.05 |
|
Severe protein calorie malnutrition |
260 through 262 |
1.13 |
|
Eating and conduct disorders |
307.1, 307.50, 312.03, 312.33, and 312.34 |
1.12 |
|
Infectious disease |
010.00 through 041.10, 042, 045.00 through 053.19, 054.40 through 054.49, 055.0 through 077.0, 078.2 through 078.89, and 079.50 through 079.59 |
1.07 |
|
Drug- and/or alcohol-induced mental disorders |
291.0, 292.0, 292.12, 292.2, 303.00, and 304.00 |
1.03 |
|
Cardiac conditions |
391.0, 391.1, 391.2, 402.01, 404.03, 416.0, 421.0, 421.1, and 421.9 |
1.11 |
|
Gangrene |
440.24 and 785.4 |
1.10 |
|
Chronic obstructive pulmonary disease |
491.21, 494.1, 510.0, 518.83, 518.84, V46.11, V46.12, V46.13, and V46.14 |
1.12 |
|
Artificial openings—digestive and urinary |
569.60 through 569.69, 997.5 and V44.1 through V44.6 |
1.08 |
|
Severe musculoskeletal and connective tissue diseases |
696.0, 710.0, 730.00 through 730.09, 730.10 through 730.19, and 730.20 through 730.29 |
1.09 |
|
Poisoning |
965.00 through 965.09, 965.4, 967.0 through 969.9, 977.0, 980.0 through 980.9, 983.0 through 983.9, 986 and 989.0 through 989.7 |
1.11 |
|
Source: Department of Health and Human Services. 2011. Federal Register 76(88):26451–26452. |
Older Patients
Reimbursement rates are altered to account for the additional costs incurred for treating older patients. Regression analysis showed that the cost per day increased with increasing patient age. Table 6.10 provides the age categories and adjustment factors used for the IPF PPS.
Table 6.10. Age-adjustment categories
|
Age |
Adjustment Factor |
|
< 45 |
1.00 |
|
45 and under 50 |
1.01 |
|
50 and under 55 |
1.02 |
|
55 and under 60 |
1.04 |
|
60 and under 65 |
1.07 |
|
65 and under 70 |
1.10 |
|
70 and under 75 |
1.13 |
|
75 and under 80 |
1.15 |
|
≥80 |
1.17 |
|
Source: Department of Health and Human Services. 2011. Federal Register 76(88):26452. |
