Question

Part A

Patient Jane Doe was treated for congestive heart failure (ICD-9: 428.0; ICD-10: 150.9). The following table provides the details of the encounter:

Figure 1: Facility Information
Bed size: 300 beds	Location: Columbus, OH
Classification: Urban	Wage Index: 0.9806
Full Service ED: Yes

Figure 2: Claim Information
Admit Date: March 1, 2014	Discharge Date: March 5, 2014	LOS: 4 days
Patient Age: 64
MS-DRG Code: ???	Documentation indicated heart failure and shock with major complexities/comorbid conditions.

Assume FY 2014 Operating Base Payment Rate of $6078. Documentation indicated heart failure and shock with major complexities/comorbid conditions. Refer to the Excel spreadsheet in commentary 2 of Lesson 7 specifically, review the worksheet/tab “Table 5.”

Based on Table 5 descriptions, which MS-DRG code will you assign based on the documentation?

Using the MS-DRG code that you selected, compute the IPPS reimbursement amount for the above scenario. Refer to Commentary 2 under Lesson 7 for computing IPPS.

Download the Excel spreadsheet in the above commentary and follow the step-by-step process outlined in the above commentary and the spreadsheet. Modify the Excel spreadsheet to include the data mentioned in this problem, and compute the reimbursement amount in the Excel spreadsheet.

Answer 1

The final FY 2014 Hospital Inpatient Prospective Payment System (IPPS) is a rule or the policy where the hospital has get payments from the patient for the services which they have given under the medicare services.The MSDRG codes stands for the Medicare Severity-Diagnosis Related group is a form of medical coding to know the the services where the patient is received from the particular hospital and this codes will will be helpful for the billing system.By using this code we can know the type of disease and its severity.Otherwise we can say it as a type of pricing system according to the products or services the patient received

Here in the present scenario of Patient Jane Doe documentation indicated that the patientis having heart failure and shock with major complexities or co-morbid conditions

So here we can the MSDRG code for the case is 291 and 292,why two codes means they are not specifiying it as a heart failure and shock with major complexities or either a co-morbid condition.

And the ICD-10 is 150.9

and ICD-9 is 428.0

That means the Heart failure is un-specifed or not otherwise specified

Thus we can compute the IPPS reimbursement as

Here the formula is :

IIPS payment for patient Jane Doe

[(Base rate labor x wage index) + (Base rate non-labor)] x MSDRG weight

[($6078 x 0.9806) + $1,553.91] x 7.648

= (5960 +1553.9) x 7.6438

=7513.9 x 7.64838

= $57434.7 - Adds on as teaching hospital or indirect graduate medical education (IME) and DHS means disproportionate share of low income patients

=57434.7 + 13917.79 + 6532.53

= $77885.0

Thus 65% of the payment as IPPS reimbursement for a larger hospital with all facilities

that means $50625.25 as the IPPS reimbursement for Patient Jane Doe