Physician Reimbursement Case Essay

1904 Words Feb 15th, 2013 8 Pages
Physician Reimbursement Case

Discuss the general differences between facility and non-facility rates. Discuss the MS-DRG system for hospital inpatient services. Include in your discussion the history of the MS-DRG system and the need for the updated system. There are two types of bills used in healthcare. Which type of bill is used for physician services? Which type of bill is used for hospital services? (Hint: your book is incorrect.)

Facility vs. Non-Facility Rates
The place of service can greatly affect reimbursement, depending on the type of service provided and the location. The reason being is that Medicare typically reimburses physicians based on a method called Relative Value Units (RVUs), which has three components: work,
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CMS preformed a comprehensive review of all diagnosis codes to determine which codes should be classified as CCs when present as a secondary diagnosis. CMS then categorized these diagnosis codes into the different severity levels. CMS also consolidated the CMS DRGs into a new set of base DRGs and then divided each into severity subclasses or MS-DRGs.
The CC list has been completely revised for MS-DRGs. The MS-DRG CC list is a very different list than the CMS-DRG CC list. Under CMS-DRGs, a CC was defined as a secondary diagnosis that increased the length of stay by at least 1 day for 75 percent of the cases. Under MS-DRGs, CMS identified those diagnoses whose presence as a secondary diagnosis leads to substantially increased hospital resource use. They then categorized this CC list into three different levels of severity as follows: * Major complications or comorbidities (MCCs) reflect the highest level of severity. * CCs represent the next level of severity. * Non-CCs are at the lowest level of severity. Non-CCs are diagnosis codes that do not significantly affect severity of illness and resource use and do not affect DRG assignment.
Additionally, CC exclusions were carried over to MS-DRGs. Some MCCs and CCs are excluded because they are too closely related to the principal diagnoses. This is called the CC Exclusion List and identifies conditions that will not be considered
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