MEPS-HC Survey Instrument

OMB#: 0935-0108

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PATIENT LABEL

OFFICE
USE ONLY

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OFFICE
USE ONLY

FORM ______ OF ______

MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT

HOSPITAL EVENT FORM
FOR
REFERENCE YEAR 2005

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\HOSP EVENT FORM 2005 (legal).doc - 12/9/2005 - 12:04 PM - Dew

HOSPITAL EVENT FORM
[COMPLETE ONE FORM FOR EACH EVENT]
QUESTIONS A1 THROUGH A4: TO BE COMPLETED WITH MEDICAL RECORDS.
READ ONLY FOR FIRST EVENT FOR THIS PATIENT: (PATIENT NAME) reported that (he/she) received health care
services from this facility during 2005.
MEDICAL RECORDS
A1. The (first/next) time (PATIENT NAME)
As an Inpatient; ............................................................................. 1
received services during calendar year
In a Hospital Outpatient Department;............................................ 2
2005, were the services received:
In a Hospital Emergency Room; or .............................................. 3
Somewhere else? (SPECIFY:) _________________________ 4
[CODE ONLY ONE]
LONG TERM CARE UNIT (SNF, etc.) (SPECIFY:) .................... 5
___________________________________________________

(A2a)
(A2c)
(A2c)
(A2c)
(A2a)

A2a. What were the admit and discharge
dates of the (event/inpatient stay)?

MO
DAY
YR
ADMIT:
______/_____ / ______
DISCHARGE: ______/_____ / ______

A2b. Was (PATIENT NAME) admitted from
the emergency room?

YES ................................................ 1 (COMPLETE SEPARATE EVENT
FORM FOR ER EVENT)
NO .................................................. 2
GO TO A3

A2c. What was the date of this visit?
A3. Please give me the name, specialty, and
telephone number of each physician who
provided services during the (TYPE OF
EVENT) on (DATE(S)) and whose
charges might not be included in the
hospital bill. We want to include such
doctors as radiologists, anesthesiologists,
pathologists, and consulting specialists,
but not residents, interns, or other
doctors-in-training whose charges are
included in the hospital bill.
A4a. I need the diagnoses for (this stay/this
visit). I would prefer the ICD-9 codes
(or DSM-4 codes), if they are available.

MO
DAY
YR
_______/_______ /______
[RECORD NAMES ON SEPARATELY BILLING DOCTOR FORM.
IF RESPONDENT IS NOT SURE WHETHER A PARTICULAR
DOCTOR’S CHARGES ARE INCLUDED IN THE HOSPITAL
BILL, RECORD INFORMATION FOR THAT DOCTOR ON
SEPARATELY BILLING DOCTOR FORM.]
SEPARATELY BILLING DOCTORS FOR THIS EVENT..........................1
NO SEPARATELY BILLING DOCTORS FOR THIS EVENT ...................2

CODE

DESCRIPTION

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OFFICE
USE ONLY

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[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]
[IF THERE ARE MORE THAN FOUR
DIAGNOSES, USE A CONTINUATION
SHEET.]

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A4b. Which of these was the principal
diagnosis?

IF ONLY ONE DIAGNOSIS, GO TO Q4c.
IF MORE THAN ONE DIAGNOSIS:
„ CHECK BOX FOR PRINCIPAL DIAGNOSIS
„ CIRCLE ‘–8’ IF PRINCIPAL DIAGNOSIS
NOT KNOWN ...................................... -8

A4c. Have we covered all of this patient’s
events during the calendar year 2005?

YES, ALL EVENTS COVERED .................. 1
NO, NEED TO COVER ADDITIONAL
EVENTS ................................................... 2

A4d. IF ALL EVENTS ARE RECORDED
FOR THIS PATIENT, REVIEW
NUMBER OF EVENTS REPORTED BY
HOUSEHOLD.

NO DIFFERENCE OR FACILITY
REPORTED MORE EVENTS THAN
HOUSEHOLD........................................... 1

(A4d)
(A1–NEXT EVENT
FORM)

(ENDING FOR
MEDICAL RECORDS)

FACILITY RECORDED FEWER
VISITS ...................................................... 2
PROBE: (PATIENT NAME) reported (NUMBER)
events at (FACILITY) during 2005, but I have
only recorded (NUMBER) visits. Do you have
any information in your records that would
explain this discrepancy?
_____________________________________________________
_____________________________________________________
GO TO ENDING FOR MEDICAL RECORDS
ENDING FOR MEDICAL RECORDS:
GO TO NEXT PATIENT. IF NO MORE PATIENTS, THANK RESPONDENT AND END. THEN ATTEMPT
CONTACT WITH PATIENT ACCOUNTS OR ADMINISTRATIVE OFFICE.

2

QUESTIONS A5a THROUGH END: TO BE COMPLETED WITH PATIENT ACCOUNTS.
READ ONLY FOR FIRST EVENT FOR THIS PATIENT: I have information from Medical Records that (PATIENT NAME)
received health care services on [READ DATES OF ALL VISITS AND INPATIENT STAYS].
I’d like to ask you about the (visit on/stay which began on) [FIRST/NEXT DATE].
BOX 1
IF EVENT IS AN OUTPATIENT VISIT OR EMERGENCY ROOM VISIT OR SOMEWHERE ELSE (SEE
A1), CONTINUE WITH A5a. IF EVENT IS AN INPATIENT STAY OR LONG–TERM CARE UNIT (SEE
A1), GO TO A8.
GLOBAL FEE
A5a. Was the visit on that date covered by a global fee,
that is, was it included in a charge that covered
YES ............................................. 1
services received on other dates as well?
NO ............................................... 2 (A6a)
[EXPLAIN IF NECESSARY: An example would be a
patient who received a series of treatments, such as
chemotherapy, that was covered by a single charge.]
A5b. Did the global fee for this date cover any services
received while the patient was an inpatient?

YES ............................................. 1
NO ............................................... 2 (A5d)

A5c. What were the admit and discharge dates of that
stay?

MO
DAY
YR
ADMIT:
______/______/ ______
DISCHARGE: ______/______/ ______

A5d. What were the other dates on which services covered
by this global fee were provided? Please include
dates before or after 2005 if they were included in the
global fee.

MO

DAY YR

____/____/______
____/____/______
____/____/______
____/____/______
____/____/______
____/____/______
____/____/______
____/____/______

Did (PATIENT NAME) receive the services on
(DATE) in an:
Outpatient Department (TYPE=OP);
Emergency Room (TYPE=ER); or
Somewhere else (TYPE=96)?

A5e. Do you expect (PATIENT NAME) will receive any
future services that will be covered by this same
global fee?

TYPE
_____
_____
_____
_____
_____
_____
_____
_____

IF TYPE 96,
SPECIFY:
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________

YES ......................................................... 1
NO ........................................................... 2

3

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OFFICE
USE
ONLY

Full established
charge at time of
visit or charge
equivalent

A6a. I need to know what services were provided during
(this visit/these visits). I would prefer the CPT-4
codes, if they are available.

CPT-4 (including modifier)

[IF CPT-4 CODES ARE NOT USED, RECORD
DESCRIPTION OF SERVICES AND PROCEDURES
PROVIDED.]

a. ___________________

$__________.____

b. ___________________

$__________.____

[IF THERE ARE MORE THAN 11 SERVICES, USE A
CONTINUATION SHEET.]

c. ___________________

$__________.____

d. ___________________

$__________.____

e. ___________________

$__________.____

f. ___________________

$__________.____

g. ___________________

$__________.____

h. ___________________

$__________.____

i. ____________________

$__________.____

j. ____________________

$__________.____

k. ___________________

$__________.____

TOTAL CHARGES

$________.___

A6b. ASK FOR EACH CPT-4 CODE OR DESCRIPTION:
What was the full established charge for this service,
before any adjustments or discounts?
[EXPLAIN IF NECESSARY: The full established
charge is the charge maintained in the hospital’s
master fee schedule for billing insurance carriers and
Medicare or Medicaid. It is the “list price” for the
service, before consideration of any discounts or
adjustments resulting from contractual arrangements
or agreements with insurance plans.]
[IF NO CHARGE: Some facilities that don’t charge for
each individual service do associate dollar amounts
with services for purposes of budgeting or cost
analysis.
This is sometimes called a “charge
equivalent.”
Could you give me the charge
equivalents for these procedures?]

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OFFICE
USE
ONLY

C2. IF NOT VOLUNTEERED, ASK: And what was the
total? [IF NOT AVAILABLE, COMPUTE.]
C3. Was the facility reimbursed for (this visit/these visits)
on a fee-for-service basis or capitated basis?
[EXPLAIN IF NECESSARY:
Fee-for-service means that the facility was
reimbursed on the basis of the services provided.

FEE-FOR-SERVICE BASIS ................... 1
CAPITATED BASIS................................. 2 (C7a)

Capitated basis means that the patient was
enrolled in a prepaid managed care plan where
reimbursement is not tied to specific visits.]
[INTERVIEWER: IF IN DOUBT, CODE FEE-FORSERVICE.]

C4. From what sources has the facility received payment for
(this visit/these visits) and how much was paid by each
source?

a. Patient or Patient’s Family .......

$__________.____

b. Medicare ..................................

$__________.____

[IF NAME OF INSURER OR HMO, PROBE: And is that
Medicare, Medicaid, or private insurance?]

c. Medicaid ...................................

$__________.____

d. Private Insurance .....................
[INTERVIEWER: IF RESPONSE IS THE PATIENT PAYS
A MONTHLY PREMIUM, GO BACK TO C3 AND
e. VA.............................................
CHANGE CODE TO 2 (CAPITATED BASIS).]
f. TRICARE/CHAMPVA/
CHAMPUS ................................

$__________.____

g. WORKER’S COMP ..................

$__________.____

h. OTHER (SPECIFY):
___________________________

$__________.____

TOTAL PAYMENTS

$__________.__

C5. IF NOT VOLUNTEERED, ASK: And what was the total?
[IF NOT AVAILABLE, COMPUTE.]

$__________.____

$__________.____

BOX 2
DO TOTAL PAYMENTS EQUAL
TOTAL CHARGES?
YES....................1 (BOX 3)
NO .....................2 (C6)

4

C6. It appears that the total payments were (less than/more
than) the total charges. What is the reason for that
difference? [CODE 1 (YES) FOR ALL REASONS
MENTIONED.]

PAYMENTS LESS THAN CHARGES:
YES
Adjustment or discount
a. Medicare limit or adjustment .................... 1
b. Medicaid limit or adjustment .................... 1
c. Contractual arrangement with insurer
or managed care organization ............... 1
d. Courtesy discount .................................... 1
e. Insurance write-off ................................... 1
f. Worker’s Comp limit or adjustment.......... 1
g. Eligible veteran ........................................ 1
h. Other (Specify:) ___________________ 1

NO
2
2
2
2
2
2
2
2

Expecting additional payment
i. Patient or Patient’s Family .......................
j. Medicare ..................................................
k. Medicaid...................................................
l. Private Insurance .....................................
m. VA ............................................................
n. TRICARE/CHAMPVA/CHAMPUS ...........
o. WORKER’S COMP .................................
p. Other (Specify:) ___________________

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

q. Charity care or sliding scale.................
r. Bad debt..................................................

1
1

2
2

PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment................................
t. Medicaid adjustment ................................
u. Private insurance adjustment ..................
v. Other (Specify:) ___________________

1
1
1
1

2
2
2
2

CAPITATED BASIS
C7a. What kind of insurance plan covered the patient for
YES
(this visit/these visits)? Was it:
a. Medicare; ................................................. 1
b. Medicaid;.................................................. 1
[IF NAME OF INSURER OR HMO, PROBE: And is
c. Private Insurance; .................................... 1
that Medicare, Medicaid, or private insurance?]
d. VA; ........................................................... 1
e. TRICARE/CHAMPVA/CHAMPUS; .......... 1
f. Worker’s Comp; or ................................... 1
g. Something else? (SPECIFY:) ................. 1
________________________________

NO
2
2
2
2
2
2
2

GO TO BOX 3

C7b. Was there a co-payment for (this visit/these visits)?

YES .......................................................
NO .........................................................

C7c. How much was the co-payment?

$___________._____

C7d. Who paid the co-payment?
a.
b.
c.
d.
e.

[IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?]

YES
Patient or Patient’s Family ....................... 1
Medicare .................................................. 1
Medicaid................................................... 1
Private Insurance ..................................... 1
Other
(Specify:) ________________________ 1

C7e. Do your records show any other payments for (this
visit/these visits)?

YES .......................................................
NO .........................................................

C7f. From what other sources has the facility received
payment for (this visit/these visits) and how much
was paid by each source?

a. Patient or patient’s family ....
b. Medicare .............................
c. Medicaid ..............................
d. Private Insurance ................
e. VA........................................
f. TRICARE/CHAMPVA/
CHAMPUS ...........................
g. WORKER’S COMP .............
h. OTHER (SPECIFY):
______________________

[IF NAME OF INSURER OR HMO, PROBE: And
is that Medicare, Medicaid, or private insurance?]

NO
2
2
2
2
2

1
2 (BOX 3)

$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____

BOX 3
GLOBAL FEE SITUATION
(A5a=YES) ...................1
RECORDED 5 OR
FEWER EVENTS ........2
RECORDED 6 OR
MORE EVENTS ..........3
5

1
2 (C7e)

(A11)
(A11)
(A7a)

REPEATING IDENTICAL VISITS
A7a. Were there any other visits for this patient during
2005 for which the services and charges were
YES............................................................ 1
identical to the services and charges for the visit
NO ............................................................. 2 (A11)
on (DATE OF THIS EVENT)?
[EXPLAIN, IF NECESSARY: We are referring
here to repeating identical visits. These
usually occur when the patient has a condition
that requires very frequent visits, such as onceor twice-a-week physical therapy.]
A7b. During 2005 how many other visits were there for
which the services and charges were identical to
those on (DATE OF THIS EVENT)?

A7c. Please tell me the dates of those other visits.
[IF THERE WERE MORE THAN 30 IDENTICAL
VISITS, USE A CONTINUATION SHEET.]

# OF VISITS_____________

MO/DAY/YR

MO/DAY/YR

MO/DAY/YR

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

___/___ 20___

___/___ 20 ___

___/___ 20 ___

GO TO A11

6

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OFFICE
USE ONLY

PATIENT ACCOUNTS QUESTIONS FOR INPATIENT.
A8.

A9.

According to Medical Records, (PATIENT NAME)
was an inpatient during the period from [DATE] to
[DATE]. What was the DRG for this stay?
Did the patient have any surgical procedures
during this stay?

DRG:_____________________________

(BOX 4)

DRG NOT RECORDED ................................ 1 (A9)
YES ............................................................... 1
NO ................................................................. 2 (BOX 4)

A10a. What surgical procedures were performed during
this visit? Please give me the procedure codes,
that is the CPT-4 codes, if they are available.

|__| ______________________________
|__| ______________________________
|__| ______________________________

[IF CPT-4 CODES ARE NOT USED, RECORD
DESCRIPTION OF SERVICES AND
PROCEDURES PROVIDED.]
A10b. Which of these was the principal surgical
procedure?

|__| ______________________________

IF ONLY ONE PROCEDURE, GO TO BOX 4.
IF MORE THAN ONE PROCEDURE:
„ CHECK BOX FOR PRINCIPAL
PROCEDURE
„ CIRCLE ‘-8’ IF PRINCIPAL
PROCEDURE NOT KNOWN................ -8

BOX 4
ADMITTED FROM
EMERGENCY ROOM
(A2b=YES) ...................1 (C2a)
OTHERWISE...................2 (C2b)

7

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OFFICE
USE
ONLY

C2a. What was the full established charge for this
inpatient stay, before any adjustments or
discounts?
Please do not include any
emergency room charges.
C2b. What was the full established charge for this
inpatient stay, before any adjustments or
discounts?
[EXPLAIN IF NECESSARY:
The full
established charge is the charge maintained in
the hospital’s master fee schedule for billing
insurance carriers and Medicare or Medicaid. It
is the “list price” for the service, before
consideration of any discounts or adjustments
resulting from contractual arrangements or
agreements with insurance plans. ]
[IF NO CHARGE: Some facilities that don’t
charge for each individual service do associate
dollar amounts with services for purposes of
budgeting or cost analysis. This is sometimes
called a “charge equivalent.” Could you give
me the charge equivalent for this inpatient stay?]
C3.

FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:
$_______________ . ________
IF HS EVENT:
EMERGENCY ROOM CHARGE
INCLUDED........................................... 1
EMERGENCY ROOM CHARGE NOT
INCLUDED OR NOT APPLICABLE....... 2
IF IC EVENT:
ANCILLARY CHARGES INCLUDED........ 1
ANCILLARY CHARGES NOT
INCLUDED OR NOT APPLICABLE....... 2

Was the facility reimbursed for this inpatient stay
on a fee-for-service basis or capitated basis?
[EXPLAIN IF NECESSARY:
Fee-for-service means that the facility was
reimbursed on the basis of the services
provided.

FEE-FOR-SERVICE BASIS .................... 1
CAPITATED BASIS.................................. 2 (C7a)

Capitated basis means that the patient was
enrolled in a prepaid managed care plan
where reimbursement is not tied to specific
visits.]
[INTERVIEWER: IF IN DOUBT, CODE
FEE-FOR-SERVICE.]
C4.

From what sources has the facility received payment
for this stay and how much was paid by each source?
[IF NAME OF INSURER, OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?]
[INTERVIEWER: IF RESPONSE IS THE PATIENT
PAYS A MONTHLY PREMIUM, GO BACK TO C3
AND CHANGE CODE TO 2 (CAPITATED BASIS).]

C5.

a. Patient or Patient’s Family ..............

$__________.____

b. Medicare .........................................

$__________.____

c. Medicaid ..........................................

$__________.____

d. Private Insurance ............................

$__________.____

e. VA ...................................................

$__________.____

f. TRICARE/CHAMPVA/
CHAMPUS .......................................

$__________.____

g. WORKER’S COMP.........................

$__________.____

h. OTHER (SPECIFY):
____________________________

$__________.____

TOTAL PAYMENTS

$__________.__

IF NOT VOLUNTEERED, ASK: And what was the
total? [IF NOT AVAILABLE, COMPUTE.]

BOX 5
DO TOTAL PAYMENTS EQUAL
TOTAL CHARGES?
YES................1 (A11)
NO..................2 (C6)

8

C6. It appears that the total payments were
(less than/more than) the total charges.
What is the reason for that difference?
[CODE 1 (YES) FOR ALL REASONS
MENTIONED.]

PAYMENTS LESS THAN CHARGES:
YES
Adjustment or discount
a. Medicare limit or adjustment ................................. 1
b. Medicaid limit or adjustment.................................. 1
c. Contractual arrangement with insurer
or managed care organization ............................ 1
d. Courtesy discount ................................................. 1
e. Insurance write-off................................................. 1
f. Worker’s Comp limit or adjustment ....................... 1
g. Eligible veteran...................................................... 1
h. Other (Specify:) _________________________
1

NO
2
2
2
2
2
2
2
2

Expecting additional payment
i. Patient or Patient’s Family ....................................
j. Medicare................................................................
k. Medicaid ................................................................
l. Private Insurance ..................................................
m. VA..........................................................................
n. TRICARE/CHAMPVA/CHAMPUS ........................
o. WORKER’S COMP ..............................................
p. Other (Specify:) .....................................................

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

q. Charity care or sliding scale ..............................
r. Bad debt ...............................................................

1
1

2
2

PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment.............................................
t. Medicaid adjustment .............................................
u. Private insurance adjustment................................
v. Other (Specify:) _________________________

1
1
1
1

2
2
2
2

GO TO A11
CAPITATED BASIS
C7a. What kind of insurance plan covered the patient for
(this visit/these visits)? Was it:

a.
b.
c.
d.
e.
f.
g.

[IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?]

YES
Medicare;........................................... 1
Medicaid; ........................................... 1
Private Insurance; ............................. 1
VA;..................................................... 1
TRICARE/CHAMPVA/CHAMPUS;.... 1
Worker’s Comp; or ............................ 1
Something else? (SPECIFY:)........... 1
______________________________

C7b. Was there a co-payment for (this visit/these visits)?

YES.......................................................
NO ........................................................

C7c. How much was the co-payment?

$___________.__

C7d. Who paid the co-payment?
a.
b.
c.
d.
e.

[IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?]

PATIENT OR PATIENT’S FAMILY ...
MEDICARE .......................................
MEDICAID.........................................
PRIVATE INSURANCE.....................
OTHER
(SPECIFY:) ___________________

1
2 (C7e)

YES
1
1
1
1

NO
2
2
2
2

1

2

C7e. Do your records show any other payments for (this
visit/these visits)?

YES....................................................... 1
NO ........................................................ 2 (A11)

C7f. From what other sources has the facility received
payment for (this visit/these visits) and how much was
paid by each source?

a. Patient or patient’s family ...........
b. Medicare.....................................
c. Medicaid .....................................
d. Private Insurance........................
e. VA ...............................................
f. TRICARE/CHAMPVA/
CHAMPUS...................................
g. WORKER’S COMP ....................
h. OTHER (SPECIFY):
__________________________

[IF NAME OF INSURER OR HMO, PROBE: And
is that Medicare, Medicaid, or private insurance?]

A11. ARE THERE ANY ADDITIONAL EVENTS FOR THIS
PATIENT TO BE ACCOUNTED FOR?

NO
2
2
2
2
2
2
2

$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____

YES............................... 1 (GO TO PATIENT
ACCOUNTS SECTION (A5a)
OF NEXT EVENT FORM.)
NO ................................ 2 (GO TO NEXT PATIENT.
IF NO MORE PATIENTS,
THANK RESPONDENT AND
END.)

9