MEPS-HC Survey Instrument

OMB#: 0935-0108

PATIENT LABEL

FORM ______ OF ______

MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT

MEDICAL EVENT FORM
FOR
OFFICE-BASED PROVIDERS
FOR
REFERENCE YEAR 2005

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\OB Medical Event Form-legal.doc - 12/9/2005 - 12:07 PM - mel

(PATIENT NAME) reported that (he/she) received health care services from someone in this practice during
the calendar year 2005.
B1. During this period, what is the (first/next) visit date in your
records for (PATIENT NAME)?

IF GLOBAL FEE,
RECORD TYPE:
______

______/_____/ ______
MO
DAY
YR

GLOBAL FEE
B2a. Was the visit on (DATE) covered by a global fee, that
is, was it included in a charge that covered services
received on other dates as well?

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

1
2 (B3)

[IF NECESSARY: Examples would be a surgeon’s fee
covering surgery as well as pre- and post-operative
care, or an obstetrician’s fee covering normal delivery
as well as pre- and post-natal care.]
B2b. What other dates of service were covered by this global
fee? Please include dates before or after 2005 if they
were included in the global fee.
[IF THERE ARE MORE THAN 8 DATES, USE A
CONTINUATION SHEET.]

MO DAY YR
____/_____/______
____/_____/______
____/_____/______
____/_____/______
____/_____/______
____/_____/______
____/_____/______
____/_____/______

TYPE
_____
_____
_____
_____
_____
_____
_____
_____

IF TYPE 96, SPECIFY:
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

|__|__|
OFFICE
USE
ONLY

B2c. Did (PATIENT NAME) receive the services on (DATE)
in a:
Physician's Office (TYPE=MV);
Hospital as an Inpatient (TYPE=SH);
Hospital Outpatient Department (TYPE=SO);
Hospital Emergency Room (TYPE=SE); or
Somewhere else (TYPE=96)?
B2d. Do you expect (PATIENT NAME) will receive any future
services that will be covered by this same global fee?

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

1
2

GO TO B4a
B3.

Did (PATIENT NAME) receive the services on (DATE)
in a:

Physician’s Office;.......................................
Hospital as an Inpatient;..............................
Hospital Outpatient Department;.................
Hospital Emergency Room; or ....................
Somewhere else?
(SPECIFY:) _____________________ ..
________________________________

B4a. I need the diagnoses for (this visit/these visits). I would
prefer the ICD-9 codes (or the DSM-4 codes), if they
are available.

CODE

1
2
3
4
5

DESCRIPTION

|__|
|__|

[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]

|__|

[IF THERE ARE MORE THAN 8 DIAGNOSES,
USE A CONTINUATION SHEET.]

|__|__|
OFFICE
USE
ONLY

|__|
|__|

B4b. Which of these was the principal diagnosis?
|__|
|__|
|__|
IF ONLY ONE DIAGNOSIS, GO TO B5a.
IF MORE THAN ONE DIAGNOSIS:
„ CHECK BOX FOR PRINCIPAL
DIAGNOSIS
„ CIRCLE ‘–8’ IF PRINCIPAL
DIAGNOSIS NOT KNOWN...................

1

-8

CPT-4 (including
modifier)

Full established charge
at time of visit or
charge equivalent

[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. ___________________

$__________.____

[EXPLAIN IF NECESSARY: The full established
charge is the charge maintained in the physician’s
billing system 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. ]

f. ___________________

$__________.____

g. ___________________

$__________.____

h. ___________________

$__________.____

i. ____________________

$__________.____

[IF NO CHARGE: Some practices 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?]

j. ____________________

$__________.____

k. ___________________

$__________.____

TOTAL CHARGES

$_________.___

B5a. I need to know what services were provided during
(this visit/these visits). I would prefer the CPT-4
codes, if they are available.

B5b. ASK FOR EACH CPT-4 CODE OR DESCRIPTION:
What was the full established charge for this
service, before any adjustments or discounts?

C2.

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

C3.

Was the practice reimbursed for (this visit/these
visits) on a fee-for-service basis or capitated basis?
[EXPLAIN IF NECESSARY:
FEE-FOR-SERVICE BASIS ..................... 1
CAPITATED BASIS .................................. 2 (C7a)

Fee-for-service means that the practice was
reimbursed on the basis of the services provided.
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 FEEFOR-SERVICE.]

C4.

From what sources has the practice 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 1
DO TOTAL PAYMENTS EQUAL
TOTAL CHARGES?
YES................ 1 (BOX 2)
NO ................. 2 (C6)

2

|__|__|
OFFICE
USE
ONLY

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
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:) _____________________

NO
2
2
2
2
2
2
2
2

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

q. Charity care or sliding scale...................... 1
r. Bad debt....................................................... 1

2
2

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

2
2
2
2

1
1
1
1

GO TO BOX 2
CAPITATED BASIS
C7a. What kind of insurance plan covered the patient
YES NO
for (this visit/these visits)? Was it:
a. Medicare;..................................................... 1
2
b. Medicaid; ..................................................... 1
2
[IF NAME OF INSURER OR HMO, PROBE:
c. Private Insurance;........................................ 1
2
And is that Medicare, Medicaid, or private
d. VA; ............................................................... 1
2
insurance?]
e. TRICARE/CHAMPVA/CHAMPUS;.............. 1
2
f. Worker’s Comp; or....................................... 1
2
g. Something else? (SPECIFY:)..................... 1
2
_________________________________
C7b. Was there a co-payment for (this visit/these
visits)?

YES.............................................................. 1
NO................................................................ 2 (C7e)

C7c. How much was the co-payment?

$___________.__

C7d. Who paid the co-payment?
[IF NAME OF INSURER OR HMO, PROBE:
And is that Medicare, Medicaid, or private
insurance?]

C7e. Do your records show any other payments for
(this visit/these visits)?
C7f. From what other sources has the practice
received payment for (this visit/these visits) and
how much was paid by each source?
[IF NAME OF INSURER OR HMO, PROBE:
And is that Medicare, Medicaid, or private
insurance?]

a.
b.
c.
d.
e.

YES NO
PATIENT OR PATIENT’S FAMILY ............. 1
2
MEDICARE.................................................. 1
2
MEDICAID ................................................... 1
2
PRIVATE INSURANCE............................... 1
2
OTHER
(SPECIFY): ________________________ 1
2

YES.............................................................. 1
NO................................................................ 2 (BOX 2)
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):
____________________

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

BOX 2
GLOBAL FEE SITUATION (B2a=YES) ............... 1 (B8)
RECORDED 5 OR FEWER EVENTS .................. 2 (B8)
RECORDED 6 OR MORE EVENTS .................... 3 (B6a)
3

REPEATING IDENTICAL VISITS
B6a. Were there any other visits for this patient during 2005
for which the services and charges were identical to
YES......................................................
the services and charges for the visit on (DATE OF
NO .......................................................
THIS EVENT)?

1
2 (B8)

[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 once- or twice-a-week physical or mental
health therapy, or weekly or monthly allergy shots.]
B6b. During 2005 how many other visits were there for
which the services and charges were identical to those
on (DATE OF THIS EVENT)?

# OF VISITS_____________

B6c. Please tell me the dates of those other visits.
[IF THERE WERE MORE THAN 30 IDENTICAL
VISITS, USE A CONTINUATION SHEET.]

B8.

Have we covered all of this patient's visits during the
calendar year 2005?

B9a. IF ALL EVENTS ARE RECORDED FOR THIS
PATIENT, REVIEW NUMBER OF EVENTS
REPORTED BY HOUSEHOLD.

MO/DAY/YR

MO/DAY/YR

MO/DAY/YR

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|__|__|__|
OFFICE
USE
ONLY

YES, ALL EVENTS COVERED .................... 1 (B9A)
NO, NEED TO COVER ADDITIONAL
EVENTS ................................................... 2 (B1-NEXT
EVENT
FORM)
NO DIFFERENCE OR PROVIDER
REPORTED MORE EVENTS THAN
HOUSEHOLD ............................................ 1 (B9b)
PROVIDER REPORTED FEWER
EVENTS..................................................... 2
[PROBE: (PATIENT NAME) reported (NUMBER)
visits to (PROVIDER) during 2005, but I have only
recorded (NUMBER) visits. Do you have any
information in your records that would explain this
discrepancy?]
___________________________________
___________________________________
___________________________________

B9b. GO TO NEXT PATIENT FOR THIS PROVIDER.

B9c. IF NO MORE PATIENTS, THANK THE RESPONDENT AND END THE CALL.

4