MEPS-MPC-Office Based

OMB#: 0935-0108

NODE ID:
PROVIDER ID:

___________________________________
|___|___|___|___|___|___|

PROVIDER NAME: ___________________________________
HOST NAME:

___________________________________

HOST ID:

___________________________________

PATIENT NAME:

___________________________________

EVENT TYPE:

___________________________________

EVENT DATE:

_____/_____/_____ (to _____/_____/_____)

FORM ______ OF ______

SPECIALTY: ____________________

MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT

MEDICAL EVENT FORM
FOR
SEPARATELY BILLING DOCTORS
FOR
REFERENCE YEAR 2005

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\SBD Medical Event Form 2005 (legal).doc - 12/9/2005 - 12:10 PM - SH

(HOSPITAL NAME) reported that (PATIENT NAME) received health care services from someone in this practice
during (an outpatient visit/an emergency room visit/an inpatient stay) on (DATE).
GLOBAL FEE
B2a.

Was the visit on (DATE) covered by a global fee; YES ......................................................
that is, was it included in a charge that covered
NO........................................................
services received on other dates as well?

1
2 (B4a)

[IF NECESSARY: Examples would be a
surgeon’s fee covering surgery as well as preand 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.]

B2c.

MO DAY YR
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____
___ / ___ / ____

TYPE
_______
_______
_______
_______
_______
_______
_______
_______

IF TYPE 96, SPECIFY
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________

|__|__|
OFFICE
USE
ONLY

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 YES ............................................................ 1
future services that will be covered by this same NO.............................................................. 2
global fee?
GO TO B4a

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

[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]
[IF THERE ARE MORE THAN 8 DIAGNOSES,
USE A CONTINUATION SHEET.]
B4b.

DESCRIPTION

|__| ______________

____________________

|__| ______________

____________________

|__| ______________

____________________

|__| ______________

____________________

|__|__|
OFFICE
USE
ONLY

|__| ______________

____________________

|__| ______________

____________________

|__| ______________

____________________

|__| ______________

____________________

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 IS NOT KNOWN .......... -8

1

B5a.

B5b.

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
DESCRIPTIONS OF SERVICES AND
PROCEDURES PROVIDED.]

a. ___________________

$___________.__

b. ___________________

$___________.__

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

c. ___________________

$___________.__

d. ___________________

$___________.__

e. ___________________

$___________.__

|__|__|
OFFICE

f. ___________________

$___________.__

ONLY

g. ___________________

$___________.__

h. ___________________

$___________.__

i. ___________________

$___________.__

j. ___________________

$___________.__

k. ___________________

$___________.__

$__________.__

Full established charge
at time of visit or
charge equivalent

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

USE

[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.]
[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
equivalent(s) for (this/these) procedures? ]

C2.

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

TOTAL CHARGES

C3.

Was the practice reimbursed for (this visit/these
visits) on a fee-for-service basis or a capitated
basis?
[EXPLAIN IF NECESSARY:]

FEE-FOR-SERVICE BASIS .....................
CAPITATED BASIS ..................................

1
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 FEE-FORSERVICE.]
C4.

From what 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?
INTERVIEWER: IF RESPONSE IS THE PATIENT
PAYS A MONTHLY PREMIUM, GO BACK TO C3
AND CHANGE CODE TO 2 (CAPITATED BASIS).

C5.

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

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

$__________.__

BOX 1
DO TOTAL PAYMENTS EQUAL
TOTAL CHARGES?
YES................1 (B10a)
NO .................2 (C6)

2

C6.

PAYMENTS LESS THAN CHARGES:
YES NO
Adjustment or discount
a. Medicare limit or adjustment..................... 1
2
b. Medicaid limit or adjustment ..................... 1
2
c. Contractual arrangement with insurer
or managed care organization................ 1
2
d. Courtesy discount ..................................... 1
2
e. Insurance write-off .................................... 1
2
f. Worker's Comp limit or adjustment........... 1
2
g. Eligible veteran ......................................... 1
2
h. Other (Specify):________________ ........ 1
2

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.]

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 B10a
CAPITATED BASIS

C7a.

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

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?

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

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

C7f.

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

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

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

B10a. ARE ALL EVENTS REPORTED BY
(HOSPITAL) FOR THIS PATIENT COVERED?

Patient or patient’s family
Medicare
Medicaid
Private Insurance
VA
TRICARE/CHAMPVA/CHAMPUS
WORKER'S COMP
OTHER (SPECIFY):
_____________________

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

B10b. GO TO NEXT PATIENT FOR THIS PROVIDER.
B10c.

IF NO MORE PATIENTS, THANK THE RESPONDENT AND END THE CALL.
3

1
2 (C7e)

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

C7e.

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

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

1
2 (B10a)

$__________.__
$__________.__
$__________.__
$__________.__
$__________.__
$__________.__
$__________.__
$__________.__

1
2 (NEXT FORM
FOR THIS
PATIENT)