Form #1 Form #1 Hospitals questionnaire

Form Approved
OMB No. 0935-0118
Exp. Date 12/31/2015

Attachment 87

MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

EVENT FORM

FOR

HOSPITAL PROVIDERS

Combined MEDICAL and billing RECORDS

REFERENCE YEAR 2014

OMB HYPERLINK ON FIRST SCREEN

DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.

PRESS NEXT TO CONTINUE IN THIS EVENT FORM

PRESS BREAKOFF TO DISCONTINUE

(Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.)

OMB No. 0935-0118; Exp. Date XX/XX/XXXX

SECTION 1 – MEDICAL RECORDS – Location of Services

[Page 1 – MEDICAL RECORDS - Location of Services (1 of 1)]

ScreeN LAYOUT

A1. The (first/next) time (PATIENT NAME) received services during calendar year 2014, were the services received: CODE ONLY ONE	As an Inpatient 1 In a Hospital Outpatient Department 2 In a Hospital Emergency Room 3 In a Long Term Care unit such as skilled nursing facility ………5 Somewhere else? ……………………………………………………4 (IF SOMEWHERE ELSE: Where was that?) IF INPATIENT: What was the inpatient venue? IF SOMEWHERE ELSE: Select one

SECTION 2 – MEDICAL RECORDS – EVENT date – Inpatient/LTC (admit/discharge dates)

[Page 3 – MEDICAL RECORDS - eVENT date – INPATIENT/LTC (1 of 1)]

A2a. What were the admit and discharge dates of the inpatient stay? REFERENCE PERIOD – CALENDAR YEAR 2014	ADMIT: MONTH DAY YEAR DISCHARGE: MONTH DAY YEAR NOT YET DISCHARGED………………1
A2b. Was (PATIENT NAME) admitted from the emergency room?	YES=1, NO=2

SECTION 3 – MEDICAL RECORDS – EVENT date – outpatient/er/other (visit date)

[Page 4 – MEDICAL RECORDS - eVENT date – Outpatient/ER/other (1 of 1)]

A2c. What was the date of this visit? REFERENCE PERIOD – CALENDAR YEAR 2014

MONTH DAY YEAR

SECTION 4 – MEDICAL RECORDS – SBD

[Page 5 – MEDICAL RECORDS - SBD (1 of 2)]

A3. I need to record the name and specialty of each physician who provided services during the (TYPE OF EVENT) (DATE(S)) and whose charges might not be included in the hospital bill. We want to include such doctors as surgeons, attending physicians, radiologists, anesthesiologists, pathologists, and consulting specialists, but not residents, interns, or other doctors-in-training whose charges are included in the hospital bill. THERE MAY BE MORE THAN ONE TYPE OF EACH DOCTOR, SO PROBE FOR MULTIPLE SURGEONS, RADIOLOGISTS, ANETHESIOLOGISTS, AND OTHER SEPARATELY BILLING MEDICAL PROFESSIONALS. IF RESPONDENT IS NOT SURE WHETHER A PARTICULAR DOCTOR’S CHARGES ARE INCLUDED IN THE HOSPITAL BILL, ANSWER YES HERE.

YES, SEPARATELY BILLING DOCTORS FOR THIS EVENT 1 NO SEPARATELY BILLING DOCTORS FOR THIS EVENT 2

SECTION 5 – MEDICAL RECORDS – SBD Subroutine

[Page 6 – MEDICAL RECORDS - SBD (2 of 2)]

EF1 I need to collect information about the doctors whose services for this event might not be included in the charges on the hospital bill. I would like to record the group name, doctor name, and National Provider ID, if available.

Physician Name:

EF3 What is this physician’s specialty?

Specialty:

If other, please specify:

EF2 Did this doctor provide any of the following services for this event: radiology, anesthesiology, pathology, or surgery?

1 Radiology

2 Anesthesiology

3 Pathology

4 Surgery

5 None of the above

6 DON’T KNOW

EF5 How would you describe the role of this doctor for this medical event?

SCREEN LABEL DISPLAY ORDER HATTERAS STORED VALUE

Active Physician/Providing Direct Care 1 6

Referring Physician 2 1

Copied Physician 3 2

Follow-up Physician 4 3

Department Head 5 4

Primary Care Physician 6 5

Some Other Physician 7 7

None of the above 8 8

DON’T KNOW 9 9

(IF OTHER DESCRIBE) What other type of physician?

EF6 ENTER ANY COMMENTS ABOUT THIS SBD INCLUDING ADDITIONAL SERVICE(S) TO THE ONE SELECTED IN EF2

SECTION 6 – MEDICAL RECORDS – Diagnoses

[Page 7 – MEDICAL RECORDS - Diagnoses (1 of 1)]

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. IF CODES ARE NOT USED, RECORD DESCRIPTIONS. RECORD UP TO FIVE ICD-9 CODES OR DESCRIPTIONS

ICD-9 CODE DESCRIPTION

SECTION 7 – MEDICAL RECORDS – SUMMARY/CONCLUSION

MEDICAL RECORDS - SUMMARY/CONCLUSION (1 of 1)]

A4c.

PRESS "BREAKOFF" TO CLOSE THIS MEDICAL RECORDS SECTION. CMS WILL ASK WHETHER YOUR MEDICAL RECORDS RESPONDENT HAS ADDITIONAL EVENTS FOR THIS PATIENT.

PRESS "NEXT" WHEN YOU ARE READY TO BEGIN PATIENT ACCOUNTS SECTION.

SECTION 8 – PATIENT ACCOUNTS – INTRODUCTION

[Page 8 – PATIENT ACCOUNTS - iNTRODUCTION (1 of 1)]

I have information from Medical Records that (PATIENT NAME) received health care services (FILL DATE)

NOTE: IF THE ONLY EVENT OF THIS TYPE KNOWN BY PATIENT ACCOUNTS IS WITHIN A DAY OR TWO OF WHAT WAS REPORTED BY MEDICAL RECORDS, ANSWER YES BELOW.

YES, RECORDS FOUND FOR THIS EVENT =1

NO, RECORDS NOT FOUND FOR THIS EVENT =2

NO, OTHER RECORDS PROBLEM =3

SECTION 9 – PATIENT ACCOUNTS – Global Fee

[Page 9 – PATIENT ACCOUNTS - Global fee (1 of 4)]

A5a. Was the visit on that date covered by a global fee, that is, was it included in a charge that covered services received on other dates as well? 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.	YES=1, NO=2

[Page 10 – PATIENT ACCOUNTS - Global fee (2 of 4)]

A5b. Did the global fee for this date cover any services received while the patient was an inpatient?

YES=1, NO=2

[Page 11 – PATIENT ACCOUNTS - Global fee (3 of 4)]

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

ADMIT: MONTH DAY YEAR DISCHARGE: MONTH DAY YEAR

[Page 12 – PATIENT ACCOUNTS - Global fee (4 of 4)]

A5c1. Were there any other dates on which services were covered by this global fee? 1 YES 2 NO A5d. What were the other dates on which services covered by this global fee were provided? Please include dates before or after 2014 if they were included in the global fee. Did (PATIENT NAME) receive services on this date in an: Outpatient Department (TYPE=OP) Emergency Room (TYPE=ER) Somewhere else (TYPE=96) IF TYPE=96 SPECIFY:	MONTH DAY YEAR
A5e. Do you expect (PATIENT NAME) will receive any future services that will be covered by this same global fee?	YES=1, NO=2
A5f. [ABS ONLY] You’ve described different dates of service covered by a global fee. Do you know if there were additional doctors providing services whose charges weren’t included in the hospital bill?	YES=1, NO=2

SECTION 10 - PATIENT ACCOUNTS – SERVICES/CHARGES – OUTPATIENT/ER/OTHER

[Page 13 – PATIENT ACCOUNTS - SERVICES/CHARGES – OUTPATIENT/ER/OTHER (1 of 2)]

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. IF CPT-4 CODES ARE NOT USED, DESCRIBE SERVICES AND PROCEDURES PROVIDED. ENTER UP TO 8 CHARACTERS. IF CODE BEGINS WITH W, X, Y OR Z, ENTER A DESCRIPTION INSTEAD. A6b. What was the full established charge for this service, before any adjustments or discounts? 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 service? NOTE: WE NEVER ENTER $0 FOR A CHARGE IF SPECIFIC CHARGE WAS APPLIED TO ANOTHER SERVICE, ENTER -4 IF CHARGES ARE APPLIED TO ANOTHER LINKED EVENT, ENTER -5

CODE DESCRIPTION CHARGE

C2. [I show the total charges as OUT_TOTLCHRG / I show the charge as undetermined. / I show the charge as OUT_TOTLCHRG, although one or more charges are missing ] Is that correct? IF INCORRECT, CORRECT ENTRIES SHOWN ABOVE AS NEEDED

C2. [I show the total charges as ________ / I show the payment as undetermined. / I show the payment as __________, although one or more payments are missing ] Is that correct? IF INCORRECT, CORRECT ENTRIES SHOWN ABOVE AS NEEDED.

[Page 14 – PATIENT ACCOUNTS - SERVICES/CHARGES – OUTPATIENT/ER/OTHER (2 of 2)]

LC2 You reported just now that the charges are linked to another event. What was the date of that other event where the charges appear? LC3 And what kind of event was that, was it…

Inpatient 1 Hospital Outpatient Department. 2 Hospital Emergency Room 3 Long term care unit such as skilled nursing facility 4 Somewhere else? 5

SECTION 11 – PATIENT ACCOUNTS – SERVICES/CHARGES – INPATIENT/LTC

[Page 15 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (1 of 6)]

A8. According to Medical Records, (PATIENT NAME) was an inpatient during the period from [ADMIT DATE] to [DISCHARGE DATE]. What was the DRG for this stay? DRG IS A CODE USED TO CLASSIFY INPATIENT STAYS AND IT IS USUALLY ONE TO THREE DIGITS LONG.

DRG: DRG NOT RECORDED:……………………….1

[Page 16 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (2 of 6)]

A9. Did the patient have any surgical procedures during this stay?

YES=1, NO=2

[Page 17 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (3 of 6)]

A10a. What surgical procedures were performed during this stay? Please give me the procedure codes, that is the CPT-4 codes, if they are available. IF CPT-4 CODES ARE NOT USED, DESCRIBE SERVICES AND PROCEDURES PROVIDED. ENTER UP TO 8 CHARACTERS. IF CODE BEGINS WITH W, X, Y OR Z, ENTER A DESCRIPTION INSTEAD. IT IS ACCEPTABLE TO ENTER ICD9-CM CODES WITH FORMAT # #. # OR # #. # # FOR THIS QUESTION.

CODE DESCRIPTION

[Page 18 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (4 of 6)]

C2a. What was the full established charge for this inpatient stay, before any adjustments or discounts? Please do not include any emergency room charges. 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? NOTE: WE NEVER ENTER $0 FOR A CHARGE

FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:

[Page 19 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (5 of 6)]

C2b Were the emergency room charges included with the full established charge?

YES=1, NO=2

[Page 20 – PATIENT ACCOUNTS - SERVICES/CHARGES – INPATIENT/LTC (6 of 6)]

C2c [IF (A1) = 5] Were the ancillary charges included with the full established charge?

YES=1, NO=2

SECTION 12 – PATIENT ACCOUNTS – REIMBURSEMENT TYPE

[Page 21 – PATIENT ACCOUNTS - REIMBURSEMENT TYPE (1 of 1)]

C3. Was the facility reimbursed for (this visit/these visits/this 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. Capitated basis means that the patient was enrolled in a prepaid managed care plan where reimbursement is not tied to specific visits, this is also called Per Member Per Month. IF IN DOUBT, CODE FEE-FOR-SERVICE.

Fee-for-service basis =1 Capitated basis =2

SECTION 13 – PATIENT ACCOUNTS – SOURCES OF PAYMENT

[Page 22 – PATIENT ACCOUNTS - SOURCES OF PAYMENT (1 of 1)]

C4. From which of the following sources has the facility received payment for (this visit/these visits/this stay) and how much was paid by each source? Please include all payments that have taken place between (DATE) and now for this (visit/these visits). RECORD PAYMENTS FROM ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? [DCS ONLY] IF PROVIDER VOLUNTEERS THAT PATIENT PAYS A MONTHLY PREMIUM, VERIFY: So, you receive a monthly payment rather than payment for the specific service? IF YES: GO BACK TO C3 AND CODE AS CAPITATED BASIS. IF ANY OF THE PAYMENTS IS A LUMP SUM THAT IS NOT YET ALLOCATED, ENTER F8 IN THE APPROPRIATE FIELD(S).	SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?)	PAYMENT AMOUNT $ $ $ $ $ $ $ $
C5. [I show the total payment as ________ / I show the payment as undetermined. / I show the payment as __________, although one or more payments are missing ] Is that correct? / [THE TOTAL PAYMENT IS ________ . IS THAT CORRECT? IF NO, CORRECT ENTRIES ABOVE AS NEEDED.	TOTAL PAYMENTS	$

SECTION 14 – PATIENT ACCOUNTS – VERIFICATION OF PAYMENT

[Page 23 – PATIENT ACCOUNTS - VERIFICATION OF PAYMENT (1 of 1)]

C5a. I recorded that the payment(s) you received equal the charge(s). I would like to make sure that I have =2

this recorded correctly. I recorded that the total

payment is [TOTAL PAYMENT FROM C5].

Does this total payment include any other amounts such as adjustments or

discounts, or is this the final payment?

YES, FINAL PAYMENTS RECORDED IN C4 AND C5 =1 _

NO

IF NO, GO BACK AND CORRECT ENTRIES AS NEEDED.

SECTION 15 – PAYMENTS LESS THAN CHARGES (now UNDERPAYMENT)

[Page 24 – SOURCES OF PAYMENT (1 of 1)]

PLC1. It appears that the total payments were less than the total charge.  Is that because …

IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS.

a. There were adjustments or discounts          YES=1 NO=2    

b. You are expecting additional payment        YES=1 NO=2    

c. This was charity care or sliding scale    YES=1 NO=2     

d. This was bad debt                                 YES=1 NO=2     

ELIGVET2.

It appears that the total payments were less than the total charges. Is that because the person is an eligible veteran?

DCS:  IF THE POC IS CONFUSED BY THE QUESTION, ANSWER THE QUESTION “NO”

YES=1, NO=2

SECTION 16 – PATIENT ACCOUNTS – DIFFERENCE BETWEEN PAYMENTS AND CHARGES

[Page 25– PATIENT ACCOUNTS - DIFFERENCE BETWEEN PAYMENTS AND CHARGES (1 of 1)]

Are you expecting additional payment from: IF ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS Expecting additional payment i. Patient or Patient’s Family? YES=1, NO=2 j. Medicare? YES=1, NO=2 k. Medicaid? YES=1, NO=2 l. Private Insurance? YES=1, NO=2 m. VA/Champva? YES=1, NO=2 n. Tricare? YES=1, NO=2 o. Worker’s Comp? YES=1, NO=2 p. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?) C6p – “Other Specify”; Auto or Accident Insurance CHDP/CHIP Indian Health Service State Public Mental Plan State/County/Local Program Other ADJEXTRA It appears that the total payments were more than the total charges. Is that correct? DCS:  IF THE ANSWER IS “NO” PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED. YES=1, NO=2

SECTION 17 – LUMP SUM PAYMENTS

[Page 26 – lump sum payments (1 of 4)]

CHECK WAS THIS EVENT COVERED BY A LUMP SUM?

YES

NO

SECTION 18 – PATIENT ACCOUNTS – CAPITATED BASIS

[Page 30– PATIENT ACCOUNTS - CAPITATED BASIS (1 of 4)]

CAPITATED BASIS
C7a. What kind of insurance plan covered the patient for (this visit/these visits/this stay)? Was it: [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance? C7a(g) – “Other Specify”; Auto or Accident Insurance CHDP/CHIP Indian Health Service State Public Mental Plan State/County/Local Program Other	a. Medicare; YES=1, NO=2 b. Medicaid; YES=1, NO=2 c. Private Insurance; YES=1, NO=2 d. VA/Champva; YES=1, NO=2 e. Tricare; YES=1, NO=2 f. Worker’s Comp; or YES=1, NO=2 g. Something else? YES=1, NO=2 (IF SOMETHING ELSE: What was that?)
C7b. Was there a co-payment for (this visit/these visits/any part of this stay)?	YES=1, NO=2

[Page 31– PATIENT ACCOUNTS - CAPITATED BASIS (2 of 4)]

C7c. How much was the co-payment?

$

C7d. Who paid the co-payment? Was it:

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

C7d(e) – “Other Specify” menu

Auto or Accident Insurance

CHDP/CHIP

Indian Health Service

State Public Mental Plan

State/County/Local Program

Other

a. Patient or Patient’s Family; YES=1, NO=2

b. Medicare; YES=1, NO=2

c. Medicaid; YES=1, NO=2

d. Private Insurance; or YES=1, NO=2

e. Something else? YES=1, NO=2

(IF SOMETHING ELSE:

What was that?)

[Page 32– PATIENT ACCOUNTS - CAPITATED BASIS (3 of 4)]

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

YES=1, NO=2

[Page 33– PATIENT ACCOUNTS - CAPITATED BASIS (4 of 4)]

C7f. From which of the following other sources has the facility received payment for (this visit/these visits/this stay) and how much was paid by each source? Please include all payments that have taken place between (DATE) and now for this visit. RECORD PAYMENTS FROM ALL THAT APPLY [DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?

SOURCE a. Patient or Patient’s Family; b. Medicare; c. Medicaid; d. Private Insurance; e. VA/Champva; f. Tricare; g. Worker’s Comp; or h. Something else? (IF SOMETHING ELSE: What was that?)

PAYMENT AMOUNT $ $ $ $ $ $ $ $

(h) – “Other Specify” menu

Auto or Accident Insurance

CHDP/CHIP

Indian Health Service

State Public Mental Plan

State/County/Local Program

Other

SECTION 19 – FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.

Hospital Event Form Page 20 of 20