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Medicare Reimbursement And Case Mix

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Medicare Reimbursement And Case Mix
Jessica McGowan
HIM 2330 – Shaw
July 2, 2014

Reimbursement Assignment and Case Mix

Case #1
Female 66yo 01-Home
ICD-9-CM Code
Code Description
Principal Diagnosis
682.7
Cellulitis, left foot
Secondary Diagnosis
892.1
Infected dog bite 041.10
Staph infection E906.0
External cause: dog bite
Principal Procedure
86.22
Wound debridement, foot
Total Charges $6,245.10
DRG: 0572, SKIN DEBRIDEMENT W/O CC/MCC
DRG Wt. 01.0077____
Full Update Hospital Reimbursement___$5,064.79__________
Reduced Update Hospital Reimbursement__$4,762.49___________
Medicare Assigned DRG : 0572, SKIN DEBRIDEMENT W/O CC/MCC
MDC : 09, DRG Weight = 01.0077, GLOS = 003.8, ALOS = 004.6
Estimated Medicare Reimbursement = $5,411.63
Grouper Version Used: 31-10/13
Full Update Hospital : 01.0077 x $5,026.09 = $5,064.79
Reduced Update Hospital: 01.0077x$4,726.10 = $4,762.49

Case #2
Male 72yo 01-Home
ICD-9-CM Code
Code Description
Principal Diagnosis
491.21
Acute exacerbation of COPD
Secondary Diagnosis
428.0
Congestive Heart Failure 790.29
Borderline Diabetes Mellitus 401.9
Hypertension

414.00
Arteriosclerotic Heart Disease
Principal Procedure
None

Total Charges $3,794.25
DRG _0192, CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC ___________
DRG Wt. __00.7120____
Full Update Hospital Reimbursement__$3,578.58____
Reduced Update Hospital Reimbursement__$3,364.98___
Medicare Assigned DRG : 0192, CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC
MDC : 04, DRG Weight = 00.7120, GLOS = 002.8, ALOS = 003.3
Estimated Medicare Reimbursement = $3,823.64
Grouper Version Used: 31-10/13
Full Update Hospital : 00.7120 x $5,026.09 = $3,578.58
Reduced Update Hospital: 00.7120 x $4,726.10 = $3,364.98

Case #3
Female 69yo 01-Home
ICD-9-CM Code
Code Description
Principal Diagnosis
161.1
Squamous cell carcinoma, supraglottic larynx
Secondary Diagnosis
592.0
Nephrolithiasis 531.90
Gastric ulcer 599.70
Hematuria
Principal Procedure
30.4
Total laryngectomy with radical neck dissection
Secondary Procedure
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