Form Approved
OMB Number 0935-0118
Expiration Date 12/31/2018
(Public reporting burden for this collection of information is estimated to average 5 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, 5600 Fishers Lane, Rockville, MD 20857.)
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
A1. WHAT WERE THE ADMIT AND DISCHARGE DATES OF THE (FIRST/NEXT) STAY?
A3. I need the diagnoses for this stay. I would prefer the ICD-9 or ICD-10 codes, or the DSM-4 codes, if they are available.
IF CODES ARE NOT USED, RECORD DESCRIPTIONS. RECORD UP TO FIVE ICD-9 OR ICD-10 CODES OR DESCRIPTIONS.
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 5 ICD-9 OR ICD-10 CODES TO BE COLLECTED.]
A2. I need to record the name and specialty of each physician who provided services during the stay starting on (ADMIT DATE) and whose charges might not be included in the facility bill. We are interested in physicians with whom your facility has contractual arrangements, not the patient's private physician.
PROBE FOR MORE THAN ONE RADIOLOGIST, ANESTHESIOLOGIST, ETC. OR OTHER SEPARATELY BILLING MEDICAL PROFESSIONAL.
IF RESPONDENT IS UNSURE WHETHER A PARTICULAR DOCTOR'S CHARGES ARE INCLUDED IN THE INSTITUTION BILL, RECORD YES HERE.
If A2 = 1, the system will automatically generate an SBD form at that time to be filled out with MR.
[IF A2=2, 3, or DK/REF/RETRIEVABLE – SKIP TO A4a
IF A2=YES, ASK EF1]
EF1. Can you please provide the full name of the (first/next) physician whose charges might not be included in the hospital bill?
EF3. What is this physician's specialty?
EF2. Did this doctor provide any of the following services for this event: radiology, anesthesiology, pathology, or surgery?
EF5. How would you describe the role of this doctor for this medical event?
EF6. ENTER ANY COMMENTS ABOUT THIS SBD INCLUDING ADDITIONAL SERVICE(S) TO THE ONE SELECTED IN EF2
SBDPR1: A diagnosis that you mentioned often involves a [FILL SPECIALTY] and we did not record such persons in the earlier questions about separately billing doctors. Do your records indicate that a [FILL SPECIALTY] was associated with this patient event?
YES=1
NO=2
IF SBDPR1=YES, RETURN USER TO A2
If SBDPR1=NO, ASK SBDPR3
SBDPR3: PROBE WHY THERE WAS NO SBD OF THE EXPECTED TYPES FOR THIS EVENT.
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.
I have information from Medical Records that (PATIENT NAME) received health care services (DATE).
NOTE: IF THE ONLY EVENT KNOWN BY PATIENT ACCOUNTS IS WITHIN A DAY OR TWO OF WHAT WAS REPORTED BY MEDICAL RECORDS, ANSWER YES BELOW.
[IF Intro = 2 or 3 THEN GO TO EXIT EVENT FORM.]
Q5. Was the facility reimbursed for this stay on a fee-for-service basis or capitated basis?
EXPLAIN IF NECESSARY:
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, such as an HMO, and reimbursement to the facility was not based on the services provided. This is also called Per Member Per Month
IF IN DOUBT, CODE FEE-FOR-SERVICE
Q6. What was the full established charge for room, board, and basic care for this stay, before any adjustments or discounts, between (ADMIT DATE) and (DISCHARGE DATE/END OF 2015)?
EXPLAIN IF NECESSARY: The full established charge is the charge maintained in the facility's master fee schedule for billing private pay patients. 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 in their records for purposes of budgeting or cost analysis. This kind of information is sometimes call a "charge equivalent". Could you give me the charge equivalent for this stay?
NOTE: WE NEVER ENTER $0 FOR A CHARGE
$________.____CHECKPOINT: HAVE YOU BEEN ABLE TO DETERMINE THE FULL ESTABLISHED CHARGE?
[If CHECKPOINT=1 go to Q7. If CHECKPOINT=2 go to Q10.]
Q7. From which of the following sources has the facility received payment for this charge and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS CAPITATED BASIS
Q8. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
PATIENT ACCOUNTS –– VERIFICATION OF PAYMENT
Q8a: I recorded that the payment(s) you received equal the charge(s). I would like to make sure that I have this recorded correctly. I recorded that the total payment is [SYSTEM WILL DISPLAY TOTAL PAYMENT FROM Q8]. Does this total payment include any other amounts such as adjustments or discounts, or is this the final payment?
IF NECESSARY, READ BACK AMOUNT(S) RECORDED IN Q7.
PLC1: It appears that the total payments were less than the total charge. Is that because...
Are you expecting additional payment from:
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER "NO" TO ALL OPTIONS
Expecting additional payment
ADJEXTRA
It appears that the total payments were more than the total charges. Is that correct?
Q10: Can you tell me what the facility's full established daily rate for room and board and basic care was during this stay?
[If Q10=1 go to Q11.
If Q10=2 go to Q12.]
Q11: This stay for [PATIENT] that we are discussing lasted [STAYDAYS.] For how many days was the patient charged during this stay? Please give only the days during 2015.
[IF RESPONDENT CAN'T PROVIDE TOTAL DAYS, GO TO Q12. ELSE GO TO Q11a.]
Q11a. From which of the following sources has the facility received payment for these charges and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS CAPITATED BASIS
Q11b. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] . Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
[If Q11b=1 go to Q14.
If Q11b=2 go to Q11a.
Q11a - DK/REF/RETRIEVABLE – CONTINUE TO Q11b.
Q11b - DK/REF/RETRIEVABLE – CONTINUE TO Q14.]
Q12. (Perhaps it would be easier if you gave me information about payments by billing period.) What was the billing start date?
Q12a. What was your billing end date?
Q12-1. BILLING PERIOD IS BETWEEN M#/ D#/ Y# and M#/D#/ Y# Thanks, that means there were (#) days in your billing period. Between (M#/ D#/ Y# and M#/D#/ Y#), how many days was the patient charged for room, board and basic care?
__________# BILLED DAYS[IF #BILLED DAYS IS LESS THAN TOTAL DAYS IN STAY from Q12 and Q12a, go to Q12-1a else go to Q12-2.]
Q12-1a. The number of days the patient was charged for room, board and basic care was (Q12-1) days and that is less than the number of days in the billing period, (TOTAL DAYS IN STAY). Do you know why?
__________________Q12-2. Between (M#/ D#/ Y# and M#/D#/ Y#), what was the private pay rate for room, board and basic care (PATIENT NAME) received? If the rate changed, please give me the initial rate.
$__________.____12-3. How many days was that rate applied during this billing period?
______________ # DAYS[Q12-3: If Q12-2 is less than Q12-3 go to Q12-Intro, else record Q12-2 in Q12-8 and continue to Q13.]
12-Intro. I see that the rate of (Q12-2) applied for (Q12-3) days, although your billing period was (Q12-1) long. I need to ask some questions to help account for the entire billing period.
12-2A. Between (M#/ D#/ Y# and M#/D#/ Y#), what other private pay rate applied to the basic care that (PATIENT NAME) received?
$__________.____12-3A. On what date did this rate of (12-2A) begin?
12-4A. During this billing period, how many days was that rate of (12-2A) applied?
# DAYS: ________12-5A. Why did the rate change? CODE ONLY ONE.
[Q12-5A: If [Q12-1] is more than [12-3 + 12-4a] ask Q12-2A to Q12-5A, else go to Q12-7. This means that we should administer Q12-A to Q12-5A until we "get up to" the end-of-billing period reported in Q12a.]
12-7. Is (RATE IN 12-2a) the private pay rate that applied at the end of the billing period?
[If Q12-7=1 skip to 12-9.
If Q12-7=2 continue to Q12-8 and record rate at end of billing period.]
12-8. What was the private pay rate that applied at the end of the billing period?
$______________._____Q13. From which of the following sources did the facility receive payments for this billing period and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS CAPITATED BASIS
Auto or Accident Insurance
Indian Health Service
State Public Mental Plan
State/County Local program
Other
Q13a. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing] IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS
[Q13 - DK/REF/RETRIEVABLE – CONTINUE TO Q13a
Q13a - DK/REF/RETRIEVABLE – CONTINUE TO Q14]
Q14. Did (PATIENT NAME) have any health-related ancillary charges for this stay? That is, were there charges for additional services not included in the basic rate?
[If Q14=1 go to Q15. If Q14=2 go to Q22.
Q14 - DK/REF/RETRIEVABLE – CONTINUE TO Q15]
Q15. What was the total of full established charges for health-related ancillary care during this stay? Please exclude charges for non-health related services such as television, beautician services, etc.
EXPLAIN IF NECESSARY: Ancillaries are facility charges that are not included in the basic charge. Ancillary charges may include laboratory, radiology, drugs and therapy (physical, speech, occupational).
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 total of the charge equivalents for health-related ancillary care during this stay?
Q16. From which of the following sources has the facility received payment for these charges and how much was paid by each source?
Please include all payments that have taken place between (ADMIT DATE) and now for this stay.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT REQUIRED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
Q17. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] Is that correct? IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS $__________.___Q17a: I recorded that the payment(s) you received equal the charges. I would like to make sure that I have this recorded correctly.
I recorded that the total payment is [SYSTEM WILL DISPLAY TOTAL PAYMENT FROM Q17]. Does this total payment include any other amounts such as adjustments or discounts,
or is this the final payment?
IF NECESSARY, READ BACK AMOUNT(S) RECORDED IN Q16.
PLC2: It appears that the total payments were less than the total charge. Is that because...
Are you expecting additional payment from:
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER "NO" TO ALL OPTIONS
Expecting additional payment
ADJEXTRA_2
It appears that the total payments were more than the total charges. Is that correct?
YES=1, NO=2
DCS: IF THE ANSWER IS “NO” PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED
Q19: Perhaps it would be easier if you gave me the information about ancillary charges by billing period.
Q20. From which of the following sources did the facility receive payments for ancillary charges for the billing period that began (BILLING PERIOD DATE) and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay. SELECT ALL THAT APPLY
Q20(h) – Menu for “Something else?”:
Q20a. [SYSTEM WILL GENERATE AFTER Q20 FOR EACH BILLING PERIOD IN Q19]
I show the total payment as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.[Q20a=NO RETURN USER TO Q20, ELSE CONTINUE TO FINISH.
[Q20a - DK/REF/RETRIEVABLE NOT ALLOWABLE.]
Q21a. What kind of insurance plan covered the patient for this stay? Was it:
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
Q21a(g) – Other Specify Menu:
Q21b. What was the monthly payment from that plan?
$___________._____Q21c. Was there a co-payment for (this visit/these visits/this stay)?
Q21d. How much was the co-payment?
Q21e. For how many (days/weeks/months/other) was the co-payment paid?
_______________#QC21f. 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?
Q21f(e) – Include the following options in a drop down menu for the “Other Specify”:
Q21g. Do your records show any other payments for this stay?
Q21h. From which of the following other sources has the facility received payment for this stay and how much was paid by each source? Please include all payments that have taken place between (ADMIT DATE) and now for this stay.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
21h (h) – Include the following options in a drop down menu for the “Other Specify”;
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.