Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013
OMB
(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, 540 Gaither Road, Room # 5036, Rockville, MD 20850)
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
BILLING
Did you bill for the services provided in (PATIENT NAME)’s home during the calendar year 2011 by month, by 60-day period, or by week?
(IF SOME OTHER PERIOD: What was that?)
VISIT DATE
E1. During calendar year 2011, what (was the (first/next) month/were the begin and end dates of the (first/next) 60-day period/were the begin and end dates of the (first/next) OTHER PERIOD/were the begin and end dates of the (first/next) weekly period) during which your records show that services were provided in (PATIENT NAME)'s home?
REFERENCE PERIOD – CALENDAR YEAR 2011DIAGNOSES
E2. 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.
IF CODES ARE NOT USED, RECORD DESCRIPTIONS. RECORD UP TO FIVE ICD-9 CODES OR DESCRIPTIONS.
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 5 ICD-9 CODES TO BE COLLECTED
CONTINUE TO B5a.]
SERVICES/CHARGES
E3. I need to know which types of home care personnel provided care to (PATIENT NAME) (during (MONTH)/from (BEGIN DATE) through (END DATE)) and either the number of hours or the number of visits for each type.
SELECT ALL THAT APPLY
EXPLAIN IF NECESSARY: By type of person I mean a housekeeper, therapist, nurse aide, yard worker, and so forth.
E4. I need the services provided (during (MONTH)/from (BEGIN DATE) through (END DATE)). I would prefer either the CPT-4 codes or the revenue codes, if they are available.
RECORD CPT-4 CODE OR REVENUE CODE. IF CODES ARE NOT USED, RECORD DESCRIPTION OF SERVICES AND PROCEDURES PROVIDED.
IF ENTERING A CPT-4 CODE, ENTER UP TO 8 CHARACTERS. IF CPT-4 CODE BEGINS WITH W, X, Y OR Z, ENTER A DESCRIPTION INSTEAD.
C1a. Could you tell me the full established charges -- before any adjustments or discounts -- for all services provided by home care personnel (during (MONTH)/from (BEGIN DATE) through (END DATE)).
EXPLAIN IF NECESSARY: This would be the charges for the (READ TYPES OF PERSONNEL FROM E3 ABOVE) who provided services (during (MONTH)/from (BEGIN DATE) through (END DATE)).
EXPLAIN IF NECESSARY: The full established charge is the charge maintained in the organization’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 organizations that don’t charge on the basis of services provided 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?
NOTE: WE NEVER ENTER $0 FOR A CHARGE
$________.____
C1b. And could you tell me the full established charges for everything other than personnel services (during (MONTH)/from (BEGIN DATE) through (END DATE)), including durable medical equipment, drugs, supplies, and so forth?
EXPLAIN IF NECESSARY: This would include charges for anything other than the services of the home care personnel you just told me about.
IF THOSE COSTS WERE INCLUDED IN PERSONNEL CHARGES, RECORD 0.00 AND CHECK THE BOX.
NOTE: WE NEVER ENTER $0 FOR A CHARGE
C2. I show the total of all of the full, established charges for (PATIENT NAME) AS [SYSTEM WILL COMPUTE AND DISPLAY TOTAL] / I show the charge as undetermined. / I show the charge as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL], although one or more charges are missing. Is that correct?
[If C1a is DK/REF/RETRIEVABLE – CONTINUE TO C1b.
If C1b is DK/REF/RETRIEVABLE – CONTINUE TO C2.]
REIMBURSEMENT TYPE
C3. Was your organization reimbursed for the charges (during (MONTH)/from (BEGIN DATE) through (END DATE)) on a fee-for-service basis or a 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 where reimbursement is not tied to specific visits.
IF IN DOUBT, CODE FEE-FOR-SERVICE
SOURCES OF PAYMENT
C4. From which of the following sources did your organization receive payment for the charges (for (MONTH)/from (BEGIN DATE) through (END DATE)) and how much was paid by each source? Please include all payments that have taken place between (MONTH/BEGIN DATE) and now for this care.
[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 SET DOLLAR AMOUNT FOR ALL CHARGES (DURING (MONTH)/FROM (BEGIN DATE) THROUGH (END DATE)), VERIFY: So, you receive a set dollar amount for all charges (for (MONTH)/from (BEGIN DATE) through (END DATE)) rather than payment for the specific service? IF YES: GO BACK TO C3 AND CODE AS CAPITATED BASIS.
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” BELOW.
C5. I show the total of all payments received for (MONTH) / (BEGIN DATE) through (END DATE)) as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
[If C4 is DK/REF/RETRIEVABLE – CONTINUE TO C5.
If C5 is DK/REF/RETRIEVABLE – CONTINUE TO BOX 1.]
BOX 1
DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?
VERIFICATION OF PAYMENT
C5a. 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 C5]. 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 C4.
PAYMENTS LESS THAN CHARGES
PLC1. It appears that the total payments were less than the total charge. Is that because...
[If [a=1 and b=1 ] or [a=2 and b=2 and c=2 and d=2] then show both C6_adjustments and C6_additional.
If both c=1 and d=1 with no other selection, show neither C6_adjustments or C6_additional.
If both c=1 or d=1 with no other selection, show neither C6_adjustments or C6_additional.]
DIFFERENCE BETWEEN PAYMENTS AND CHARGES
C6. It appears that the total payments were (less than/more than) the total charges. What is the reason for that difference? Please include all adjustment activity that has taken place between (VISIT DATE) and now for (this visit/these visits). Was it a:
C6_adjustments
PAYMENTS LESS THAN CHARGES:
Adjustment or discount
C6_additional
Expecting additional payment
Q6_extra
PAYMENTS MORE THAN CHARGES:
[After C6 - GO TO LUMP SUM PAYMENT QUESTION]
LUMP SUM PAYMENTS
LSPCHECK WAS ANY LUMP SUM ASSOCIATED WITH THE SOURCES OF PAYMENT?
[GO TO FINISH.]
CAPITATED BASIS
C7a. What kind of insurance plan covered the patient (for (MONTH)/from (BEGIN DATE) through (END DATE))? Was it:
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
C7b. Was there a co-payment for any of the services provided (for (MONTH)/from (BEGIN DATE) through (END DATE))?
[If C7a is DK/REF/RETRIEVABLE – CONTINUE TO C7b.
If C7b is DK/REF/RETRIEVABLE – GO TO C7e.]
C7c. What was the total of all co-payments (for (MONTH) /from(BEGIN DATE) through (END DATE))?
$___________._____
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?
If C7c is DK/REF/RETRIEVABLE – CONTINUE TO C7d.
If C7d is DK/REF/RETRIEVABLE – CONTINUE TO C7e.]
C7e. Do your records show any other payments for any of the services provided (for (MONTH)/from (BEGIN DATE) through (END DATE))?
[If DK/REF/RETRIEVABLE – GO TO FINISH.]
C7f. From which of the following other sources has the practice received payment for (this visit/these visits) and how much was paid by each source? Please include all payments that have taken place between (MONTH/BEGIN DATE) and now for this care. Was it:
RECORD PAYMENTS FROM APPLICABLE PAYERS.
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[If DK/REF/RETRIEVABLE – CONTINUE TO FINISH.]
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.