MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
EVENT FORM
FOR
HOME CARE - HEALTH CARE PROVIDERS
FOR
REFERENCE YEAR 2016

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, 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

BILLING

Did you bill for the services provided in (PATIENT NAME)’s home during 2016 by month, or by 60-day period?
Was it:

BY MONTH = 1
BY 60-DAY PERIOD = 2
BY SOME OTHER PERIOD?
(USE THIS RESPONSE ONLY IF PROVIDER ABSOLUTELY CANNOT CALCULATE COSTS BY MONTH) = 3

(IF SOME OTHER PERIOD: What was that?)

DK/REF/RETRIEVABLE – CONTINUE TO E1

VISIT DATE

E1. During calendar year 2016, 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 2016

MONTH:
Month:_____
Day:________
Year:_______
OR

BEGIN DATE:
Month:_____
Day:________
Year:_______
END DATE:
Month:_____
Day:________
Year:_______

DK/REF/RETRIEVABLE – CONTINUE TO E2

DIAGNOSES

E2. I need the diagnoses for (this visit/these visits). I would prefer the ICD-10 codes or the DSM-5 codes, if they are available.

IF CODES ARE NOT USED, RECORD DESCRIPTIONS. RECORD UP TO FIVE ICD-10 CODES OR DESCRIPTIONS.

ICD-10 CODE_________________ DESCRIPTION:_________________

[SYSTEM WILL ALLOW FOR A MAXIMUM OF 5 ICD-10 TO BE COLLECTED]

Any more Diagnoses?
1. YES
2. NO

DK/REF/RETRIEVABLE – CONTINUE TO E3

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.

  1. HOME HEALTH AIDE

    HOURS/MINUTES_____ OR VISITS_____

  2. HOMEMAKER

    HOURS/MINUTES_____ OR VISITS_____

  3. I.V./INFUSION THERAPIST

    HOURS/MINUTES_____ OR VISITS_____

  4. NURSE/ NURSE PRACTITIONER

    HOURS/MINUTES_____ OR VISITS_____

  5. NURSE’S AIDE

    HOURS/MINUTES_____ OR VISITS_____

  6. OCCUPATIONAL THERAPIST

    HOURS/MINUTES_____ OR VISITS_____

  7. PERSONAL CARE ATTENDANT

    HOURS/MINUTES_____ OR VISITS_____

  8. PHYSICAL THERAPIST

    HOURS/MINUTES_____ OR VISITS_____

  9. RESPIRATORY THERAPIST

    HOURS/MINUTES_____ OR VISITS_____

  10. SOCIAL WORKER

    HOURS/MINUTES_____ OR VISITS_____

  11. SPEECH THERAPIST

    HOURS/MINUTES_____ OR VISITS_____

  12. YARD WORKER

    HOURS/MINUTES_____ OR VISITS_____

  13. DRIVER

    HOURS/MINUTES_____ OR VISITS_____

  14. BABYSITTER

    HOURS/MINUTES_____ OR VISITS_____

  15. Any other home care personnel?

    YES = 1
    NO = 2

  16. DURABLE MEDICAL EQUIPMENT?

    YES = 1
    NO = 2

_______ CHECK HERE IF CURRENT BILLING PERIOD PROVIDED JUST DURABLE MEDICAL EQUIPMENT

E3 - DK/REF/RETRIEVABLE – CONTINUE TO E4

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.

CPT-4 CODE:_______ REVENUE CODE: _____________ DESCRIPTION:_____________
CPT-4 CODE:_______ REVENUE CODE: _____________ DESCRIPTION:_____________
CPT-4 CODE:_______ REVENUE CODE: _____________ DESCRIPTION:_____________
CPT-4 CODE:_______ REVENUE CODE: _____________ DESCRIPTION:_____________

Any more Services?
1. YES
2. NO

DK/REF/RETRIEVABLE – CONTINUE TO C1a

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

FULL ESTABLISHED CHARGES FOR: PERSONNEL SERVICES: $________.____

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 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 everything other than personnel services, including durable medical equipment, drugs, supplies, and so forth?

IF THOSE COSTS WERE INCLUDED IN PERSONNEL CHARGES, RECORD 0.00 AND CHECK THE BOX.

ALL OTHER CHARGES: $________.____

___ CHECK HERE IF INCLUDED WITH PERSONNEL CHARGES

C2. I show the total of all of the full, established charges for (PATIENT NAME) (during (MONTH)/from (BEGIN DATE) through (END DATE)) as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?

[C1a - DK/REF/RETRIEVABLE – CONTINUE TO C1b
C1b - DK/REF/RETRIEVABLE – CONTINUE TO C2
C2 - DK/REF/RETRIEVABLE – CONTINUE TO C3]

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; this is also called Per Member Per Month.

IF IN DOUBT, CODE FEE-FOR-SERVICE

Fee-for-service basis = 1
Capitated basis = 2 (GO TO C7a)

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.

  1. Patient or Patient’s Family .... $__________.____
  2. Medicare ............................... $__________.____
  3. Medicaid ................................ $__________.____
  4. Private Insurance ................... $__________.____
  5. VA/Champva ......................... $__________.____
  6. Tricare .................................... $__________.____
  7. Worker’s Comp; ..................... $__________.____
  8. Or something else? ................. $__________.____
    (IF SOMETHING ELSE: What was that? __________)

Any more sources?
1. YES
2. NO

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 NO, CORRECT ENTRIES ABOVE AS NEEDED.

YES=1, NO=2

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.

YES, FINAL PAYMENTS RECORDED IN C4 AND C5 = 1 (GO TO LUMP SUM PAYMENT QUESTION)
NO = 2 (GO BACK TO C4a)

PAYMENTS LESS THAN CHARGES

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.

  1. There were adjustments or discounts ..... YES=1 NO=2
  2. You are expecting additional payment .... YES=1 NO=2
  3. This was charity care or sliding scale ..... YES=1 NO=2
  4. This was bad debt ................................ YES=1 NO=2
  5. Person is an eligible veteran................... YES=1 NO=2

DIFFERENCE BETWEEN PAYMENTS AND CHARGES

Are you expecting additional payment from:
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS

C6_additional
Expecting additional payment

  1. Patient or Patient’s Family? ................... YES=1 NO=2
  2. Medicare? ........................................... YES=1 NO=2
  3. Medicaid? ............................................ YES=1 NO=2
  4. Private Insurance? ............................... YES=1 NO=2
  5. VA/Champva? ..................................... YES=1 NO=2
  6. Tricare? .............................................. YES=1 NO=2
  7. Worker’s Comp? ................................. YES=1 NO=2
  8. Something else ................................... YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

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

LUMP SUM PAYMENTS

LSPCHECK WAS THIS EVENT COVERED BY A LUMP SUM?


DK/REF/RET ALLOWABLE and SKIP TO END OF EVENT FORM

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?

OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.

  1. Medicare? ...................................... YES=1 NO=2
  2. Medicaid? .......................................YES=1 NO=2
  3. Private Insurance? ......................... YES=1 NO=2
  4. VA?Champva? ............................... YES=1 NO=2
  5. Tricare? .......................................... YES=1 NO=2
  6. Worker’s Comp? ............................ YES=1 NO=2
  7. Something else? .................................. YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

C7b. Was there a co-payment for any of the services provided (for (MONTH)/from (BEGIN DATE) through (END DATE))?

C7b - [IF C7b=2 GO TO C7e]
C7a - DK/REF/RETRIEVABLE – CONTINUE TO C7b
C7b - 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?

  1. Patient or Patient’s Family? ................... YES=1 NO=2
  2. Medicare? ........................................... YES=1 NO=2
  3. Medicaid? ............................................ YES=1 NO=2
  4. Private Insurance? ............................... YES=1 NO=2
  5. Something else ................................... YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

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?

  1. Patient or Patient’s Family ....... $__________.____
  2. Medicare ............................... $__________.____
  3. Medicaid ................................ $__________.____
  4. Private Insurance ................... $__________.____
  5. VA/Champva ......................... $__________.____
  6. Tricare .................................. $__________.____
  7. Worker’s Comp; ..................... $__________.____
  8. Or something else? ................. $__________.____
    (IF SOMETHING ELSE: What was that? __________)
Any more sources?
  1. YES
  2. NO

[If DK/REF/RETRIEVABLE – CONTINUE TO FINISH.]

FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.