(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. The (first/next) time (PATIENT NAME) received services during calendar year 2016, were the services received:
CODE ONLY ONE
IF INPATIENT: WHAT WAS THE INPATIENT VENUE?
[IF A1=1 or 5 GO TO A2a,
IF A1 =2 or 3 or 4 GO TO A2c]
A2a. What were the admit and discharge dates of the inpatient stay?
IF A2a = NOT YET DISCHARGED, CODE DISCHARGE AS 99/99/9999
A2b. Was (PATIENT NAME) admitted from the emergency room?
IF A2b = 2 go to A3, OTHERWISE CONTINUE TO A2c
A2c. What was the date of this visit?
DK/REF/RETRIEVABLE – CONTINUE TO A3
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, ANESTHESIOLOGISTS, 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.
[IF A3=NO, DK/REF/RETRIEVABLE – SKIP TO A4a
IF A3=YES, ASK EF1]
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
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
A4a. I need the diagnoses for (this stay/this visit). 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.
DK/REF/RETRIEVABLE – CONTINUE TO A4c
SBDPR1:A diagnosis that you mentioned often involves a (FILL SPECIALTY). We did not record such persons in the earlier questions about separately billing doctors. Did you not mention them for this patient event because they were residents or interns?
IF SPECIALTY RECORDED IN COMMENTS, ANSWER “NO” HERE.
SBDPR2:Do your records indicate that a (FILL SPECIALTY) was associated with this patient event?
IF SPECIALTY RECORDED IN COMMENTS, ANSWER “NO” HERE.
SBDPR3:PROBE WHY THERE WAS NO SBD OF THE EXPECTED TYPES FOR THIS EVENT
IF SPECIALTY RECORDED IN COMMENTS, NOTE THAT HERE.
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.
PA_Intro I have information from Medical Records that (PATIENT NAME) received health care services on (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.
[IF PA_Intro = 1 AND A1 = 2, 3, or 4 CONTINUE WITH A5a.
IF PA_Intro = 1 AND A1 = 1 or 5 GO TO A8.
IF PA_Intro = 2 THEN GO TO EXIT EVENT FORM.]
A5a. Was the visit on (VISIT 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.
A5b. Did the global fee for this date cover any services received while the patient was an inpatient?
A5c. What were the admit and discharge dates of that stay?
A5c1. Were there any other dates on which services were covered by this global fee?
A5d. What were the other dates on which services covered by this global fee were provided? Please include dates before or after 2016 if they were included in the global fee.
Did (PATIENT NAME) receive services on this date in an:
A5e. Do you expect (PATIENT NAME) will receive any future services that will be covered by this same global fee?
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?
A5c1 – “NO” GO TO A5e
DK/REF/RETRIEVABLE NOT ALLOWED
A5d - [SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT ON NUMBER OF DATES REQUIRED]
A5d - DK/REF/RETRIEVABLE – CONTINUE TO A5e
A5e - DK/REF/RETRIEVABLE – IF MODE=ABS THEN CONTINUE TO A5f. IF MODE=DCS GO TO C2a.
A5f –This question should only appear when mode=abs.
[IF A5f = 1, GO TO A3. IF A5f = 2, DK/RF/RETRIEVABLE GO TO A6A]
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.
[If A6a is DK/REF/RETRIEVABLE – CONTINUE TO A6b.]
A6b. What was the full established charge for this service, before any adjustments or discounts?
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
[If A6b is DK/REF/RETRIEVABLE – CONTINUE TO C2.]
C2. I show the total charges 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?
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...
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.
[If A8 is answered, GO TO C2a. If NODRG (A8=1) GO TO A9. DK/REF/RETRIEVABLE – CONTINUE TO A9.]
A9. Did the patient have any surgical procedures during this stay?
[If A9 = 2 GO TO C2a. If A9 is DK/REF/RETRIEVABLE – GO TO C2a]
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 ICD10-CM CODES WITH FORMAT # #. # OR # #. # # FOR THIS QUESTION.
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?
IF POSSIBLE, RECORD ONLY INPATIENT CHARGE HERE. IF YOU CANNOT SEPARATE THE INPATIENT CHARGE FROM THE EMERGENCY ROOM, YOU MAY REPORT THE COMBINED TOTAL.
NOTE: WE NEVER ENTER $0 FOR A CHARGE
FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:
$________.____C2b. [IF ADMITTED FROM ER, ASK FOLLOWING QUESTION] Were the emergency room charges included with the full established charge?
C2c. [IF LONG TERM CARE, ASK FOLLOWING QUESTION] Were the ancillary charges included with the full established charge?
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 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
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 (VISIT 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).
[If C4 is DK/REF/RETRIEVABLE – CONTINUE TO C5]
C5. [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.
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.
IF NO, GO BACK AND CORRECT ENTRIES AS NEEDED.
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.
C6_additional
Are you expecting additional payment from:
IF 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?
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
LSPCHECK
WAS ANY LUMP SUM ASSOCIATED WITH THE SOURCES OF PAYMENT?
[GO TO FINISH]
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?
[If C7a is DK/REF/RETRIEVABLE – CONTINUE TO C7b]
C7b. Was there a co-payment for (this visit/these visits/this stay)?
C7c. How much was the co-payment?
$___________._____[If C7b is DK/REF/RETRIEVABLE – CONTINUE TO C7d]
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 (this visit/these visits/this stay)?
C7f. From which of the following other sources has the practice received payment for (this visit/these visits/ this stay) and how much was paid by each source? Please include all adjustment activity that has taken place between (VISIT 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?
[If A1 = 2, 3, or 4 GO TO BOX 3. If A1 = 1 or 5 GO TO FINISH SCREEN.]
If DK/REF/RETRIEVABLE – CONTINUE TO BOX 2.]
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.