PART A
INSTRUCTIONS
Step 1: Click on this link to access the DRG Calculator https://www.tricare.mil/drgrates/
Step 2: Access the DRG calculator for FY2015 Discharges (revised Oct102014) click on the Payment calculator tab at the bottom of the worksheet.
To Determine the Tricare DRG payment, enter the following information in the yellow highlight fields
Billed Charges $250,000.00
Length of Stay 20
DRG 2
Discharge Status 01
# of interns & Residents 20
# of beds 150
Answer the following questions:
1. What is the amount of the cost outlier threshold? (round to reflect dollar amount)
2. What is the total payment amount?
Source: https://www.tricare.mil/tma/default.aspx
PART B
INSTRUCTIONS
You are assigned to perform the yearly office fee schedule update. Using the information provided, calculate the total fee for the E/M codes.
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CPT
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RVU (w)
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RVU (pe)
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RVU (m)
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GPCI (w)
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GPCI (pe)
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GPCI (m)
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CF
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Fee
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99201
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0.48
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0.57
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0.03
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1.009
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1.001
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1.110
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$36.8729
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|
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99202
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0.93
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0.88
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0.06
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1.009
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1.001
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1.110
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$36.8729
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|
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99203
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1.42
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1.19
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0.10
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1.009
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1.001
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1.110
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$36.8729
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|
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99204
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2.43
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1.61
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0.16
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1.009
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1.001
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1.110
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$36.8729
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|
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99205
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3.17
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1.91
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0.20
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1.009
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1.001
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1.110
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$36.8729
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PART C
INSTRUCTIONS
Using the partial chargemaster below, answer the following questions:
1. Patient A was having difficulty breathing. A chest radiograph, 2 views was ordered; identify the CPT Code, Revenue Code, and total charge for the procedure. _________________________
2. Which department is this chargemaster for? _______________________
3. What is the service description for CPT Code 74241?
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Good Medicine Hospital
123 Anywhere Street
Anywhere, NY 12345
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Depart: Radiology
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Date Printed: 07/25/YYYY
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Service Code
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Service Description
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CPT Code
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Revenue Code
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Charge
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RVU
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81500098
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Chest X-ray, single view
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71010
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0320
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73.95
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0.72
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81500099
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Chest X-ray, two views
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71020
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0320
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94.65
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0.93
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81500102
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Chest X-ray, special view (bucky)
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71035
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0320
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78.90
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0.77
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81500104
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Upper GI X-ray, with KUB
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74241
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0324
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353.50
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2.44
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PART D
INSTRUCTIONS
Use the following information to complete a CMS 1500 claim form.
1. Login in and access the Student Online Companion that accompanies the textbook.
2. Open SimClaim and use a blank CMS 1500 claim form and fill in the information.
3. Save the completed CMS 1500 claim form as Project2_PartD and submit the form along with the completed Parts A, B and C above to your instructor.
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Date of Service: 6/15/YYYY
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Patient ID: 789
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Patient Name: Tall, Man
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Primary Insurance Name: Aetna
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Physician name: Bo Peep
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Address: 120 Young Street
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Address: PO Box 1121
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Address: 456 Old St
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City/State: Anywhere, NY
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City/State: Medical, PA
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City/State: Fall, NY
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Zip: 12345
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Zip: 12357
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Zip: 12345
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DOB: 06/03/1955
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Plan ID: ZJW55544
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EIN: 331234567
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Phone: (123) 788-1245
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Group #: 650
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NPI: 3345678901
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Gender: Male
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Primary Policyholder: Tall, Man
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Phone: (123) 788-6666
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Status: Married
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Address: 120 Young Street
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Place of Service: 11
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Employed: Full-Time
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City/State: Anywhere, NY
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Diagnosis 1: Dyspnea
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Zip: 12345
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Diagnosis 2: Hypertension
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Policyholder DOB: 06/03/1955
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Services: 99213 $85.00
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Pt Relationship to Insured: Self
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Employer Name: Will Solve IT
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Work Related? No
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Auto Accident? No
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Other Accident? No
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