IPPS: High cost devices are used in many inpatient surgery cases. The Safe-Cross, radio frequency total occlusion crossing system, is such a device.

The Safe-Cross guidewire is present on the following claim. First, complete an inpatient payment calculation to determine whether this claim would qualify for a high cost outlier add-on payment. Second, calculate the total reimbursement for this claim, including the additional amount that the facility would receive for the high cost outlier if applicable. Does this facility have a profit or loss for this encounter?

The 2015 IPPS high-cost outlier threshold is $24,758; the hospital specific CCR is: 0.429; the hospital base rate is $6,200.00.

Inpatient Claim
Admit Date:	January 1, 2015	Discharge Date:	January 10, 2015	Length of Stay:	9 days
Principal Diagnosis*:	410.71	Subendocardial infarction, initial episode of care
Secondary Diagnosis:	414.01	Coronary atherosclerosis of native coronary artery
Secondary Diagnosis:	427.1	Paroxysmal ventricular tachycardia
Secondary Diagnosis:	272.0	Pure hypercholesterolemia
Principal Procedure:	00.66	Percutaneous transluminal coronary angioplasty
Secondary Procedure:	36.07	Insertion of drug-eluting coronary artery stent
Secondary Procedure:	39.29	Other vascular shunt or bypass
Secondary Procedure:	37.22	Left heart cardiac catheterization
MS-DRG: 246 RW: 3.2368	Percutaneous cardiovascular procedure with drug-eluting stent with major complication/comorbidity or 4+vessels/stents
*Diagnosis and procedures not converted to ICD-10-CM/PCS because service dates for this claim are prior to implementation of ICD-10-CM/PCS

Claim Detail
Revenue Code	Revenue Code Description	Charge
110	Room & board private	$8,375.00
120	Room & board semi private	$3,700.00
200	Intensive care general	$5,910.00
206	Intensive care intermediate ICU	$2,780.00
250	Pharmacy general	$1,486.66
255	Pharmacy drugs incident to radiology	$728.13
258	Pharmacy IV solutions	$1,583.60
259	Pharmacy other pharmacy	$7,766.18
270	Medical/surgical supplies general	$8,256.00
272	Medical/surgical supplies sterile supply	$8,366.25
272	The Safe-Cross guidewire	$15,000.00
278	Medical/surgical supplies other implants	$28,623.00
301	Laboratory chemistry	$2,739.00
302	Laboratory Immunology	$648.00
305	Laboratory Hematology	$2,335.00
323	Laboratory Arteriography	$2,491.00
360	Operating room general	$23,875.00
361	Operating room minor surgery	$517.00
370	Anesthesia - general	$209.00
390	Blood and blood component admin, process, storage - gen	$668.00
410	Respiratory services general	$21.00
420	Physical therapy - general	$314.00
430	Occupational therapy general	$441.00
480	Cardiology general	$5,629.00
481	Cardiology cardiac cath lab	$6,249.00
483	Cardiology - echocardiology	$1,786.00
710	Recovery room general	$1,648.00
730	EKG/ECG - general	$1,098.00
921	Other diagnostic services peripheral vascular lab	$359.00
TOTAL CHARGE:		$143,601.80

IPPS Outlier: If the cost of the case is greater than the fixed-loss cost threshold then an outlier add-on payment is warranted. The fixed-loss cost threshold equals the MS-DRG payment + the HC outlier threshold amount for the applicable year.

Outlier Add-on Amount is equal to 80% of the difference between the cost of the case and the fixed-loss cost threshold.

Outlier paid if: cost of claim > reimbursement of claim + threshold

Cost = charge * hospital specific cost to charge ratio

Cost =

Cost =

Claim reimbursement = MS-DRG relative weight * hospital base rate

Claim reimbursement = Claim reimbursement =

Outlier =

Outlier =

Does this claim qualify for a high cost outlier payment?

HC outlier payment = 80% * (cost (claim reimbursement + threshold))

HC outlier payment =

HC outlier payment =

HC outlier payment =

TOTAL reimbursement for claim = claim reimbursement + HC outlier payment

TOTAL reimbursement for claim =

TOTAL reimbursement for claim =

LOSS = Cost Total payment

LOSS =

Outlier payment reduces loss from $ ---------- to $ -----------