Question: IPPS: High cost devices are used in many inpatient... 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 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 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 $ -----------