Unit 6 Assignment 2
Referring to the above table, answer the following questions (responses for a-c should be 2-3 well developed paragraphs with each paragraphs having 5-7 sentences):
a. Which type of case has the lowest Total Relative Weight? Heart failure & shock w/o CC/MCC
b. Discuss each column on the table and the type of data it provides (be specific).
c. Select two of MS-DRG’s from the tables, identify 3-4 procedures which fall under this grouping.
d. 4. What is the common “theme” found in the procedures listed under each of your two selected MS-DRG’s?
e. The DRG relative weight is the average amount of resources it takes to treat a patient in that DRG. Using examples from the table, how would hospitals use this information when discussing reimbursement & resources?
2. Refer to your LaTour text, the sample calculation below, and Table W14.2 and Table W14.3 to answer the following questions.
Table W14.2. Sample 2014 RVUs for selected HCPCS Codes
HCPCS Code Description Work RVU Practice Expense RVU Malpractice Expense RVU
99203 Office Visit 1.23 0.48 0.09
99204 Office Visit 2.00 0.71 0.12
10080 I&D of pilonidal cyst, simple 1.17 1.11 0.11
45380 Colonoscopy with biopsy 4.43 1.73 0.35
52601 TURP, complete 12.35 5.1 0.87
Table W14.3. Sample GPCIs for selected U.S. Cities
City Work GPCI Practice Expense GPCI Malpractice Expense GPCI
St. Louis 1.000 0.946 0.941
Dallas 1.010 1.063 1.061
Seattle 1.010 1.115 0.819
Philadelphia 1.020 1.098 1.386
Sample Calculation
How much can a physician in St. Louis bill Medicare for an office visit for a new patient with a detailed history and physical and low-complexity medical decision making (assuming the patient has met any deductible for the year)? Answer: $59.96
Calculation: [RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF = Payment
Answer: $59.96
Calculation: Billing 99203 in St. Louis
1.23 x 1.000 = 1.23
0.48 × 0.946 = 0.45
0.09 × 0.941 = 0.08
Total = 1.76 × 34.0682 = $59.96
Using the formula above and the tables, answer the following questions. Make sure to show all of your calculations.
• In which city would a physician receive the highest reimbursement for a TURP (you must show name and calculations for correct city only)
• In which city would a physician receive the lowest reimbursement for a colonoscopy with biopsy (you must show name and calculation for correct city only)?
• Calculate the expected payment for an incision and drainage of a pilonidal cyst in each of the cities listed. Conversion Factor: $34.0682 (show calculations for ALL 4 cities)
