Exercise 1 - Jane Doe is an 83-year-old patient who only has Medicare Part A insurance. After reviewing the following information, answer the questions regarding her listed hospitalizations.
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DATE ADMITTED
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DATE DISCHARGED
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PATIENT'S FINANCIAL RESPONSIBILITY
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01/01
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01/13
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$912.00
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03/20
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03/30
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$912.00
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07/04
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11/02
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$21,888 ($912 + 6,840 + 14, 136)
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12/01
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12/05
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$2,280
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a. How many benefit periods were used during this calendar year?
b. Were any lifetime reserve days used during this period of time? If so, how many?
c. If lifetime reserve days were used, how many does the patient have left to be used at a later date?
d. How many times was the patient required to pay a hospital deductible during this time period?
e. Following this last hospital admission, Jane was transferred to a skilled nursing facility (SNF) and remained there for continued treatment for 22 days.
i. How much was Jane required to pay for her SNF care for days 1-20?
ii. How much was she required to pay for the remainder of her SNF stay if the copay is $114?
f. After Jane's discharge from the skilled facility, she received home health care as prescribed by her physician for 14 days. During this time period, she met all Medicare's medical necessity criteria for her care. How much did the patient have to pay for her home health care?
Exercise 2 - Use the tables below to answer the following questions. The first portion of part b "St. Louis" has been completed for you.
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Table 6.7 Sample 2011 RVUs for selected HCPCS codes
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HCPCS Code
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Description
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Work RVU
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Facility Practice Expense RVU
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Malpractice Expense RVU
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99203
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Office visit
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1.42
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.72
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.14
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99204
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Office visit
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2.43
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1.21
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.23
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11010
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Debridement skin at fracture site
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4.19
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3.49
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.76
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45380
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Colonoscopy with biopsy
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4.43
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2.73
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.67
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52601
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TURP, complete
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15.26
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8.09
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1.49
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Table - Sample GPCIs for selected U.S. cities
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City
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Work GPCI
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Practice Expense GPCI
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Malpractice Expense GPCI
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St. Louis
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.99163
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.939923
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1.05944
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Dallas
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1.0113
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.99943
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.82543311
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Spokane
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.98989
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.932469
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1.670886
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The national conversion factor for 2011 is $33.9764.
a. How much can a physician in St. Louis bill Medicare for an office visit (99203) 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)?
Fee Schedules by Provider Type
Fill in the blanks with the correct dollar amounts as indicated
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PAR Provider
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Physician's fee
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$180.00
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MFS
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$105.00
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Medicare pays 80% of MFS or
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_____________
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Patient pays 20% of MFS or
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_____________
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Physician write-off
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_____________
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Non PAR accepts assignment
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Physician's fee
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$180.00
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MFS
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$105.00
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Medicare NonPAR fee (95% of MFS)
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_____________
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Medicare pays 80% of nonPAR fee
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_____________
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Patient pays 20% of nonPAR fee
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_____________
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Physician write-off
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_____________
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