According to CMS a Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined fixed amount. The payment amount for a

Part I. MS-DRG Payment Determination
According to CMS a Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined fixed amount. The payment amount for a particular service is derived based on the classification system of that service – for example, diagnoses-related groups for inpatient hospital services.
Case Scenario: Your are the HIM Director in your facility. Administration wants to know the estimated MS-DRG payment for several MS-DRGs. The grouper on your system has crashed. Administration needs this information immediately, so you need to calculate the MS-DRG payment manually. The add-on percentage for your facility is 1.03%. The hospital’s base rate is $6,321.67. The MS-DRGs that administration is concerned about are shown in Table 1.
Deliverable: Use Table 1. To enter the relative weight from Table 2 and calculate the estimated payment.
CAHIIM III.C.2, Blooms Level 3 – Apply
Table 1. Medicare-Severity Diagnosis-Related Groups (MS-DRGs) with Relative Weight and Estimated Payment
MS-DRG with Relative Weight and Estimated Payment
MS-DRG
MS-DRG Title
Relative Weight
Estimated Payment
190
Chronic Obstructive Pulmonary Disease without MCC
193
Simple Pneumonia & Pleurisy with MCC
231
Coronary Bypass with PTCA with MCC
281
Acute Myocardial Infarction Discharged Alive with CC
304
Hypertension with MCC
334
Rectal Resection without MCC/CC
374
Digestive Malignancy with MCC
389
GI Obstruction with CC
472
Cervical Spinal Fusion with CC
509
Arthroscopy
Table 2. MS-DRG
MS-DRG
MS-DRG Title
Relative Weight
190
Chronic Obstructive Pulmonary Disease without MCC
1.1924
193
Simple Pneumonia & Pleurisy with MCC
1,4796
231
Coronary Bypass with PTCA with MCC
7,8582
281
Acute Myocardial Infarction Discharged Alive with CC
1,1912
304
Hypertension with MCC
1,0263
334
Rectal Resection without MCC/CC
1,6267
374
Digestive Malignancy with MCC
2,0674
389
GI Obstruction with CC
0,9344
472
Cervical Spinal Fusion with CC
2,7722
509
Arthroscopy
2,7722
Part II (5 pts)
List and describe the steps of MS-DRG Assignment.
What are the four domains used in the Hospital Value-Based Purchasing Program?
Discuss the importance of the present on admission (POA) data element in the HAC POA program.
One of the two domains in the HAC reduction program tracks healthcare associated infections (HAI). Name two measures used in this domain.
List a focus area of the Hospital Readmissions Reduction Program (HRRP).

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