Case Mix Management

g
CMI usage and calculations
By: Deborah Balentine M.Ed, RHIA, CCS-P

What is a Case-Mix?

Age
Gender
Type of Insurance
Diagnosis
Risk Factors
Treatments received
Resources used

Purposes
To determine reimbursement.
DRGs
APCS
MPFS

To describe a population being served.

To identify differences in practice patterns
or coding complexity.

Severity of Illness Classifications

Extent of the disease
Risk of mortality
Need for intervention
Urgency of care
y of resources
Intensity
Difficulty of treatment

Severity of Illness Classfications

Adjusted Clinical Groups
National Association of Childrens
Hospital and Related Institutions
NACHRI
(________)
Medical Outcomes Study Short Form
Health Survey
Atlas System

Diagnostic/Procedural/Severity
Classifications
RUGs
Resource Utilization Groups (_____)

Functional Related Group System

IRFPPS
(______)
H
Home Health
H lth Resource
R
G
Grouping
i
HHPPS
System (______)

Risk Adjustment
Age
g and g
gender adjustments
j
Clinical risk adjustments
Situation-specific adjustments
Adjustments for specific clinical
conditions
Adjustments by specialty type

Case-Mix Index (four components)

Classification by disease conditions and/or procedures
____________________________
Comparison to other facilities
____________________________
Determines patterns of resource use
____________________________

____________________________
Used to determine anticipated reimbursement

Factors that influence Case-Mix

Services
Changes in ___________
Relative weights
Changes in ____________

________
in Documentation and
Accuracy
Coding
Accuracy in DRG/APC assignment

Calculating Case-Mix Indexes

Calculating
g Total CMS Relative Weight
g
Calculating Case Mix Index
Calculating Medicare Payment
Determining the Highest Relative
W i ht
Weight

Calculating Case-Mix Index

Services to be measured
Relative Weight
# of Cases

Case Mix Formulas

Calculating Total CMS Relative
Weights
Calculating Medicare/Third-Party
Payment
Calculating Case-Mix Index
Determining the Highest Relative
Weight for a group of cases

Calculating Total CMS Relative

Weight
Formula: Multiply the CMS Relative
Weight by the total number of cases
(patients) in the DRG group

Example One
A facility has 29 Medicare cases that are
assigned to DRG 69 which has a
relative weight of 1.0005. What is the
Total Relative Weight
g for the cases?

Answer
______________
(answer)
29.0145
__________________
1.0005 x 29
(show calculation)

Example Two
A facility has 15 Medicare cases that are
assigned to DRG 117 which has a
relative weight of 0.7789. What is the
Total Relative Weight for all of the
cases?

Answer
______________
(answer)
11.6835
__________________
0.7789 x 15
(show calculation)

Calculating Medicare Payment

Formula: Multiply the reimbursement
per case by the number of cases
performed

Example Three
A facility has 22 Medicare cases which
are reimbursed at $6,175 per case.
What is the total Medicare
reimbursement
i b
t ffor all
ll off th
the cases?
?

Answer
______________
(answer)
$135,850.00
6,175 x 22
__________________
(show calculation)

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Example Four
A facility has 59 Medicare cases that are
assigned to DRG 175 which has a
relative weight of 0.9557.
If the hospital PPS rate is $4,200, what
is the total reimbursement for all of
the cases?

Answer
$236,822.46
________

(answer)
Step One: Calculate the reimbursement
per case
____________________(calculation)
0.9557
x $4,200 (PPS rate) = $4,013.94
Step Two: Multiply by the number of
cases
$4,013.94 x 59 = $236,822.46
____________________(calculation)

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Calculating Case Mix Index

Formula: The total number of CMS
Relative Weights divided by the total
number of patients served.

Example Five
The top ten DRG surgical procedures
performed by a facility have a total
CMS Relative Weight of 45.8775.
If the total number of patients served is
29 what is the Case
29,
Case-Mix
Mix Index for
the facility?

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Answer
1.5819
______________
(answer)
44.8775 / 29 = 1.5819
__________________
(show calculation)

Example Six
The top ten DRG medical procedures
performed by a facility have a total
CMS Relative Weight of 23.6651
If the number of patients served is 55,
what is the Case
Case-Mix
Mix Index for the
facility?

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Answer
0.4302
______________
(answer)
23.6651
/ 55 = 0.43027 or 0.43028
__________________

(show calculation)

Recap
The case mix of a patient population is a
description of that population based on any
number of characteristics.
Case-Mix indexes are used to describe a
population that is being served, to
determine reimbursement, and to identify
differences in practice patterns or coding
complexity.
complexity
The most commonly used Case-Mix Index
uses disease conditions and/or procedures
to determine resource use.

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Recap (cont.)
Severity of Illness case-mix methodologies
were developed
d
l
d to address
dd
concerns that
h
traditional case-mix methodologies do not
capture the severity of an illness.
Risk Adjustment is any method used to
compare the severity of illness in one group
of patients in comparison to the severity of
illness in another group of patients. Used
make a fair comparison of diverse
populations and treatment patterns

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