$3.50 or $10,800,000? How Much Does a Service Actually Cost?

Dr. Ronald HirschOctober 2, 2023

Many of us eagerly, or with dread, await the yearly payment system rules that the Centers for Medicare & Medicaid Services (CMS) releases.


Keeping up with the rules is actually a year-round project, with the first set of proposed rules appearing each April, to be finalized in August, and the second set of proposed rules released in July, to be finalized in November.


Of course, the first place I go is to search for any changes to the Two-Midnight Rule, which was thankfully left intact for 2024, except for the expansion to apply to Medicare Advantage (MA) plans, which was addressed in CMS-4201-F.


On the more mundane level, every year CMS looks at outpatient payment rates and Diagnosis-Related Groups (DRGs) to ensure that the assignments are appropriate and the payment rates are correct.


As new medications, devices, and surgical techniques are developed, the DRG assignments need adjusting. I would not dare to try to explain the changes, leaving that to the experts at ICD10monitor.com, but I will remind you that because of the DRG realignment starting on Oct. 1, your overall Case Mix Index (CMI) may shift, even without any changes to your patient population or coding practices.


Read the full article here. 

Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.

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