CMS Releases Annual Medicare Payment Data

on Tuesday, 09 June 2015. All News Items | Case Management | Quality | Outpatient Services | Billing

Promoting Better Care, Smarter Spending and Healthier People through Annual Medicare Hospital and Physician Data Release

Baseball, hotdogs, apple pie and Medicare utilization and payment data is not quite how it goes but it is that time of year when baseball is in full swing, families are gearing up for their long anticipated summer vacations and CMS releases their now annual Medicare hospital, physician and other supplier utilization and payment data. This year’s data release builds upon the Administration’s measurable goals and timeline of moving toward paying for quality rather than quantity. CMS indicated in their June 1st, 2015 Press Release that the “data releases are part of a wide set of initiatives to achieve better care, smarter spending, and healthier people through our health care system. Open sharing of data securely, timely, and more broadly supports insight and innovation in health care delivery.”

About the Hospital Inpatient Data:

  • Data comes from the Medicare Providers Analysis and Review (MedPAR) data set for fiscal year 2013 (October 1, 2012 – September 30, 2013) for the most recent data.
  • Data consists of information for 2013, as well as data released for years 2011 and 2012, about the average amount a hospital bills for services that may be provided in an inpatient stay or outpatient visit.
  • CMS notes that with three years data it is now possible to conduct trending analyses of charges, payments, and utilization.
  • Data includes payment and utilization information for services that may be provided in connection with the 100 most common Medicare inpatient stays and 30 select outpatient procedures at over 3,000 hospitals in all 50 states and the District of Columbia.
  • The top 100 inpatient stays from the data are associated with approximately $62 billion in Medicare payments and over 7 million hospital discharges.
  • CMS points out some limitations of the Inpatient Public Use File (PUF) that are noteworthy:
    • The data is limited to Medicare beneficiaries with Part A fee-for service coverage,
    • The data is limited to only the top 100 DRGs (in Fiscal Year 2013 there were 751 DRGs) and thus does not necessarily include all Medicare discharges from a hospital.

The CMS Hospital Utilization Fact Sheet provides a table of the top ten DRGs by discharges for Fiscal Year (FY) 2013. This table includes the ten DRGs with total discharges and total allowed amount. Keeping in mind the goal of payment for quality over quantity, the table below also identifies which of these DRGs are a part of the Hospital Value Based Purchasing (VBP) Program and the Hospital Readmission Reduction Program (HRRP) and what the current National Readmission Rates are for these DRGs.

Top Ten Medicare Diagnostic Related Groups by Discharges, FY 2013

Diagnostic Related Group Code and Description Total Discharges Total Allowed Amount Hospital VBP Program DRG HRRP DRG National Readmission Rate
DRG 470: Major Joint Replacement or Reattachment of Lower Extremity w/o MCC 446,148 $6.6 billion No Yes(*) 5.2%
DRG 871: Septicemia or Severe Sepsis w/o MV 96+ Hrs w/MCC 398,004 $5.56 billion No No N/A
DRG 392: Esophagitis, Gastroenteritis & Miscellaneous Digest Disorders w/o MCC

199,292

$1.08 billion No No N/A
DRG 292: Heart Failure & Shock w/CC 198,483 $1.42 billion Yes Yes 22.7%
DRG 291: Heart Failure & Shock w/MCC 194,697 $2.1 billion Yes Yes 22.7%
DRG 194: Simple Pneumonia & Pleurisy w/CC 182,388 $1.29 billion Yes Yes 17.3%
DRG 690: Kidney & Urinary Tract Infections w/o MCC 174,529 $9.82 million No No N/A
DRG 683: Renal Failure w/CC 154,280 $1.09 billion No No N/A
DRG 190: COPD w/MCC 152,880 $1.27 billion No Yes(*) 20.7%
DRG 193: Simple Pneumonia & Pleurisy w/MCC 145,391 $1.5 billion Yes Yes 17.3%
(*)Planned THA & TKA and COPD diagnoses are new diagnose for the FY 2015 Hospital Readmission Reduction Program (HRRP).
The Data Collection Period for the National Readmission Rates currently posted on Hospital Compare are from the data collection period 7/1/2010 – 6/30/2013.

About the Hospital Outpatient Data

  • The data includes estimated hospital-specific charges for 30 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Years (CY) 2011, 2012, and 2013.
  • The Medicare payment amount includes the APC payment amount, the beneficiary Part B coinsurance amount and the beneficiary deductible amount.
  • Estimated average charges and average Medicare payments are provided at the individual hospital level.

About the Medicare Part B Physician Data

  • The data was created using information from the Physician/Supplier Part B Claims File which is also known as the Carrier File.
  • The data identifies individual providers using their National Provider Identifier (NPI) and the specific services that they furnished using Healthcare Common Procedure Coding System (HCPCS) codes.
  • CMS notes that with this second annual release of physician and other supplier utilization and payment data it can now be used for trend analyses.
  • CMS indicates that the data “allows for comparisons by physician, specialty, location, types of medical services and procedures delivered, Medicare payment, and submitted charges.”
  • The data set has information for over 950,000 distinct health care providers who collectively received $90 billion in Medicare payments.
  • CMS points out some limitations of the Inpatient Public Use File (PUF) that are noteworthy:
    • The data file is only for Medicare beneficiaries with Part B FFS coverage.
    • The data does not indicate the quality of care being provided.
    • The file only contains cost and utilization information.
    • Medicare allowed amounts and Medicare payments for a given HCPCS code/place of service can vary based on a number of factors, including modifiers, geography, and place of service.

For additional information you can access the Press Release and Fact Sheets posted to the CMS website from the following links:

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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