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RNALL001 - IS-H: Propose Charges

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Description

This program makes proposals for the billability of flat rates per case and procedures surcharges and checks whether the flat rates per case and procedures surcharges already assigned to the case are authorized for billing.

The program determines flat rates per case/procedures surcharges on the basis of the ICD/ICPM combinations assigned to the case and in relation to the rules defined in the Customizing activity Define assignment rules for flat rates per case/procedures surcharges. It can generate the following messages:

No ICPM codes assigned to the case (no charge proposal)
No ICPM flagged as main surgical procedure - flat rates cannot be determined
No FR or PS proposal defined for the combination of ICD and ICPM codes
FR or PS can be billed for - service has been entered
FR or PS can be billed for - service has not been entered

Moreover, the program checks the validity of the flat rates per case and procedures surcharges assigned to the case. It checks whether the flat rates per case and procedures surcharges assigned to the case are covered by the number of flat rates per case and procedures surcharges determined.

Selection Parameters

The following can be specified to select the dataset to be evaluated:

A billing selection ('selection indicator')

Movements (either in the admission interval or the discharge interval)

Departmental organizational units

Case numbers

You can specify case numbers in addition to other selection criteria. Departmental OUs can only be specified in conjunction with another selection.

The departmental OU of a case that is still open is the departmental OU of the movement valid at the current date. For discharged cases, this OU is the departmental OU of the discharge movement. If there are several movements at the key date (system date), the last movement of the day applies.

An option enables you to specify whether final billed cases should be included in the evaluation.

It is also possible to restrict the evaluation to cases for which ICPM codes were entered also.

You can sort the cases included for the evaluation by patient name, case number or discharge date. Moreover, you can decide whether information on surgical procedures codes/diagnoses or surgeries/relevant rules should be displayed in the initial list.

Output

The output list displays the diagnoses (ICD codes) and surgical procedures (ICPM codes) per case. If these ICD/ICPM combinations stored for the case point to a valid assignment rule, this rule is output along with the service code, service text, identification of a flat rate per case or a procedures surcharge, rule number and its ICD/ICPM definition.

For each flat rate or procedures surcharge proposed, the system outputs the corresponding movement (surgery) in which the service was performed.

The messages mentioned above relating to the flat rates per case and procedures surcharges are also displayed.

A number of specifications relating to the case such as names, admission type and admission date, discharge type and discharge date and the billing status are displayed.

You can call the transactions for maintaining Services, Diagnoses and Surgeries directly by choosing the corresponding function keys. Changes you make in these transactions take immediate effect in the output list.

The function key Messages lists all messages relating to flat rate determination and those relating to the charge check from the program Check Charges (RNLBTAG0) separately. You can also branch to the message long texts from this list.

The function Compare charges enables you to simulate the valuation of defined case configurations for an individual case.

The function key Generate creates the proposed services (flat rates per case or procedures surcharges). When flat rates per case are generated, the system cancels any existing nursing charges up to the maximum length of stay covered by the flat rate and may then create daily nursing charges for the period thereafter.

The system cancels all services with the charge type Base nursing charge, Departmental per diem and General nursing charge. Whether or not services are to be created as of the maximum length of stay depends on whether your billing procedure complies with the transitional regulation or not. If you do not bill according to the transitional regulation, the base nursing charge is taken from the service specified in the Customizing activity Configure proposal of flat rates per case/ procedures surcharges and the departmental per diem is determined in relation to the respective movement.

If your billing procedure does comply with the transitional regulation, the service specified in this Customizing activity will be used for the general nursing charge.

You also make the settings for billing according to the transitional regulation in this table.

The services generated are created with the date and the organizational unit of the respective surgery for which the service was performed. For post-operative flat rates (as of 5th amendment to the BPflV 1995), an assignment to a surgery can be determined, since these flat rates are not performed within a surgery and surgical procedures codes are not defined for these flat rates. Here the system would send a dialog box for you to specify the date to be generated for these flat rates. The date corresponds to the day on which the wound has healed and, as such, marks the end of flat rate for acute treatment. The system proposes the admission date plus the standard length of stay covered by the corresponding acute treatment flat rate.

If flat rates per case for newborns (flat rate type = 6) are generated, the system does not cancel nor align the daily nursing charges.

Requirements

The program only checks inpatient cases for which final billing has not taken place.

If you execute the program for a specified admission or discharge period (i.e. by movement), it only selects cases that have movements with the status 'actual'. In other words, cases for which an admission is planned are not evaluated. In contrast, should you execute the program with a specified selection indicator, all movements (including those planned) are taken into account.

Please note the following prerequisites for the FR/PS determination:

The results of the FR/PS determination depend on the specifications in the control table for the FR/PS determination search logic.

The ICD/ICPM to PS/FR assignment table must be correctly maintained.

The check based on the ICD codes cannot be restricted to a specific diagnosis type.

For certain flat rates per case and procedures surcharges, exclusion criteria relating to age and sex can be defined which prevent a charge proposal depending on the sex and age of the patient. If necessary, check the settings for these services in the service master.

Moreover, certain charge proposals are dependent on the flat rate type specified in the service master of the flat rate per case in question. For instance, a flat rate with the type Obstetrics (hospital stay of under 24 hours will only be proposed for cases of less than 24 hours duration.

Postoperative flat rates are only proposed if the corresponding acute treatment flat rate is also contained in the proposal quantity. However, this check does not apply if you entered the number of previous days pertaining to an admission in the other case data. Here the system would recognize a previous patient case or an admission from an external hospital, in which the acute treatment flat rate was performed in a previous case or in the transferring hospital.

When the flat rate for the postoperative phase is generated, the system checks if the minimum length of stay has been reached. For discharged cases, the program compares the period between the discharge date and the service performance date of the flat rate (date at which the wound is healed) with the minimum length of stay defined. For non-discharged cases, the program uses the current date instead of the discharge date. This flat rate per case can only be generated if the minimum length of stay is reached. Moreover, the post-operative flat rate can only be generated if the assigned acute treatment flat rate exists as a billable or non-billable service.

The generation of flat rates per case and the resulting cancellation and creation of daily nursing charges is dependent on the specifications in the Customizing activity Configure proposal of flat rates per case/procedures surcharges.

Flat rates per case can also be generated for interim-billed cases; the simultaneous modification of daily nursing charges is, however, subject to certain restrictions. For example, if services to be modified (pre-admission and post-discharge treatment flat rates, base nursing charges or departmentals per diem) are interim-billed, these are not cancelled when flat rates per case are generated. As a result of this, it may also not be possible to create new services as of when the maximum length of stay is reached in order to prevent overlapping periods. In these cases the system generates a message prompting you to check the charges after generation.

Please note that you can also use the flat rate generation program to align the daily nursing charges with the current case configuration. If you entered the flat rates manually, but did not delimit the daily nursing charges when the maximum length of stay was reached, you can align the daily nursing charges with the current case configuration by generating the flat rate per case. A second flat rate per case is not generated by the program.

When you generate flat rates for newborns (flat rate per case type = 6) the daily nursing charges are not canceled. These flat rates can also be generated several times for each case.

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