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Provider Analysis Definitions

The data in this report are taken from the CMS Medicare Standard Analytical File (SAF) for hospital IPPS claims during a recent 12 month period and are consistent with CMS Data Release policies. Because of these policies, only physicians and MS-DRGs with more than 10 patients during the period are reported.

The attending physician for each patient is identified by NPI number in the SAF. Physician names and other FOIA-disclosable data information are taken from the National Plan and Provider Enumeration System (NPPES).

Medical Service

Medical service categories are based on groupings of patient MS-DRGs. These groupings are defined in the Statistics by Medical Service section of the Inpatient Report.

NPI

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for health care providers. The National Plan and Provider Enumeration System (NPPES) collects identifying information on health care providers and assigns each a unique National Provider Identifier (NPI).

Name

The National Plan and Provider Enumeration System (NPPES) contains FOIA-disclosable data for health care providers. These data include Provider Name and other identifying information.

Cases

The number of IPPS claims for a physician. IPPS claims are Medicare fee-for-service inpatient claims paid under the Inpatient Prospective Payment System (IPPS).

Days

Patient Days is calculated as the total lengths of stay for all of a physician’s patients.

ALOS

The Average Length of Stay is calculated as the total patient days for a physician’s patients divided by the physician’s total number of patients.

ICU ALOS

The Intensive Care Unit Average Length of Stay is calculated as the total patient days spent in an intensive care unit for a physician’s patients divided by the physician’s total number of patients.

Charges

The total gross charges for a physician’s patients. Gross charges are amounts billed by the hospitals but are not necessarily the amounts paid by Medicare or other payers.

Payment

The total payment is the amount paid to the hospital for a physician’s patients. This amount does not include any capital pass-thru amount or organ acquisition amount. It includes payments by Medicare (i.e. base MS-DRG payment, outlier payment, disproportionate share adjustment (DSH), indirect medical expense adjustments (IME), adjustments for certain transfers, etc.) It also includes amounts paid by or on behalf of the patient (e.g. deductibles or coinsurance) and amounts paid by third party insurers.

Cost

The total cost to the hospital for a physician’s patients. Costs are calculated for each patient on the basis of ratios of costs to charges for routine services and ancillary areas. Click here for cost allocation methodology.

CMI

The case mix index is the average relative weight for all of a physician’s patients. MS-DRGs at lower severity levels have lower relative weights and MS-DRGs at higher severity levels have higher relative weights. The CMI provides an index of patient mix among levels of severity for a physician’s patients.

CC Rate

The complication rate measures the incidence of CCs or MCCs for a physician’s patients. The MS-DRG assigned to a patient is effected by the presence of either complications (CCs) or major complications (MCCs). The numerator is the number of a physician’s patients effected defined by the presence of a CC or MCC. The denominator is the total number of patients for the physician.

Provider Address

The address of a physician’s office is taken from the National Plan and Provider Enumeration System (NPPES).

Provider Specialty

A physician’s taxonomy information is taken from the National Plan and Provider Enumeration System (NPPES). This information includes a primary medical specialty.

Base MS-DRG

The Medicare Severity - Diagnosis Related Groups (MS-DRGs) provide up to three levels of severity for a particular condition. A "Base" MS-DRG combines all levels of severity into a single category. The MS-DRG numbers listed are the individual MS-DRGs that have been combined into a Base MS-DRG for reporting.

Base MS-DRG Description

Individual MS-DRGs within a Base MS-DRG are differentiated according to the presence of a complication (CC) or a major complication (MCC). The descriptors of these CC/MCCs are removed when describing the Base MS-DRG