NATIONAL CENTER Series 2

For HEALTH STATISTICS Number 28

VITAL and HEALTH STATISTICS

DATA EVALUATION AND METHODS RESEARCH

pilot study on

PatientCharge

Statistics

A study to develop methodology for collecting

information on hospital charges in the Hospital

Discharge Survey..

Washington, D. C. May 1968

U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

Wilbur J. Cohen

Acting Secretary

Public Health Service

Wil Iiam H. Stewart

Surgeon General
Public Health Service Publication No. 10[!O-Swie* L2.No. 28

For sale by the Superintendent, of Documents, U.:. C+ovemmcmtPrintim (1’Ike

Washington, D. C., 20402- Price 4ficents
NATIONAL CENTER FOR HEALTH STATISTICS

THEODORE D. WOOLSEY, Director

PHILIP S. LAWRENCE, SC. D., Associate Director

OSWALD K. SAGEN, PH.D.,, Assistant Director for Health Statistics Development

WALT R. SIMMONS, M.A., Assistant Director foT Research and Scientific Development

ALICE M. WATERHOUSE, M. D., Medical Consultant

JAMES E. KELLY, D. D. S., Dental Advisor

LOUIS R. STOLCIS, M. A., Executive Of/icer

OFFICE OF STATISTICAL METHODS

MONROE” G. SIRKEN, PH. D., OUPCfO,

Public Health Service Publication No. 1000-Series 2-No. 28

L] brun I 1 o?~~r( ,.. (.fzta/og Card \’ur?kr 67-6237 ?
FOREWORD

This report presents the results of a pilot

study which was undertaken to investigate the

feasibility of collecting information about hospital charges from the patient charge ledgers

on file in the business offices of hospitals. The

report also presents findings and recommendations regarding the methodology for collecting

patient charge statistics on a continuing basis

for a national sample of patients in the Hospital

Discharge Survey.

The objective of the Hospital Discharge Survey is to produce national statistics on hospital

patients which are representative of the experience of the civilian population in short-term hospitals. Since the latter part of 1964, selected items

of social and medical information about discharged

patients have been abstracted from the patient

medical records. It is planned to expand the content of the Hospital Discharge Survey by linking

the information about the patient, which is currently being collected from the medical records,

to information about his hospital charges, that

will be collected from the patient charge ledgers.

In July of 1965, the National Center for Health

Statistics convened an Ad Hoc Committee on Hospital Charges to advise on matters pertaining to

the collection of statistics on hospital charges and

sources of payment. In particular, the Center

sought the advice of this Committee with regard

to (1) the kinds of patient charge data that would

be most useful, and (2) the problems that could

be expected in abstracting these data from the

patient charge ledgers. The members of this Committee included: Mrs. Agnes W. Brewster, Division of Community Health Services, PHS, HEW;

Dr. Donald C. Riedel, Blue Cross Association;

Mr. Robert M. Sigmond, Hospital Planning Association of Allegheny Colmty, Pa; Mr. William

Spector, American Hospital Association; and Mr.

Theodore D. Woolsey, Dr. Monroe G. Sirken, and

Mr. Milton C. Rossoff from the Center.

In 1966, the Center contracted with Booz,

Allen, and Hamilton, Inc., to undertake a pilot

study on hospital patient charges. The project

was started in July 1966 and the work was completed as planned about 8 months later. During

this period, there was very close collaboration

between the staffs of Booz, Allen, and Hamilton,

Inc., and of the Center. Dr. Robert H. Hamlin of

Booz, Allen, and Hamilton was project director

and he and his staff, including Michael A. Green,

Douglas W. Metz, and John L. McKee, were responsible for conducting the pilot study and preparing this report. The Center staff included John

Monroe and Milton C. Rossoff, and Monroe G.

Sirken, who was project officer. The Demographic

Survey Division of the Bureau of the Census participated in the field work of the study.

From the viewpoint of the National Center for

Health Statistics, this was an efficiently conducted

pilot study that was exceptionally weIl planned

and implemented on a timely basis. The results

of the study presented in this report have demonstrated the feasibility of collecting national hospital charge statistics classified by types of services provided and by sources of payment based

on information reported in the patient charge ledgers. The findings will be valuable in deciding on

methods to be used and in preparing the procedures for collecting this information in the Hospital Discharge Survey.

Monroe G. Sirken, Director

Office of Statistical Methods

...

Ill
CONTENTS

Page

Foreword --------------------.----------=----------------------------

I.

II.

III.

IV.

Summary of the Study ----------------------------------------------

Background -------------------------------------------------------

Objectives of the Study ---------------------------------------------

Methodology ------------------------------------------------------

Major Findings andConclusions -------------------------------------

Study Methodolo~-------------------------------------------------

Phase L Development of InterviewSchedules, AbstractForms, andProcedures ------------------------------------------------------

Phase II. Administration of the Field Test --------------------------

Phase III. Administration ofthe Final Field Test ---------------------

Limitations k Pilot Study ------------------------------------------

Major Characteristics of Patient Charge Systems in Hospitals ---------

Types of Hospital Patient ChargeSystems ----------------------------

The Completed Patient Ledger --------------------------------------

Feasibility of Abstracting Patient Charges on a Continuing Basis -------

Major Issues in Abstracting Patient Charge Ledgers ------------------

Interpretation of Fin&ngs md Conclusions ---------------------------

Appendix A.

Appendix B.

Appendix C.

Appendix D.

Appendix E.

Appendix F.

Appendix G.

Glossary of Terms ----------------------------------------

Contact Letters Used WithHospitals -------------------------

Interview Schedule Used With Selected Hospital Personnel-- ---

PatientChargeAbstract Form Used in Field Test Hospitals- ---

HospitalInstruction Manual Usedin Final Test Hospitals ------

SuggestedPatient Charge Abstract Form for Fumre lJse -------

Alternative Methods for Selecting and Relating Patient Charge

Ledgers and Medical Records for Abstracting ina Continuing Abstracting

Pro~am -----------------------------------------------------------

...

111

1

1

1

1

2

3

4

6

8

10

11

11

11

15

15

24

27

31

34

43

44

51

52

v
IN THIS REPORT, the results of a pilot study to develop the methodology for ins tituting a continuous pvogvam for collecting information

on patient chavges and sources of payment as a part of the Hospital

Discharge Survey are presented. These ves?.dts relate specifically to

the development of methodology fov utilizing hospital ledgevs of patient

chavges as the sowce of information on churges fov the national sam -

ple of patients in the swvey. Cuwently, the Hospital Dischavge Survey is limited to the collection of specified items of information about

patients available from the patient medical recovds.

The study concludes that it is both feasible and pvactical to institute a

continuous program fov collecting patient chavges and souvces of payment data as pavt of the Hospital Discharge Suvvey. The pvincipal findings weve thut (1) the dollar amounts of ehuvges by selected types of

se-vvices and sources of payment ave available from the ledgers of

patient chavges or can be estimated in all hospitals, (2) the agweement in the definition of types of chavgks and souvces of payment is

sufficient to permit gross comparisons among hospitals, and (3) hospitals ave cooperative and theiv employees can accurately abstract the

information from the ledgers of patient chw-ges.

SYMBOLS

Data not available ------------------------ ---

Category not applicable ------------------- . . .

Quantity zero ---------------------------- -

Quantity more than O but less than 0.05---- 0.0

Figure does not meet standards of

reliability or precision ------------------

*

VI
PILOT STUDY ON PATlENT CHARGE STATISTICS

1. SUMMARY

This chapter summarizes the background,

objectives, methodology, and principal findings

and conclusions of the pilot study on hospital

patient charge statistics.

BACKGROUND

The subject of patient charges in hospitals

is receiving increased attention by the medical

and health care communities, government agencies with public health responsibilities, and the

general public. The rapid rise in hospital charges

and costs, the increasing demand for hospital

services, and the rather substantial restructuring of mechanisms for financing hospital care

(e.g., the growth of third parties as sources of

payment, including the Medicare and Medicaid

programs), have stimulated both the need and

desire for improved data on patient charges in

hospitals,

Currently, little information on a national

basis is available on patient charges which (1)

reflects a cross section of U.S. hospitals, enabling generalization to the total population of

patients and hospitals; and (2) presents a trend

analysis, on a continuing basis, of variations in

charges over time.

To meet the general need for additional and

improved data on patient charges in hospitals,

the National Center for Health Statistics (NCHS)

of the U.S. Public Health Service sponsored this

pilot study on patient charge statistics.

OBJECTIVES OF THE STUDY

The purpose of the pilot study was to determine the feasibility and practicality of institutor THE STUDY

ing a continuous program for collecting patient

charge and source-of-payment information as a

part of the Hospital Discharge Survey of NCHS,

which currently is limited to the collection of

patient medical record information.

The major objectives of the study were to

determine whether:

Information in hospitals is available on the

dollar amount of total charges for a single

episode of hospitalization, broken down into

room and board charges and other charges,

and by source of payment (e.g., Blue Cross,

Medicare, personal, etc.), as prescribed by

the Ad Hoc Committee on Hospital Charges.

Consistent definitions exist among hospitals

for the requisite patient charge and sourceof-payment information.

Specified patient charge and source-of-payment data are readily obtainable.

Valid patient charge data can be abstracted”

from hospital records by hospitaJ personneI.

Abstracting can be done by hospital personnel

at a reasonable cost.

Patient charge and source-of-payment data

can lx related to medical record data abstracted for the same patient and admission.

METHODOLOGY

The methodology of the pilot study involved

three major phases.

Phase 1.—Development and pretesting of an

interview schedule, abstract form, and study pro1
cedures in five hospitals not apart of the Hospital

Discharge Survey.

Phase 2. -–Administration of the interview

schedule with selected hospital personnel and abstraction of patient charge ledgers by survey

staff in a national sample of 20 field test hospitals

not a part of the Hospital Discharge Survey.

Phase 3.—Administration of a revised interview schedule and abstraction of patient charge

ledgers by hospital personnel in five hospitals

already included in the Hospital Discharge Survey, with verif icat ion of their abstraction accuracy by independent review of survey staff.

Throughout the report the 20 hospitals in

Phase 2 of the study are referred to as the field

test hospitals and the 5 hospitals in Phase 3 as

the final test hospitals. A glossary of terms

used in the report is presented in Appendix A, at

the end of this report.

Direct interviews were conducted with more

than 50 hospital administrators and accounting

department personnel in the 25 hospitals surveyed. Of the more than 2,000 patient charge ledgers identified by random and purposive selection, 1,064 patient ledgers, with complete data,

were abstracted.

The study team was composed of six individuals, three of whom conducted the field work.

Persomel from NCHS and the Bureau of the

Census participated with the study team in abstracting patient charge records in several hospitals. Hospital personnel in the five final field

test hospitals abstracted patient charge records

in accordance with a training and an instruction

manual developed by the survey team and administered in each hospital by a team member.

In the 20-hospital field test, it was found

that data from 2 hospitals with computerized

patient charge systems were not obtainable because special programming would have been required to secure the information needed for

patient charge abstracting. Therefore, such hospitals were excluded from the final field test

phase of the study.

MAJOR FINDINGS AND

CONCLUSIONS

On the basis of the principal. study findings,

it was concluded that it is both feasible and practical for NCHS to institute a continuous program

for collecting patient charge and source-of-payment data as a part of the Hospital Discharge

Survey. The principal findings were:

Data on the dollar amounts of room and board

charges, other charges, personal nonmedical

charges, and sources of payment are available or can be estimated in all hospitals.

Sufficient consistency exists in the elements

that hospitals include in room and board

charges to permit gross comparison of such

charges among hospitals. Hospitals vary in

the items included in the category of other

charges, but comparisons of other charges

among hospitals can be made since significant

variations are limited to only a few classes

of charges, such as anesthesiology services.

Hospital employees can’ accurately abstract

valid pat ient charge and source-of-payment

data if appropriate on-site training is provided by the survey staff.

Hospital personnel can abstract patient

charge ledgers at a reasonable cost ranging,

among hospitals, from $12.50 to $50.00 per

100 abstracts, or an average of $25.00 per

100 abstracts.

A continuous program for abstracting patient

charge and source-of-payment data can be

established as a part of the Hospital Discharge Survey since it is possible for NCHS

to:

Use the same patient sample for patient

charge and medical data abstracting, except for well- newborn infants when their

charges are combined with the mother’s

on the same ledger.

Match the abstracts of patient charge data

with abstracts of medical data for the same

patient, even though the two sets of data

will not be available at the same time,

Obtain the cooperation of the great majority

of hospitals in a continuous abstracting program, provided the approach to the hospitals is carefully planned and personal in

nature, and the time required of hospital

personnel is held to a minimum by careful

planning of hospital time requirements and

by training of hospital personnel by survey

2
staff. NCHS and U.S. Public Health Service

prestige is sufficient to stimulate hospital

cooperation, although hospital association

endorsement should be obtained if possible.

Prior to initiation of a program of abstracting patient charge information on a continuing

basis, NCHS should develop detailed procedures

for:

Abstracting patient charges in hospitals with

automated patient charge systems.

Assuring that the same sample of patients is

selected for patient medical and patient

charge data abstracting. (Alternative methods

available to NCHS are evaluated

quent chapters of this report.)

in subseLinking medical record abstracts and patient

charge record abstracts, once completed,

for the same patient and same admission

since the two abstracts will be prepared at

different points in time. (Alternative methods

available to NCHS are evaluated in subsequent chapters of the report.)

Ensuing chapters of this report discuss in

greater detail the study methodology, the major

characteristics of hospital patient charge systems, and the feasibility of abstracting patient

charges on a continuing basis.

Il. STUDY METHODOLOGY

This chapter describes the methodology employed to conduct the pilot study on hospital

patient charge statistics. Basic methodology consisted of the following steps:

Development of an interview schedule (Appendix C).

Administration of the interview schedule

through direct interviews with hospital administrators and key accounting department

personnel in 25 hospitals—20 hospitals not

participating and 5 participating in the present NCHS Hospital Discharge Survey. The”

interview schedule was administered by three

members of the study team, with one member responsible for conducting 15 of the 25

direct interviews, training the other team

members, and closely supervising their work.

Development of an abstract form (Appendix

D) for eliciting patient charge and source-ofpayment data according to the following

prescribed categories.

Patient Charges

Room and board charges

Other charges

Total charges

Sources of Payment

Blue Cross

Commercial insurance

Personal payments

Welfare (Title XIX— Medicaid)

Hospital discounts

Private charity

Medicare (Title XVIII)

Workments Compensation

Federal public service programs

Other

Use of the abstract form to abstract patient

charge and source-of-payment data from

patient charge ledgers in the 25 hospitals.

Abstracting was accomplished by members

of the study team and personnel from NCHS

and the Bureau of the Census in the 20-hospital field test. In the last phase of the study,

the final field test, hospital employees in the

five hospitals performed the abstracting in

accordance with an instruction manual developed by the study team. This abstracting

was verified by independent abstracting of

the same patient charge ledgers by the survey team.

Exhibit I is a chart depicting the work plan

for the study. As outlined in the sections which

follow, the study design comprised three major

phases and a series of steps to accomplish the

objectives of each phase.

3
I

1. RESEARCH FILES AND STAFF

2 PRELIMINARY “OSP, TAL INTERVIEWS

3. PREPARE pRE. TEST MATERIAL

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.Ab, ,,o, , ,.,.

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1“ 4 CONDUCT PRE. TEST (4 HOSPITALS)

5, PREPARE TENTATIVE FORMS FOR FIELD TEST

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.C.n! ... 1.,,.,,

6, SELECT H05P1TAL$ FOR F)ELD TEST

7, REVIEW FINDINGS, FORM S,AND SELECTION

OF HOSPITALS WITH NCHS.

8. CONDUCT FIELD TEST

9 REVISE AND PREPAF?E FORIA$ FOR FINAL TEST

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10. SELECT FINAL TEST HOSPITALS

!1 CONDUCT FINAL FIELD TEST

12, DEVELOP FINDINGS AND CONCLUSIONS

OF FINAL FIELD TEST

,3. DEVELOP REPORT OUTLINE

)4. PREPARE REPORT

EXHIBIT 1, WORK PLAN FOR THE STUOY

I?,.ld ,,.d, . . . <.. o,.n,.d . . ,.1, 15, ,’+66, ..d w., c.mslo,.d . . Moreh !. 1967

— PLANNED .0,. SCHEDULE

‘,1,1,,,, .,,.,, WORK ,CH, C’ULE

PHASE 1. DEVELOPMENT OF

INTERVIEW SCHEDULES, ABSTRACT

FORMS, AND PROCEDURES

The objectives of this phase were to:

Obtain a general understanding of patient

charge systems in hospitals.

Determine attitudes of hospital personnel

concerning the value of the survey and the

key factors that would influence a hospital

to participate in the pilot study and, later, a

continuous program of collecting patient

charge data.

Ascertain the opinion of the hospital staff on

the following key items which would influence

,

I !

II

11,

the feasibility and practicality of abstracting

charge data: (1) data availability and accessibility, (2) consistency and complexity of

patient charge systems, including coding

systems used, (3) time within which most

patient ledgers are completed and ready for

abstracting, and (4) time required for collection of data.

Phase I involved accomplishment of the following

steps.

Preliminary Interviews With Knowledgeable

Personnel

In this initial step, interviews were conducted with selected administrators and accounting department personnel in four hospitals. In

A
addition, actual primary patient charge data

sources were examined for format, content, and

variations and compared with study requirements to determine the availability of data.

Preparation and pretesting of Survey

Material

In this step, the following survey materials were

developed:

Procedures for contacting hospitals, following up contacts, and expressing appreciation

for participation. Appendix B includes materials developed and used during the study by

NCHS and the study team.

An interview schedule for use in interviewing hospital administrators and accounting

department personnel.

A data collection (abstract) form in a format

adaptable to a broad range of hospital primary data source (patient charge ledger)

characteristics.

A list of five hospitals for pretesting of the

initial interview schedule and abstract form.

The hospitals which were not a part of the

present Hospital Discharge Survey were

selected on the basis of diversity in type, size,

and other pertinent characteristics.

The resulting interview schedule and patient

charge abstract form were submitted, as required, to the Bureau of the Budget for approval

and subsequently pretested in the five hospitals

by a member of the survey team in accordance

with the following procedures:

Contact letters from NCHS were sent to the

five selected hospitals to explain the purpose of the study and to request cooperation.

The letter was followed by a personal telephone call from a study team member to

each hospital administrator to verify cooperation, arrange for a personal visit, and

outline the procedures to be followed during

the personal visit.

The interview schedule was administered by

direct interview with each hospital administrator, and with accounting managers or designated employees in the accounting department, if the administrators were not able to

answer the detailed technical questions on

accounting procedures.

Approximately 100 patient charge records

were selected in each hospital— 75 randomly

from the hospital’s daily patient discharge

listing for the most current 4-month period

and 25 purposively for the types of patient

charge records which were identified as

potential problem areas (e.g., welfare, Workmen’s Compensation, Medicare, and automobile accident cases) during the interviews

with hospital administrators and accounting

department personnel.

Hospital personnel in the accounting department of each hospital searched their files to

locate the 100 selected ledgers.

A study team member completed abstracts

for the selected ledgers, asked questions

whenever necessary, and made notes regarding portions of the abstracting process which

would necessitate changes in the study procedures, the abstract form, or the interview

schedule. Because some records could not be

located, slightly fewer than 100 ledgers were

abstracted in each hospital.

Letters of appreciation were sent to the participating hospitals.

Modification of Forms and Instructions for

Use in the Field Test

This step involved preparation and review

of findings from the pretest phase of the study,

revision of the interview schedule and abstract

form based upon the findings of the pretest, and

preparation of an interviewer’s instruction manual

for the additional study staff to be used in’ conducting the field test involving 20 hospitals.

5
PHASE Il. ADMINISTRATION OF THE

FIELD TEST

The objectives of Phase II of the study were

to:

Determine the availability and accessibility

of hospital patient charge and source-of-payment data in a sample of 20 hospitals not presently participating in the Hospital Discharge

Survey.

Determine hospital procedures for handling

patient charge and source-of-payment data

and delineate

charge ledger

problems in linking patient

and medical record data in a

continuous program to collect patient charge

information.

Ascertain the likelihood of hospital cooperation in a continuous program of collecting

patient charge statistics.

Test and refine the interview schedule, abstract form, and procedures developed during

the pretest phase of the study.

The following steps were accomplished in this

phase.

Exhibit II. Hospital characteristics prescribed for the field test

Type of hospital

Total hospitals --------------------------------------------------------------

Nonfederal Government

Large teaching i--------------------------------------------------------------------

Large nonteaching------------------------------------------------------------------

Not large mban --------------------------------------------------------------------

Not large mral --------------------------------------------------------------------

Nonprofit church

Large------------------------------------------------------------------------------

Not large wban --------------------------------------------------------------------

Not large rWal --------------------------------------------------------------------

Other nonprofit

Large teaching---------------------------------------------------------------------

Large nonteaching ------------------------------------------------------------------

Not large.wban --------------------------------------------------------------------

Not large rual --------------------------------------------------------------------

Proprietary

Large------------------------------------------------------------------------------

Not large mban --------------------------------------------------------------------

Not large rmal --------------------------------------------------------------------

Special types

Osteopathic------------------------------------------------------------------------

Hospital participating in a prepaid group practice plan----------------------------

Specialty hospital, such as a hospital for crippled children-----------------------

Number of

hospitals

in field

test

20

1

1

1

1

1

1

1

2

2

2

1

1

1

1A large hospital is one with 500 beds or more.

One

(a)

(b)

(c)

(d)

(e)

of each of the following kinds of hospitals was to be included among the 20 listed above.

Hospital owned by physicians or by an industrial corporation

Hospital with a highly automated record system

Hospital with an all-inclusive charge rate

Hospital with long-term care, psychiatric, or other specialized units

Hospital in which radiologist, pathologist, etc., bill separately for their departments

6
Selection of Hospitals

In the first step 20 hospitals, not presently

included in the Hospital Discharge Survey, were

selected for the field test. The characteristics of

the 20 hospitals, as prescribed by NCHS, are presented in Exhibit II. As reflected in Exhibit II, the

purpose was to select a broad, representative

sample of hospitals in the United States. The hospitals therefore represented a range in size,

location (regional distribution was as follows:

East, 6; Midwest, 4; South, 5; and West, 5), ownership, accounting equipment, patient charge sys -

terns, and special characteristics.

In the 20-hospital field test, great effort was

made to select hospitals with characteristics

identical to those requested. This was not possible

in all cases because most large hospitals (500 beds

and over) were already in the Hospital Discharge

Survey and, therefore, were excluded from the

requirements of the field test. In addition, the

number of 500-bed church-affiliated and 500-bed

proprietary hospitals is quite limited.

The following variations in characteristics of

hospitals selected for the field test were approved

by NCHS, since it was felt that the variations

would not affect the outcome of the study.

NonpYofit chuvch—a 472-bed hospitaI substituted for a 500. bed hospital.

Other nonpvofit-a large teaching hospital

substituted for a large nonteaching hospital.

Pvopvietavy-A 174-bed hospital substituted

for a 500-bed hospital.

Exhibit HI, summarizes the specific characteristics of the 20 field test and 5 final test

hospitals.

Administration of Interview Schedule

In the next step, the interview schedule used

in the 20-hospital field test (see Appendix C) was

administered by three members of the survey team. The member who conducted the pretest administered the direct interviews in 10 hospitals and trained and closely supervised the

performance of the two other members in theremaining hospitals. Administration of the interview

schedule consisted of an introductory interview

with the administrator, a followup interview with

the accounting manager or designated person in

the accounting department, and completion of the

interview schedule by the interviewer.

Information about the hospitals and their

patient charge procedures was collected from interviews with 52 hospital employees, including 2

medical directors, 19 hospital administrators, 20

controllers, 6 business managers, and 5 accounting supervisors.

Abstraction of Data on Patient Charges

This step involved the completion of approximately 100 abstracts in each hospital by members

of the study team accompanied in some cases by

personnel from NCHS and the Bureau of Census.

(See Appendix D for the abstract form used.)

In the field test (20 hospitals) and final test

(5 hospitals) more than 1,000 abstracts of patient

charge ledgers were completed. Of 2,084 patient

ledgers identified by random and purposive selection, 1,064 were abstracted because they were

completed. Exhibit IV analyzes the ledgers reviewed during the study.

23 of the 25 survey hospitals produced ledgers

for review. One hospital had a computerbased patient charge system that would have

required programming to collect patient

charge data and the other hospital was in the

process of converting from a manual to a

bookkeeping machine system and ledgers

were not available.

2,038 ledgers were requested from the hospitals for review.

2,084 ledgers were searched for, of which

1,904 were located. (One hospital searched

for more ledgers than requested.)

Of the 1,904 ledgers that were located, payments had been completed for 1,064, which

therefore could be abstracted.

7
Exhibit III. Hospital characteristic observed in the 25 survey hospitals

Hospital

TotalField teat

hospitals

1

--- --- - - --

2----------

-- - - -- ----

:----------

5----------

6----------

------- ---

;----------

9----------

1o----------

11----------

12----------

13----------

14----------

15----------

16----------

17----------

18----------

19----------

20----------

Final test

hosnitals

21----------

22----------

23----------

24----------

25----------

Vumber

of

beds

. . .

704

762

160

4;;

249

126

656

460

348

141

174

140

87

46

44

LE

180

112

289

1?:

244

1,298

Type of

wnership

-5

; - 11

VC-3

P-6

G

G

G

G

Vc

v

Vc

v

v

v

v

P

P

P

P

P

P

v

v

v

Vc

v

v

v

G

Type of

posting

squipment

c-:

T-:

- 1! L:

:

B

B

c

B

B

c

B

B

B

B

B

B

M

B

B

B

B

B

B

B

N

B

B

~ype of

:harge

system

A-I- 4

s&s-21

...

...

A-1

A-1

s&s

s&s

s&s

s&s

s&s

1s&s

A-I

s&s

s&s

s&s

s&s

s&s

s&s

s&s

s&s

s&s

SW

s&s

s&s

s&s

A-I

s&s

s&s

:eographic

location

M-L

E - 1(

s-(

w-!

M

E

s

w

s

s

M

E

E

s

M

E

w

w

w

w

E

E

E

E

E

s

Special characteristic

Psychiatric unit, teaching

Long-term care unit

Rehabilitation aervice,teaching

Teaching

Psychiatric unit, teaching

Progressive patient care

Doctor-owned

Doctor-owned

Doctor-owned

Doctor-owned

Community-owned

Corporation

Osteopathic hospital

Prepaid group plan

Crippled child care

Teaching

Iwelfare patienta have an all-inclusive rateLegend: Type of ownership Type of posting equipment Type of charge system Geographic location

G = Government C = Computer A-I = All-inclusive M = Midwest

V = Voluntary, B = Bookkeeping machine daily rate E = East

nonprofit T = Tabulator S&S = Charge according s = south

VC = Voluntarv. M = Manual to supply or W = West Coast

church - -

P = Proprietary

service received

Modification of Forms and Procedures for

Use in Final Field Test

This step involved the development offindings and conclusions from the 20-hospital field

test, and the design ofan instructionmanualtobe

adapted to each individual hospital by a survey

team member for use by hospital employees in

the final field test (Phase III). In addition, this

procedure included the revision of the interview

schedule and abstract form, based upon the experience of the 20-hospital field test.

PHASE Ill. ADMINISTRATION OF THE

FINAL FIELD TEST

The objectivesof the third and final phaseof

the study were to:

Test theapplicability offormsandprocedures

developed during the 20-hospital field test,

8
Exhibit IV. Patient charge ledgers reviewed

—

Hospital

Total------------------

Field test hospitals

1 ------- ------- ------- ------

2 ---------------------------

---------------------------

:---------------------------

5 ---------------------------

6----------------------------

7---------------------------

8?--------------------------

---------------------------

1:---------------------------

11---------------------------

12---------------------------

13---------------------------

---------------------------

:;---------------------------

lfj3 -------- -------- -------- --

-- -- - - - -- ---- - -- -- -- - - -- ---

K--------------------------

19---------------------------

20---------------------------

Final test hospitala

21---------------------------

22---------------------------

23---------------------------

24---------------------------

25---------------------------

Total ledgers

requested

*

1,64S

,038

389

10

31

26

2:

Total ledgers

I

Found Not found

1,904

65

:;

1%

97

99

---

68

103

82

66

98

1%

---

:;

1::

45

:;

45

95

12.084

180

25

2

3

3

i

1

---

32

1;

31

2

2

---

7

2;

8

9

i

1

Total ledgers found

Information Information

complete not complete

1,904

1,064

3:

::

42

55

32

---

40

58

%

48

47

59

---

49

58

9:

45

40

:;

74

lDifference between total ledgers requested and

from hospital No. 25.

total ledgers accounted for by extra ledgers

~Computer system, charge data on magnetic tape.

31n process of conversion to computer system. Ledgers not available.

450 ledgers were requested in hospital No. 25 but 96 were searched for.

including procedures for preparing an in- and source-of-payment data asapart of the

struction manual for use by hospital employ- HospitalDischarge Survey.

ees who would perform therecordsabstractPhase III included the following steps. ing.

Determine the accuracy and validity of the

abstracts prepared by hospital employees Selection of Five Hospitals

byhaving astudy teammemberindependently In the first step, five hospitals already par- abstract the same patient charge ledgers. ticipating in the Hospital Discharge Survey were

Develop findings andconclusions onthefeasi- selected for testing the accuracy and validityof

bility and practicality of establishing aeon- patient charge abstracting by hospital personnel.

tinuous program for collectingpatientcharge (See Exhibit III for characteristics of these hos-
pitals.) Hospitals with computerized accounting

systems were excluded as a result of findings

from the field test that special programming was

required to retrieve the necessary patient charge

and payment data from automated sources, and

that consequent delays would be encountered.

Administration of the Interview Schedule

In step 2, a general interview was conducted

by a study team member with each hospital

administrator, and a followup interview was held

with the accounting manager or a designated employee in the accounting department.

Preparation of the Instruction Manual

In this step, a member of the study team:

Modified the basic instruction manual to make

it applicable to the individual hospital and to

guide the hospital employee involved in selecting and abstracting patient charge ledgers.

Adapted the manual to each hospital. This

was made possible by a format which listed

alternative instructions from which the pertinent instruction for the individual hospital

could be selected. (See Appendix E for Hospital Instruction Manual.)

Explained the instruction manual to the selected hospital employee and demonstrated

abstracting procedures.

Supervised the completion of two or three

abstracts by the hospital employee, for training purposes, and answered any questions.

Provided the hospital with a supply of blank

abstracting forms and the names of patients

whose patient charge ledgers were to be abstracted. These names were selected from

the list of patients whose medical records had

been previously abstracted for the Hospital

Discharge Survey.

Abstraction of Records by Hospital

Employees

An employee in each of the five hospitals

utilized the instruction manual and prepared approximately 50 abstracts of patient charge ledgers

after the study team member had left the hospital.

(See Exhibit IV for data on ledgers abstracted.)

Audit of Abstracting Performed by

Hospital Personnel

The last step of the study consisted of a return visit to each hospital by a study team member for the purpose of:

Independently abstracting the same patient

charge ledgers that had been abstracted by

the hospital employee.

Comparing abstracts completed by the hospital employee and the team member to determine the accuracy and validity of data

collected by the hospital employee.

Revising forms and instructions based on

findings from the audit of hospital employee

performance.

LIMITATIONS

IN PILOT STUDY

Principal limitations in the pilot study on

hospital patient charge statistics were the following.

Hospitals with automated patient charge systems were not analyzed in depth in the study

because special programming would have

been required to retrieve the patient charge

data to be abstracted.

It was not possible to include the number of

large hospitals prescribed for the field test

(six) because most large hospitals were al10
ready participants in the Hospital Discharge

Survey and because the number of large

church-affiliated and proprietary hospitals is

very limited.

The purpose of the survey was to conduct a

“one-time” study of short duration, and

therefore the survey did not test the extent

of hospital cooperation for a continuing program of abstracting hospital patient charge

data. Also, the study did not provide conditions for preparing the staffing requirements, procedures, and forms for an ongoing

abstracting program as compared with a

“one-time” program.

The analysis of the patient charge data collected in the small sample of 25 hospitals

cannot be considered representative of the

total universe of hospitals in the United

States.

Ill. MAJOR CHARACTERISTICS OF

PATlENT CHARGE SYSTEMS IN HOSPITALS

The purpose of this chapter is to describe

patient charge systems as observed in the 25 test

hospitals prior to the presentation of findings and

conclusions on the feasibility of initiating a program of abstracting patient charge data on a

continuing basis. The chapter provides information on the major components of patient charge

systems relating to the format and content of a

completed patient charge ledger, and the procedures for creating, updating, and maintaining

patient charge ledgers in hospitals.

TYPES OF HOSPtTAL

PATlENT CHARGE SYSTEMS

Two major types of patient charge systems

were observed in the surveyed hospitals— the

itemized charge system wherein a charge is

posted to the ledger for each supply and service

provided to the patient, and the all-inclusive per

diem rate system wherein all patients are charged

the same flat rate per day regardless of the

amount and type of supplies and services provided.

THE COMPLETED PATlENT LEDGER

The patient charge ledger is the only hospital

record of the supplies and services provided to a

patient, the charges made, and the payments received. The information on the ledger is used by

the hospital for billing (invoicing) responsible

parties for payment and for accounting audits.

A completed patient charge ledger contains

the information on all hospital charges to the

patient and the dollar amount of these charges

as well as all payments received by the hospital,

a description of the source(s) of payment, and the

dollar amount of responsibility of the source of

payment (the source of payment may pay less

than its responsibility because of discounts, maximum allowances, etc.). These two items constitute

all the data required for patient charge and

source-of-payment abstracting.

In addition to information on patient charges

and source of payment, the patient charge ledger

also includes the patient’s name, admission number, and admission and discharge dates. These

three items comprise all the information needed

to locate a patient’s charge ledger in the file and

to verify that the ledger is for the same patient

and admission selected for patient charge abstracting.

A compIeted Iedger frequently contains other

information such as admitting diagnosis, attending

physicians name, type of accommodation, etc.,

but this information is not necessary for patient

charge and source-of-payment abstracting.

Information on patient ledgers was relatively

constant among the survey hospitals, but significant variations existed in the following areas:

Ledger Format

Some hospitals use single-column ledgers,

whereby descriptions of all charges and payments

11
EXHIBIT V. SANPLE OF SINGLE COLUMN PAll ENT OIARGE LEDGER

.“., “... T“., . . . . ,.”, ,.,, ,.,.

,,,, ,., ICI.Room R.,. D.,. .,,

‘r,msl.r

I ( I

1 1 1

9.,. A&l ,,.d

ID

.,. 1“1,, “.... ”., s.. MuFL01.. C,... N., .nd TyP. .,,.

e“”., “..

Clolm No. 00?.

,,, ,,” 0”,

E

D1..h.,,. C1..k Only

.s,1.s D.,. smt-al Ch.,g.,

R... & no. ,d

1

T.,.! O,h., Ch.,g., D.w .,

T.,.l 8!11 0111.d61.. Cm,.

Paid by P.N.n, Gor L

Cw.c.d by Bl”. Cr... Blu. c.-. Pm.{

are placed in the same column and usually are

posted consecutively by date of occurrence. These

postings may use color (red) or symbol codes for

denoting debits or credits. Other hospitals use

multiple- column formats, whereby charges are

posted to specific prelabeled columns (e.g., column may be labeled “laboratory’ ‘). Again, the

postings are consecutive by date. In hospitals

using multiple- column ledgers, a description of

the source of payment is usually spread across

several columns unless the source is coded, in

which event any column can be used. Exhibit V

is a sample single-column ledger, and Exhibit VI

is a sample multicolurnn ledger.

Equipment Used for Posting

The design and format of a hospital’s patient

ledger is usually controlled by the type of accounting equipment used by the hospital. Three

types of equipment were observed.

Bookkeeping machines. — Entries are manually typed and automatically calculated.

Talmlatovs. —Entries are manually typed on

cards via keypunch and fed into the tabulating

equipment, which automatically posts, calculates, and prints charges and sources of payment on the patient charge ledger.

Computers. -–Entries are manually typed on

cards via keypunch and converted to magnetic tape from which calculations are made

on charges and sources of payment.

Among the surveyed hospitals, bookkeeping machines were by far the most frequently used type

of equipment,

Number of Postings Made

Hospitals with all- inclusive rates often post

only one charge on a ledger, whereas hospitals

with itemized charge systems post for each individual charge made. Variation among the hospitals using itemized systems is significant because room and board charges may be posted

daily or only once per patient stay. While personal

charges, such as telephone and television service,

may be posted daily, once per patient stay, or

may not be posted at all since they may be billed

separately, included in other charges, or not provided.

Extent of Computations

Grand totals for room and board and personal

charges may or may not be shown on the ledger.

Method of Describing Charges and Sources

of Payment

Hospitals may describe the type of patient

charge or source of payment on the ledger by

spelling out in full or abbreviated

alphabetical or numerical code.

Method of Handling Writeoffs

Some sources of payment (e.g.,

commercial insurance paying for

form or by

Blue Cross,

Workments

12
EXHIBIT V1. SAMPLE OF MULTIPLE COLUMN PATIENT CHARGE LEDGER

PATIENT ADD RE SS

miirmtz=r== r..”, 16.2”,6.- —

——. ]AoMrimFrie,-

.——

BILL 70 r

L

M

Rk. & B

AND

NURSIN

_

~

) RUGS

_

_

LA8(l.

3ATORY

_

03DE Fon

I

,

U.SXLLMEWS 3

,— 4

‘E RATINI

:LIVERY

AMO”MT

_

-

X. RAY

_

-

6

LECTRO

CiRDICGRAM

.

-

J

MED. &

JRGICAL

uPPLIE$

——

3LOOD

_

.—.

$

ISCELUNEW

.“0””7

_

—.

TOTAL I CREOIT$ IOLD BALANCEI __

T

CHARGES

Mou”r

I

VAT E

—

BALANCE

OVERED BY INsIRANCE ——k”” HARGES TO PATIENT BALANCE

lsTHETICUATER!ALS ●.TISSUECHAK.E ,. E14C”, EN,-Y Roux

CO’ERY R-W” 1. OXYGEN ,.. .

ALL BILLS ARE PAY4nLE LPCU PE.E5UlTA17011

. SOLUTIONS 6. ‘rE LEPHON# ,, Or”k”s

m.* RGESARWWNG AI CmlkR.50FF1CE AFIERIWCHAIGEm LLt.&BILLEDA TALA?StD ATE

Compensation, and welfare) often do not pay the

hospital the full amount of their dollar responsibility. When posting these discounted payments,

some hospitals show both the amount of the payment and the writeoff. Other hospitals post only

the amount of the actual payment to the ledger

and subtract the full amount of the responsibility.

All patient charge ledgers, regardless of the

patient charge system, accounting equipment, or

ledger format used, provided for the posting of

dollar amounts in the form of debit or credit entries. Charges for supplies and services provided

patients were posted as debits. Payments for

such supplies and services provided are posted as

credits. AH debits are added to the balance due

and all credits are subtracted.

PROCEDURE FOR CREATING,

UPDATING (POSTING), AND FILING

PATlENT CHARGE LEDGERS

Creating Patient Charge Ledgers

in Hospitals

The patient charge ledger is usually created

by a clerk in the admitting or accounting office

at the time the patient is admitted to the hospital.

However, in many hospitals, the admitting office

is managed by the controller or business manager since the major portion of the admitting

information is obtained for the hospital’s accounting department.

13
The patient’s name and address, admission

number and date, and name and policy number

of the responsible source of payment, if other

than the patient are recorded on the ledger at the

time of creation. (This information may be first

recorded on an admitting form and then transferred to the ledger.)

The necessary information is usually typed

or written in the heading portion of the ledger. In

computerized hospitals, this information is obtained in the admitting office and later keypunched and entered into the system through a

card- to- tape converter.

Posting Charges to the Patient

Charge Ledger

Ml charges for supplies and services provided, for which the hospital expects to receive

payment, are posted to the ledger by a posting

clerk in the accounting department. On a multiplecolumn ledger, dollar amounts of the charges are

posted to the column prelabeled for that charge

or type of charge. On a single-column ledger,

the dollar amount for each charge is posted to

the single column.

In hospitals using itemized charge systems,

charges are posted to the patient’s charge

ledger usually within 24 to 48 hours after the

supply or service is provided. Charge slips are

prepared for each supply and service by the

servicing departments. These slips are then forwarded to a posting clerk in the accounting department, who transfers (posts) the information

from the charge slip to the patient’s ledger. The

following entries constitute a typical posting

operation--date of posting, description of the

charge, amount of the charge, and amount of the

new balance due. This operation is repeated until all charges are posted to the pat ient’s charge

ledger.

In hospitals with all-inclusive rates, charges

are usually posted to the ledger only on the day

the patient is discharged. The amount to be posted

is calculated by determining the number of days

the patient remained in the hospital and multiplying this figure by the all-inclusive rate. The resulting total is then posted to the patient charge

ledger.

Posting Payments to the Patient

Charge Ledger

All payments received by the hospital for

supplies and services provided are posted to the

patient’s ledger by a posting clerk in the accounting department. Payments are posted as

soon as they are received by the hospital,, and the

procedure is the same regardless of the type of

charge system.

The patient charge ledger for which a payment is received is removed from the active

ledger file and given to a posting clerk with the

payment information. Then the dollar amount of

the payment is posted as a credit, and the source

of payment is spelled out or a code is employed

for the entry. The following entries will be made in

posting a payment--date of posting, a description

of the party making the payment, the amount of

the payment, and the amount of the new balance.

This procedure is repeated as each payment is

recei!’ed until all charges are paid.

Filing the Patient Charge Ledgers

A hospital maintains a series of files for

patient charge ledgers. The particular file within

which a patient charge ledger is placed depends

upon whether all charges have been posted and all

payments have been received or whether payments

are substantially overdue. While a patient is in

the hospital and for a short time after his discharge, ledgers are kept in a file for accounts in

which all charges have not been posted. After

posting is complete, the patient ledger may be

found in one of several files, depending on the

status of the account. To find a patient ledger for

a discharged patient, therefore, several files may

need to be searched. Ledgers are filed alphabetically by the patient’s last name in each file.

Patient charge ledgers are maintained in the

following hospital files:

The open file, maintained by a clerk responsible for posting, contains files for which all

charges have not been posted.

14
The active file, maintained by a clerk responsible for accounts receivable, is composed of ledgers forwhich all charges have

been posted but for which payments are still

due.

‘The agency file, maintained by an accounts

receivable clerk, consists of accounts substantially past due that have been referred

to collection agencies. A hospital may not

always keep a record of individual ledgers

missing from its files that have been transferred to a collection agency.

The completed file, maintained by a ledger

file clerk, is composed of ledgers for which

all charges have been posted and payments

made.

The size of the hospital determines the number of personnel involved in posting charges and

payments and maintaining ledger files. In small

hospitals one person may perform all functions

whereas in larger hospitals one or more persons

may be responsible for each activity.

IV. FEASIBILITY OF ABSTRACTING PATlENT CHARGES

ON A CONTINUING BASIS

The analysis of the data from the 25 hospitals included in the pilot study permits findings

and conclusions to be made on issues of abstracting in a broad spectrum of noncomputerized hospitals of different size, location, and type. Such

an analysis can assist in deciding the feasibility

of abstracting patient charge data on a continuing

basis for a larger national sample of hospitals.

MAJOR ISSUES IN ABSTRACTING

PATlENT CHARGE LEDGERS

r~

Issue 1 can pa.fientChvge ,ledgemand medical

yecovds be abstyactedfov the same sam -

Findings

A patient charge ledger was prepared for

each patient and for each admission except newborn infants in the hospitals. Charges for wellnewlxmn infants who were discharged from the

hospital at the same time as the mother were

posted to the mother’s ledger in 22 of the 25 hospitals. (Three hospitals prepared separate ledgers for newborn infants.) In hospitals using single

ledgers for both the mother and child, it is impossible to distinguish from the ledger whether

certain charges are for supplies or services provided to the mother or to the child (e.g., drugs,

special nursing, and central supplies).

Of the ledgers requested, S.5 percent were

not found. Major reasons for not finding all requested ledgers in the 25 hospitals were as follows:

Hospital employees locating the ledgers often

searched only one hospital file for a ledger.

Ledgers filed in separate facilities were not

searched for. (These were usually completed

ledgers for which all payments had been

received.)

In the 20-hospital field test, some ledgers

were requested for patients discharged within

the previous few days, and the hospital did

not wish to remove these ledgers from the

open file.

Limited time available in the 20-hospital

field test did not permit an extensive search

of the files. In the five final test hospitals

where sufficient time was provided, two hospitals with problems in locating ledgers were

certain that the ledgers had been transferred

to a collection agency.

Conclusions

It is possible to use the same sample of patients and admissions for patient charge and medical record abstracting except for well newborn

infants, whose charges are usually combined with

and are often indistinguishable from those of the

mother on the same ledger.

15
In a

missing

not lost,

“one-time” study, such asthepilotstudy,

ledgers area problem. ‘lleledgers are

but are difficult to locate since they may

be kept in files (particularly the closed file for

completely paid accounts and the collection agency

file for overdue accounts) that are placed in separate facilities or at some distance from the accounting department. In a continuing abstracting

program, however, the percentage of ledgers not

found should not be significant for the following

reasons:

Hospital employees will have more time and

will search more thoroughly for all ledgers

requested.

Ledgers for recently discharged patients will

not be included.

Ledgers will be abstracted in the hospital

accounting department before being trans -

ferred to separate facilities.

Ledgers transferred to collection agencies

will be abstracted after they are returned to

the hospital.

[ssue 2 Can patient ckzwge and medical vecovds data ah tvacts, once pwpaved, be

matched fov the same patient and admission?

Findings

Abstracting medical records and patient

charge data can only be done when the source

record is complete.

Medical records and patient ledgers are completed at different times in most hospitals. Medical data originate in the medical records department and are usually available 2 to 4 weeks after

the patient is discharged. Charge and source payment data originate in the accounting department

and are usually available in 90 percent of the

hospitals within 60 days after discharge for 90

percent of the patients. This was determined by

direct questioning of the hospital accounting

managers and then verified by the study staff

during actual abstracting in the 20 field test hospitals. In the five final test hospitals, all ledgers

requested were for patients discharged 60 days

or more earlier; in four of the five hospitals 90

percent of the ledgers were complete. In the other

hospital, welfare, whose payments are frequently

delayed, was the predominant source of payment,

resulting in the high percentage of incomplete

ledgers.

Conclusions

Patient charge and medical records data

are not available at the same time, but it is possible to match the two data sets. This can be

done in three locations-in the hospital by the

accounting department, in the hospital by the

medical records department, and in Washington,

D.C., by NCHS.

Since medical records and patient ledgers

for the same patient are generally completed at

different times, separate lists of patients

selected for patient-charge-ledger and medicalrecord abstracting will be required in a continuing abstracting program. Unless arrangements are made to rely upon the coordination of

the two surveys within each hospital, both the

medical records and account departments will

have to prepare separate listings of patients

sampled for later cross-matching by NCHS.

Issue 3 Can room and boavd chavges be identified on patient chavge ledgers?

Findings

Patient ledgers in hospitals that charge according to each supply and service provided have

room and board charge data identified separately

on the ledger. Room and board charge data do not

exist on patient ledgers in hospitals that charge

an all-inclusive per diem rate. Some of these

hospitals have cost accounting breakdowns of the

all-inclusive rate which can be used to calculate

per diem room and board charges. The all-inclusive-rate hospitals that do not have cost accounting can provide estimated room and board charge

data which they already supply to third-party

payers upon request.

Four of the 25 hospitals used all-inclusiverate charge systems. In two of these hospitals

room and board charges had been determined

by cost accounting, and in the other two such

charges could only be estimated.

16
Conclusions

Accurate room and board charge data can be

identified in all hospitals that charge according to

each supply or service provided and in all-inclusive-rate hospitals where cost accounting exists.

The room and board charge data obtained

from all-inclusive-rate hospitals without cost

accounting breakdowns will be estimates of actual

charges.

Issue 4 Ave items included in Yoom and board

charges consistent among all hospikzls?

Findings

In most survey hospitals the room and board

charge was generally considered a catchall item.

Any item that is not separately charged for is

incorporated in the room and board charge.

The major portion of the items which is included in room and board was consistent among

the hospitals surveyed. ‘I’he following supplies

and services were included in room and board

charges in all 25 survey hospitals—room, food

(routine and special diets), routine nursing, laundry (linens, etc.), overhead (administration and

supervision), and building and building equipment

(maintenance of facility, depreciation, heat and

light, etc.).

These supplies and services, consistently

included in the room and bard charge of all

survey hospitals, constitute the bulk of items

and prices in the room and board charge. Laboratory services were excluded from the room

and board charge in all 25 hospitals. Exhibit VII

analyzes variations in selected items included

in room and board charges in the 25 hospitals.

Conclusions

There is sufficient consistency in the elements that make up room and board charges to

permit gross comparison of room and board

charges among hospitals. In all hospitals, the

room and board charge includes the same major

items including room, food, routine nursing, laundry, administrative overhead, and building and

equipment maintenance.

ssue 5 Can charges other than room and boar

I (other charges) be identified on patienq

Findings

Although per diem room and hard charges

are usually similar for all patients in hospitals

which charge for each supply and service provided, other charges will vary from patient to

patient according to the type and amount of supplies and services provided. Other charges can

be most easily computed by subtracting room and

board charges from total charges less personal

charges on the patient ledger.

Other charges in all-inclusive-rate hospitals

can be computed on an average per diem basis

for all patients; in other words, other charges

in all-inclusive-rate hospitals will be the same

per day for all patients.

Conclusions

Other charges can be computed in all hospitals, but only accurately for each patient in hos -

pitals that charge according to each supply and

service provided. Therefore, comparison of other

charges among patients (e.g., by diagnosis, length

of stay, etc.) will be reasonable only in hospitals

which charge according to each supply and

service provided; such comparisons will not

be meaningful among all-inclusive-rate hospitals

since per diem other charges will be the same

for all patients.

ssue 6 Aye items included in other charges consistent among all hospitals?

Findings

Only supplies and services billed for by the

hospital are included in other charges on the

patient charge ledgers. Exhibit VIII summarizes

the variations of items billed for as other charges

in the 25 hospitals.

Not all supp~es and services provided in the

hospital are billed for by the hospital. Supplies

and services may be billed for by various other

parties, including physicians, private nurses,

hospital auxiliary groups, and agencies other than

hospitals.

17
Exhibit VII. Variations in supplies and services included in room and board charges in

Hospital

1-----------------

2-----------------

-----------------

:-----------------

5--------------.--

6-----------------

------- ---------

L---------------

9-----------------

1o-----------------

11-----------------

12-----------------

13-----------------

14-----------------

15-----------------

16-----------------

17-----------------

18-----------------

19-----------------

20-----------------

21-----------------

22-----------------

23-----------------

24-----------------

25-----------------

. .

25 survey hospitals

Drugs

Routine

x

x

x

x

x

Percent of

hospitalsl-------- 20

Special

x

x

x

x

i

x

x

x

x

x

x

;

x

x

x

x

x

x

x

x

x

92

Surgical

dressing

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

68

Special equipment and services

<ecovery

room

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

72

Intensive

care

NP

NP

NP

NP

NP

x

NP

x

N:

x

N;

N:

NP

NP

x

x

Intravenous

feeding

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

I

57 88

Blood

setups

x

x

x

x

x

2

x

x

x

x

x

x

x

x

x

x

x

x

x

x

:

92

Oxygen

setups

x

x

x

x

x

x

x

$

x

x

x

x

x

x

:

x

x

x

:

x

92

lpercent of hospitals for which each supply or service is not included in room and board.

NOTE : The following supplies

25 survey hospitals: room,

and services were included in the room and board charge in all

food (routine and special diets), routine nursing, laundry (linens,

etc.),and overhead (administration, superviaion), building and building equipment (maintenance of

facility, depreciation, heat and light, etc.). Laboratory services were excluded from the room

and board charge in all 25 survey hospitals.

Legend: X = Supply or service not included in room and board charge.

NP = Supply or service not provided by the hospital.

Items for which thehospitals billunderother

charges are constantly changing because of new

programs (e.g., Medicare), decisions to separate

or combine billings with those of the hospital (e.g.,

pathology and radiology), and changes inaccounting standards.

Medicare rna yincrease the frequencyof billingby parties other that the hospital forsupplies

and for services provided in the hospital because

of its required separation of charges for certain

services such as pathology and radiology.

Conclusions

Not all other

ices received by

18

charges for supplies and servthepatient ina hospital willbe

included on the hospital’s patient charge ledger.

Although variations occur among hospitals onthe

items theyinclude inthecategoryofother charges,

gross comparisons of other charges among hospitals can be made since significant variations

occur only for a few items, particularlyfor anesthesis services. Comparisons can be made more

meaningful by obtainingperiodic informationfrom

each hospital on what items they include in other

charges.

‘Issue 7 Can chuvgesfov”blood be identified on

patient ledg-evs?

Findings

Charges for blood werepostedtothe patient’s

ledger in230f the 25 survey hospitals .In the two
Exhibit VIII. Nlethod of billing for selected other charges

Hospital

Field test hospitals

-----------------------

;-----------------------

3-----------------------

4-----------------------

-----------------------

:-----------------------

-----------------------

:-----------------------

9-----------------------

-----------------------

i!-----------------------

12-----------------------

13-----------------------

-----------------------

K----------------------

16-----------------------

17-----------------------

18-----------------------

-----------------------

;?-----------------------

Final teat hosDitak

21-----------------------

22-----------------------

23-----------------------

-----------------------

::-----------------------

Percent of hospitaLs?----

Pathology

H

H

H

H

H

H

H

H

H

H

H

H

100

Radiology

H

H

H

:

H

H

H

H

HM

H

;

H

G

H

H

H

H

J

H

d

100

Anesthesiology

:

H

0

0

4

0

0

HM

0

H

H

H

H

0

0

0

H

H

0

0

H

0

H

48

Blood

H

H

4

H

H

:

H

H

0

4

HM

$

H

H

H

H

H

H

H

H

H

96

Surgeon’s

fees

:

0

0

0

0

:

0

0

0

0

0

0

0

H

0

4

Regular

physician

visits

0

:

0

(;

0

0

0

0

0

0

:

0

0

0

0

H

0

0

0

4

Private

duty

nursing

o

0

0

0

(1?

:

0

0

0

0

0

0

0

0

0

0

0

0

0

:

:

4

lSupply or service is not provided at the hospital.

‘Percentage of hospitals included that billed for specified charges.

Legend: H = Billed as an individual charge by the hospital.

HM = Billed asanindividu+ chargeby the hospital except for Medicare patients where the

Dhvsician sends a aeDarate bill.

O = ~i~led separatelyby~he physician, auxiliary group,or agency (other than hospital).

other hospitals, blood was provided free through

the community’s blood bank. Patients were never

billed independently by the blood bank.

The posting of charges for blood is similar

to any other charge posting. When blood is provided the charge isposted to the ledger. If blood

is paid for by replacement through donors, a

credit posting similar to any other credit posting

is made.

Conclusions

Identifying charges for blood willbe aproblem only if hospital blood banks bill the patient

directly and the hospital doesnot post the charge

to the ledger. (This did not occur in any of the

25 survey hospitals .) In the hospitals thatprovide

blood free of charge, the charges to the patient

are truly reflected on the patient charge ledger

since there isno blood chargeor payment.

For hospitals which accept or prefer payment for blood through donor replacement (payment in kind), it will be necessary on the patient

charge abstract form to record the credits replacements as personal payments.

Issue8 Canpwsonal (nonmedical) chwges be

identifiedon patient ledgers?

Findings

Personal charges noted on patient charge

ledgers included those for television and tele19
phone. Personal charges were nothidden in any

other hospital charge in the 25 survey hospitals.

Telephone service was provided in 23 of the

25 hospitals and the charges for both long distance and local telephone calls could be identified

from the patient’s ledger in all 23 hospitals.

Television was provided in 24 of the 25 hospitals. Charges for television, however, could be

identified from the patient’s ledger in only 11 of

the hospitals (44 percent) because an auxiliary

group or television service in the other hospitals

independently billed the patient for the service.

Conclusions

Television and telephone service are the only

frequent personal charges that will be encountered

on patient charge ledgers, and these charges can

be identified from the patient charge ledger only

when the hospital does the billing. The hospital

will usually bill for telephone service, but other

parties such as auxiliary groups will often bill

independently for television.

A continuing program for abstracting patient

charge data may require identification of personal

(nonmedical) charges since such charges can

distort an analysis of patient medical costs. Personal charges should be deducted from total hos -

pital charges before any calculation is made ‘of

room and board and other charges. The number

of personal charge entries varies considerably

among hospitals, and will influence abstracting

time significantly in some hospitals.

Lssue 9 Can souvce of payment ofpatient chuvges

be easily identified fvompatient ledgevs?

Findings

Of the 10 sources of payment prescribed for

the study, 7 could be identified with consistency

from patient charge ledgers in all 25 hospitals

and 3 in only some hospitals. They are:

Identified in all hospitals

Blue Cross

Commercial insurance

Personal payments

Welfare (Including Title XIX-Medicaid)

Hospital discounts

Private charity

Medicare (Title XVIII)

Identified in some hospitals

Federal public service programs

Other service programs

Workmen’s Compensation insurance

Of the seven sources of payment ‘that can

always be !identified on patient ledgers, five accounted for more than 97 percent of total payments made to the hospitals.

Major sowces of payment

Total -----------------

Personal payments -----------

Blue Cross ------------------

Commercial insurance -------

Welfare ---------------------

Medicare (Title XVIII)--------

In pevfcent

97(,4

43.0

30.2

18.0

5,,5

0,7

Medicare, which had only been initiated at the

time of the study, will account for a greater percentage of payments in the future.

The seven sources of payment most frequently

identified in the hospitals (except Medicare) pay

the hospital directly. Medicare, paid through an

intermediary y agent, can be identified easily because the Social Security Administration requires

that .Nledicare payments be marked in red on the

ledger.

Workmen’s Compensation insurance cannot

always be identified from ledgers because it is

often paid by commercial insurance or government agencies that may be recorded by the hospital as the source of payment.

Federal public service programs and other

service programs also often do not pay bills directly but rather through intermediary agents

that are identified as the sources of payment on

the patient charge ledger. With special effort

Workmen’s Compensation often can be identified,

but this is not true with Federal public service

and other service programs.

20
Writeoffs (discounts) are frequently made by

hospitals for some sources of payment. Discrepancies, therefore, frequently occur between the

amount of patient charges for which the source of

payment is responsible and the amount that it

actually pays.

Personal payments to the hospital by patients

often include third-party payments made to the

patient as well as his out-of-pocket payments.

These third-party payments to patients are rarely

recorded on the patient charge ledgers.

Conclusions

Except for Medicare, sources of payment can

be accurately identified only when the source pays

the hospital directly. Therefore, Workmen’s Compensation, Federal public service programs, and

other service programs are probably not appropriate sources of payment to use in obtaining accurate information from patient charge ledgers.

These three sources, furthermore, accounted for

a minor proportion of total payments to the 25

survey hospitals. (See Appendix F for suggested

patient charge abstract form for future use.)

Information can be readily obtained for more

than 98 percent of the total payments to the hospitals (five of the seven easily identifiable sources

of payment accounted for 97.4 percent of the total

payments) if it is recognized that the amount of

third-party sources of payment will be understated

and that personal payments will be overstated,

since third-party payments made directly to the

patient will be posted as personal payments.

Although personal payments are one of the

most frequent sources of payment (43 percent of

sources of payment identified on all ledgers),

they are often only for personal charges such as

television and telephone, which constitute less

than one-half of 1 percent of total dollar charges

(although they may be significant in some individual cases).

To collect meaningful information on personal

payments as a source of payment, a subdivision

of personal payments into payments for nonmedical charges (e.g., telephone and television) and

payments for medical charges may be required.

By dividing this source of payment into two divisions, it will be possible to analyze patient responsibility more objectively and, if desirable, to

discount patient responsibility as a source of

payment when the payment is for telephone and

television only. Also, a provision in the abstract

form for a writeoff (discount) for Blue Cross,

commercial insurance, and welfare, when the

actual payment is less than the source of payment’s financial responsibility, may help assure

the collection of accurate data on who pays patient

charges in hospitals.

Issue 10 Can ualidpatient cha~ge data be obtained

if abstracting is done by hospital emplo yees?

Findings

In the five final test hospitals in which hospital employees and study staff independently abstracted the same patient charge ledgers, employee abstracting errors occurred in 6.2 percent

of the abstracts, as follows: Six arithmetic errors,

one patient charge overlooked, two figures copied

incorrectly, and two incorrect sources of payment

recorded.

Most errors found are correctable since

arithmetic errors can be controlled by validity

checks, and incorrect sources of payment can

be avoided by clarification of definition of source

of payment in the instruction manual for hospital employees.

Incorrect transposition of figures and overlooked figures cannot be controlled. Uncontrollable errors occurred in only 3 out of 176 abstracts, or 1.7 percent of abstracts completed.

Conclusions

Hospital employees can abstract patient

charge ledgers with considerable accuracy if

properly trained. Proper training will require

personal contact with the hospital employee and

the use of a carefully developed instruction manual for teaching and reference.

21
Issue 11 What will be the cost to hospitals to abstract patient chavge data on a continuing basis ?

Findings

Average time for a hospital to complete abstracts of patient charge ledgers varied considerably among the survey hospitals. Exhibits IX and X

summarize the time required to abstract patient

charge ledgers by study staff in the 20 field test

hospitals and by hospital employees in the 5 final

test hospitals. Average time required to abstract

a ledger ranged from 3.1 minutes to 12 minutes

for the following reasons:

Accessibility of the files. All files may not be

in the same location.

Quality of record maintenance. Files not

located averaged 8 percent and ranged from

O percent to 32 percent among hospitals.

Number of room and board postings. Hospitals may post room and board charges daily

or only upon discharge.

Extent of computations on the ledger. Some

hospitals have already totaled room and board

and personal charges and these figures need

only be transposed without computation.

Number of postings. Low number of postings

in hospitals with all-inclusive rates makes

abstracting easier. Frequency of posting of

personal charges (e.g., telephone and television) depends upon hospital systems and

policies and will vary considerably.

Ability and familiarity with the procedures.

Quality of staff assigned by the hospital and

training of these personnel influence the rate

of abstracting.

Time required by hospital employees to find

and remove patient ledgers from the files averaged 32 percent of total abstracting time for the

25 hospitals and more than 50 percent of abstracting time in several individual hospitals.

The difference in time required by study staff

and hospital employees to abstract a patient charge

ledger was not great (4.0 minutes for study staff

and 4.5 minutes for hospital employees). Hospital employees located ledgers in both parts of

the survey, and the average locating time in the

field test hospitals (1.9 minutes) was more realistic for future estimates of time requirements

because one of the final test hospitals required

excessive ledger locating time.

Conclusions

Based upon results of the survey and an assumed employee cost of $2.50 per hour, the cost

to the hospital to prepare 100 abstracts will

range from $12.50 to $50.00, or an average of

$25.00 for 100 abstracts. Reimbursement to hospitals may need to be on a variable rather than

a flat rate basis since time for abstracting can

vary considerably among hospitals based upon

their individual accounting system characteristics.

I

Issue 12 When will patient chavge ledgevs be

ready fov abs tvacting?

Findings

Since source-of-payment data can only be

accurately identified after all payments are received, patient charge ledgers cannot be abstracted until all charges and payments have been

posted to the ledger. The time required for this

complete posting of payments varied considerably

among survey hospitals. The time required after

discharge of patients for 90 percent of the ledgers to be completed in the 25 survey hospitals

was: within 15 days for 1 hospital, within 30 days

for 8, within 60 days for 14, and more than 1 year

in 1 hospital. This time lag was determined by

direct questioning of the hospital accounting

manager and then verified by the study team

while abstracting. In 23 of the 25 hospitals, 90

percent or more of the patient charge ledgers

were ready for abstracting within 60 days.

Variations among the study hospitals in the

time required to complete ledgers primarily

result from the degree of efficiency of ‘the hospital’s billing procedure and the dominant

sources of payment in the hospital (e.g., Blue

Cross pays more rapidly than welfare, which

often delays payment for months).

22
Exhibit IX. Time required by study team to abstract patient charge ledgers

Field test hospital

,

●

Total---------------------------------------------

l------------------------------------------------------

2------------------------------------------------------

3------------------------------------------------------

4------------------------------------------------------

5------------------------------------------------------

6---------------------------- ------------------------- -

7------------------------------------------------------

82-----------------------------------------------------

9------------------------------------------------------

10 ------------------------------------------------------

ll------------------------------------------------------

12------------------------------------------------------

l3------------------------------------------------------

l4------------------------------------------------------

l5------------------------------------------------------

l63-----------------------------------------------------

L7------------------------------------------------------

l8------------------------------------------------------

19------------------------------------------------------

2o------------------------------------------------------

Ledgers

reviewed

1.631

65

98

97

96

100

97

99

---

68

103

82

66

98

98

100

---

93

93

75

103

Time to

locate

ledgersl

(hours)

50.8

2.0

1.0

5.0

2.0

5.0

2.5

3.0

---

4.0

2.5

4.0

2.0

2.0

1.5

2.0

---

4.0

2.0

3.0

3.3

Time to

abstract

ledgers

(hours)

109.1

4.0

4.0

6.6

4.0

6.0

7.5

9.5

---

8.0

8.0

4.0

4.0

3.0

4.0

10.5

---

6.0

5.0

6.0

9.0

Average

time per

abstract

(minutes)

5.9

5.5

3.1

7.2

3.7

6.6

6.2

7.5

---

10.5

6.1

5.9

5.5

3.1

3.4

7.5

---

6.5

4.5

7.2

7.2

lThe locating time is an estimate because this was done by hospital employees while the study

staff member was abstracting.

2Computer system, charge data on magnetic tape.

‘?Inprocess of conversion to computer system. Ledgers not ava~lable.

Exhibit X. Time required bv hosp~tal emplovees to abstract ~atlent led~ers In

ILve linal tei.tiospltals

Final test hospital

Total--------------------------------

L1-----------------------------------------

22-----------------------------------------

23-----------------------------------------

24-----------------------------------------

25-----------------------------------------

Ledgers

reviewed

273

45

41

47

45

95

Time to

locate

ledgers

(hours)

18.25

2.00

0.50

2.00

1.75

12.00

Time to

abstract

ledgers

(hours)

20.25

1.00

4.25

1.00

7.00

7.00

Average

lme per

bstract

mmutes

8.5

4.0

6.9

5.1

11.7

12.0

Employee

completmg

abstract

...

Accountant

Clerk

Controller

Clerk

CLerk

(Insurance

department)

23
In all hospitals payments for certain types

of cases (e.g., Workmen’s Compensation or

automobile accident) may not be received for

several years.

Conclusions

More than 90 percent of patient charge ledgers will be complete and ready for abstracting

in the great majority of hospitals within 60 days

after patient discharge. Availability of completed

patient charge ledgers will be significantly delayed in some hospitals (particularly hospitals

with a high proportion of welfare patients) and

for some cases in all hospitals (e.g., Workmen’s

Compensation, automobile accident, and welfare).

Issue 13 Will hospitals cooperate in a continui~

program to abstract patient churges?

Findings

No hospital approached in the pilot study

refused to cooperate, although considerable explanation and persuasion were required to achieve

cooperation of several hospitals.

No hospital raised objections to the releasing

of patient charge data because of the issue of

confidentiality of hospital records.

In the five final test hospitals, certain problems in implementing a continuing abstracting

program were identified by hospital personnel,

including extensive new manpower and space

problems in the accounting department due to

Medicare workload and prior commitments to

other studies and surveys.

Survey staff found that the most important

factors that hospitals will consider in deciding

whether to cooperate in a program of continuing

patient charge abstracting are the time required

by hospital personnel to participate in an abstracting program and the attitude of top hospital administrative staff

to sources outside

Conclusions

to the value of providing data

the hospital.

The great majority of hospitals will cooperate in a continuing program to abstract patient

charge data, provided the approach is carefully

24

planned and personal, the time required is held

to a minimum by careful planning of hospital

time requirements, and training of hospital personnel is conducted by survey staff.

Other factors of somewhat less importance

in obtaining cooperation include making equitable

financial reimbursement for required hospital

time, stressing the national importance of the

information gathered from continued abstracting,

and providing an advance indication to the hospital

of the amount of time required of hospital staff

to abstract patient charge ledgers (such estimates

can be based on findings of the pilot study).

INTERPRETATION OF

FINDINGS AND CONCLUSIONS

In summary, the pilot study of hospital patient

charge statistics in 25 hospitals throughout the

United States supports the following conclusions.

Conclusion 1 It is feasible to collect patient

chavge and souvce-of-payrnent data

Patient charge data can be abstracted since

information is readily available in noncomputer

hospitals, valid data can be collected by hospital employees, and patient charge and source-ofpayment data can be collected at a reasonable

cost.

Conclusion 2 Most of the information collected

from an ongoing patient chavge abstracting pvogram will be accurate

and use&l; however, caution must

be exercised when using some information

Some incorrect source-of-payment data will

be collected because hospitals cannot determine

whether personal payments by patients include

third-party reimbursement made to the patients.

Special studies will be needed to determine the

extent of the third-party reimbursement that is

made directly to patients.

Patient charge data in all-inclusive-rate

hospitals will not reflect the individual patient’s

treatment requirements because all patients in

these hospitals have the same per diem charge.

Also, in addition, most all-inclusive-rate hospitals do not have cost accounting, and therefore
patient charge data cannot be broken down accurately between room and board and other

charges. Only a limited number of hospitals

presently use all-inclusive rates, so this problem is not great.

Items included in room and board charges

vary among hospitals, although most of the items

(i.e., room, food, and nursing) are consistently

included in all hospitals. Therefore, valid comparison of room and board data among hospitals

is possible.

Although items included in other charges

differ somewhat among hospitals because of variations in items for which the hospitals bill, gross

comparisons of other charges can be made since

significant variations occur with only a few items.

Periodic information from the hospitals regarding

items included in other charges can assist in

making more accurate comparisons of other

charges among hospitals.

Personal charge practices vary among hospitals because of different methods of billing for

television. Charges for television may be included

on the patient ledger or billed by a separate group

or agency. This should not create any major problem because total charges for television account

for a very minor percentage of total charges

(less than one-half of 1 percent for both television and telephone).

Personal (nonmedical) charges and payments

may be eliminated altogether in a continuing

abstracting program since they are small in

amount. By separately collecting charge and

payment data for personal items at the early

stages of a continuing program, a decision can

be made on whether personal charges should be

eliminated in a full-scale abstracting program.

~

Conclusion 3 Some technical problems must be

resolved befove implementation oJ”

Development of a Method to Insure That

Medical and Patient Charge Abstracts Are

Prepared for the Identical Discharge

The following four alternative methods are

available to ensure that the same sample of

patients is selected for medical record and patient

charge abstracting. (See Appendix G for a detailed description of these four alternative s.)

Initial selection of patient sample by the accounting department from the daily admissions list, with referral of the sample listing to the medical records department.

Initial selection of patient sample by the

medical records department from the daily

discharge list, with referral of the sample

listing to the accounting deparnnent.

Independent sample selection by the accounting department from the daily admissions

list and by the medical records department

from the daily discharge list.

NCHS referral of sample list for patient

charge abstracting to the hospital accounting

department after NCHS receipt of hospital

medical record abstracts.

Unless NCHS selects the last alternative, the

choice of sample selection method should be left

to the individual hospital. Permitting a choice

from among the other three alternatives should

assist in obtaining hospital cooperation.

The selection of the sample by the accounting department and referral of the sample listing to the medical records department is the most

economical because only one hospital department

has to select the sample and prepare the sample

list. In addition, ledgers for later abstracting

could be identified at the time of their preparation

and the time-consuming and therefore costly

process of locating completed patient ledgers

would be essentially eliminated.

Development of a Method for Matching

Medical and Patient Charge Abstracts

A decision must be made on the basis of the

following choices as to where abstracts of medical

record and patient charge data are to be matched.

Abstracts can be matched at the hospital by the

medical records or accounting departments, or

at NCHS, with the two sets of abstracts being submitted independently by the

accounting departments.

It would appear to be

match the medical record

medical records and

better for NCHS to

and patient charge

25
abstracts because hospital time and cost will

be reduced, NCHS can match at a lower cost by

computer use, and NCHS will need a matching

program for control anyway. NCHS matching will

also “minimize the need for additional contact between the accounting and medical records departments, which normally have limited association. In addition, completed abstracts for medical

record data will arrive earlier at NCHS because

they can be sent as soon as they are prepared

without waiting for the delayed patient charge

abstract. The possibility of abstracts being lost

within the hospital while waiting to be matched

will also be eliminated.

Development of Methods for Abstracting

Patient Charges on a Continuing Basis

From Automated Data Sources

It was decided not to abstract patient charge

data for automated sources in the pilot study because special computer programming to retrieve

patient charge data from automated sources

would be costly for a one-time survey, and because time requirements to complete such programming would have substantially delayed the

study.

Since automated data system hospitals were

reemphasized in the survey, the following questions still need to be answered:

Is data on patient charges retrievable from

automated sources ?

Can patient charge abstracting be automated?

Will hospital staff and computer time be

available to develop programs to retrieve

data? Will machine time be obtainable on

a periodic basis for abstracting?

Can valid patient charge data be collected

from automated sources at a reasonable

cost?

Will different interview schedules, instruction manuals, and abstract forms be required?

Until these questions are answered, NCHS

cannot begin abstracting patient charges on a continuing basis in hospitals with auton’iated patient

charge systems. Very few hospitals now have

fully automated patient charge systems, and even

in these hospitals it will often be possible to

abstract patient charge information using the

same procedures as in nonautomated hospitals

since printed ledgers are available. However, as

the number of hospitals with automated patient

charge systems increases, programs to abstract

mechanically will be needed because many hospitals will otherwise be unable or unwilling to

provide the data.

000

26
APPENDIX A

GLOSSARY OF TERMS

Accounting Equipment

Bookkeeping machine. —Equipment used by most hospitals for preparing patient charge ledgers and

posting patient charge and source-of-payment information to the ledgers. The machine consists of a

typewriter keylward and a calculator.

Conz@tev. —Equipment used in some of the larger hospitals for preparing patient charge ledgers

and posting patient charge and source-of -payment information to the ledgers. The ledger in these hospitals is often on magnetic tape and a program is required to abstract the patient charge and sourceof-payment data.

Tabulato~. — Equipment used in a few hospitals for preparing patient charge ledgers and posting

patient charge and source-of-payment information to the ledgers. Its capabilities are midway between

those of the bookkeeping machine and the computer. The tabulator can compute automatically but cannot

store information on magnetic tape.

Accounting Terms

Debit. —Accounting term for an entry on the side of an account (ledger) showing indebtedness. All

charges to the patient are posted to the debit column of the ledger.

Credit. –Accounting term for an entry to an account (ledger) of the reduction of a debit. All payments to the hospital for charges incurred by a patient are posted to the credit column of the ledger.

BaZance due. —Amount of money owed to the hospital. When balance due is zero, the ledger is completed, or paid.

Charges

Other chazges.— All charges to the patient, except room and board and personal, which are posted

to the patient charge ledger.

Personal chumys. —All nonmedical charges to the patient for items such as telephone, television,

guest meals, etc., which are posted to the patient charge ledger.

Room and board charges. -Hospital charges to the patient, usually for room, food, and nursing plus

any other miscellaneous item for which the hospital does not make a separate charge.

Total charges .—Total of room and board, personal, and other charges which are posted to the patient

charge ledger.

Charges Covered

For a ledger to be completed (paid), a payment covering each charge on the ledger must be received

by the hospital. Usually, the amount of the payment equals the amount of the charge, but in several cases

27
this may not be true.

than the full charge.

For example, Blue Cross has contracts with hospitals in many States to pay less

Commercial insurance companies, when paying for a Workmen’s Compensation

case, may pay less than the full charge and welfare often pays the hospital less than the full charge. In

all these cases, the payment covers less than the full charge, so that the hospital must write off the

difference between the charge and the payment received.

The pilot study investigated the amount each source of payment is responsible for, not how much it

actually pays. Therefore, the abstract form collected data on total amount covered. To avoid errors in

abstracting the source-of-payment information in hospitals that post the amount of the payment, provisions were made on the abstract form for writeoffs. This alerts the abstracter to a possible reason for

total charges not equaling total amount covered. It is not necessary to record the amount of the writeoff

if the hospital would prefer just to add this amount to the amount covered and record this as a single

figure.

Charge Systems

All-inclusive vate.—Patient charge system used by some hospitals whereby the patient is charged a

flat daily rate no matter what supplies or services are provided by the hospital. All patients, no matter

what the severity of their illness, are charged the same rate in these hospitals.

Itemized- chavge, according to suppl y or service provided .—Patient charge system whereby the

patient is charged for each supply or service provided. Each charge is separately itemized on the patient

charge ledger.

Files

Active file. —File of patient charge ledgers for which all charges are posted but are still unpaid.

Sometimes referred to as Accounts Receivable, Awaiting Payment, or Billing Files.

Agency jile.—File of patient ledgers determined uncollectable by the hospital and turned over to a

collection agency for recover y. Sometimes referred to as the Bad Debt File.

Completed file. - File of patient charge ledgers for the current fiscal year for which all charges

have been posted and all payments received, leaving a balance of zero. Sometimes referred to as the

Closed File.

Inactive file .—File of completed patient ledgers (all charges posted and all payments made) more

than one year old. (Seven years is the usual legal requirement for file retention.) Sometimes referred to

as the Dead File.

Open file . — File of patient charge ledgers for which all charges have not been posted. Sometimes

referred to as the In-House or Posting File.

Hospital Departments,

Accounting depavt?nerzt.-Hospital department responsible for preparing, updating, and maintaining

patient charge ledgers which are the source documents for patient charge and source-of-payment abstracting.

Medical ~ecoyds depa?dment.— Hospital department responsible for preparing, updating, and maintaining the hospital’s medical records which are the source documents for patient medical data abstracting.

Hospital Forms

Bill .—Document sent by the hospital to the patient or other responsible party describing the charges

and requesting payment for the amount shown on the bill. Also called an Invoice.

28
Patient charge ledgev.-Accounting department record of all supplies and services provided, charges

made, and payments received for all patients admitted to the hospital.

Patient Charge

A hospital charge to the patient for supplies or services provided.

Patient Charge Abstracting

Process by which patient charge and

recorded on a patient charge abstract.

Payments

source-of-payment information on the patient charge ledger is

Discozmts.—Full or partial credit for a patient given by hospitals, usually to employees, physicians,

etc. A discount is posted like a payment since full charges are posted to the ledger for patients receiving discounts. Sometimes called an Allowance.

Pevsoruzl. —Payments made to the hospital by the patient.

Third @@P- ayments made by party other than the patient for supplies and services received in

the hospital.

Posting

Process of recording patient charge and payment information to the patient’s ledger. Information

usually includes a description of the charge or party making the payment plus the amount of the charge

or payment.

Separate Billing

Billing for a supply or service provided in the hospital but billed for by a physician, an agency, or

auxiliary groups (e.g., anesthesiology, pathology, radiology, television).

Survey Materials and Forms

Hospital instruction manual. -Manual prepared for each individual hospital by the survey team during the initial visit to the hospital. It includes instructions for:

. Selecting sample for abstracting

. Identifying ledgers for abstracting

. Removing completed ledgers from file

. Preparing abstracts for completed ledgers

. Mailing abstracts to NCHS

Interview schedule.— Document used to record information collected by direct interview of hospital

personnel pertaining to characteristics of the hospital and its patient charge system.

Patient chcwge abstvact. —Form used for recording patient charge data for patients included in the

study.

Tvaining nzanual.-l%cument used to train pilot study staff to conduct interviews and abstract

patient charge data during the field test.

29
Survey Staff

Personnel who were responsible for planning and conducting the pilot study of hospital patient

charge statistics.

000

30 I
APPENDIX B

CONTACT LETTERS USED WITH HOSPITALS

INTRODUCTORY LETTER FROM NATIONAL CENTER FOR HEALTH STATISTICS TO HOSPITAL

Dear Administrator:

The National Center for Health Statistics of the U.S. hblic Health Service is planning tc undertake a national survey to collect hospital charge statistics for patients treated in short-stay

hospitals. This project is a phase of the Hospital Discharge Survey, which is currently collecting national hospital patient statistics. The objectives and design of the Hospital Discharge

Survey are described in the enclosed report.

The purpose of this letter is to request your cooperation in a pilot study on patient charges

involving a small number of hospitals. Your hospital was recomme~ed by of the

areawide Planning Council as one whose information would make an important contribution toward

developing souredconclusions in this project. Within the next several days, a representative

of Booz, Allen, & Hamilton Inc., acting as an agent of the National Center for Health Statistics,

will telephone you to arrange for an appointment to discuss the details of the project more

fully.

The National Health Survey program, of which the Hospital Discharge Survey is a part, has been

aPProved by the House of Delegatesof the American Medical Association, and the Hospital Discharge Survey itself has been endorsed by the Board of Trustees of the Americah Hospital

Association.

All information collected in this pilot study will be accorded strict confidential treatment

as provided by Federal regulations and will be used for statistical purposes on>~.

Without the cooperation of your hospital amd otaers like yours, this important research project

cannot succeed. I therefore urge you to participate in this project.

Sincerely yours,

Monroe G. Sirken, Ph.D.

Chief, Division of Health Records Statistics

31
LETTER FROM STUDY STAFF TO HOSPITAL TO EXPRESS APPRECIATION FOR

HOSPITAL COOPERATION IN PRETEST

mar Administrator:

We would like to express our sincere thanks for your help in the pretest phase of our study for

the Public Health Service. The informationwe received at is now being

used to modify our questionnaire and abstract forms for the next phase of the study.

Although we cannot promise that there will be a direct way in which we can repay you for your

help, you csm be assured that if we do come upon any ideas that we think would be beneficial to

your hospital, we will certainly pass them along to you.

Very truly yours,

BOOZ, ALLEN & HAMILTON, Inc.

32
LETTER FROM STUDY STAFF TO EXPRESS APPRECIATION FOR COOPERATION

OF FIELD TEST AND FINAL TEST HOSPITALS

Dear Mr.

We deeply appreciate the time which you have extended to us and the U.S. Public Health Service

in the important study we are conducting for the National Center for Health Statistics to de.

velop a method.olo~ for abstracting patient charges as a means of securing important national

data for health program planning.

The informationwe obtained in your hospital and the excellent results achie~ed by your people

in our field survey were most useful and encouraging to us.

Thank you again for your cooperation.

Sincerely yours,

BOOZ, ALLEN & HGMILTON, MC.

000

33
INTERVIEW

Initial

Mail

Contact

Telephone

Contact

APPENDIX C

SCHEDULE USED WITH SELECTED

Form Approved

Budgcc Bureau No. 68-R620.R2

INTERVIEW SCHEDULE FOR FINAL TEST HOSPITALS

CONFIDENTIAL. All information which would permit identification of an

.—

individual or of an establish lnent will be held co]]fid~ ,mial, will be used only

by persons engaged in au d for the purposes of the survey and wi 11 not be dis- 001

closed or released to other persons or used for any other purpose (22.FR 1687) ZZe*/86

Hospital Charge Pilot Study Name and Address (verify

Booz, Allen & Hamilton on behalf of and correct, if necessary)

National Center for Health Statistics

U. S. Publlc Health Service

Department of Healrb, Education, and Welfare

Section A - Summasy of Telepho!]e Appointment and First Personal Visit

Date Sent Received

a. National Center for Health Statistics Letter yes 110

b. Booz, Allen & Hamillon Letter yes no

a.

b.

c.

d.

Date of telephone contact

Appointments made for personal visir a.m.

Date Time p.m.

Name Title

Room and Building

Comment and important items discussed with administrator on The telephone

Other telephone contacts

Name Title

Nalme Title

Summary

of Personal

Interview

with

Administration

a, Hospiral Cooperation _U nqualifie d cooperation _Qualified cooperation (describe)

Refused to cooperate (describe)

Interviewer

Coordinator’s Name:

If additional space is needed for comments, use last page of questionnaire

Name: Date fosm completed:

34

\
INTERVIEW SCHEDULE WITH ADMINISTRATOR

The U.S. Public Health Service is interested in collecting information from patient ledgers on charges

and sources of payment, and in relating this data to the medical information nnw being collected by

the medical records department for the Hospiral Discharge Survey.

The medical records deparmnent in your hospital is currently supplying ~he Public Health Sertice with

data from the medical records fm about 30 discharges per month. The additional information that the

Public Health Service is interested in collecting is:

1. Total Charges

2. Room and Board Charges

3. Other Charges

4. Somces of Payment

5. Dollar Amount of Responsibility by Snurce of Payment

This inform ation would be obrained from rbe patient’s ledger and would have to be fnr the same

patient and hospitalization episode now being used by the medical records deparrmem for medical

data abstracting.

Booz, Allen & Hamilton Inc. has been conducting this study for the U.S. Public Health Service. The

study is now in its final phase. To date, hospitals in Illinois, Michigan, California, Louisiana, and

New Jersey have been studied. As a result of these stndies, it has been determined that it is possible

to collect TM information from patient ledgers. Procedures and forms have been developed which

need to be teated in this final study phase.

The study will require a maximum of two days and probably leas in each hospital. Each hospital will

be visited during the week of November 7, 1966, to develop the procedures and again on the week of

December 15, 1966, to see how the procedures were followed and to discuss any prnblems rhat may

have occurred. It is to be emphasized that this study will not continue beyond the above mentioned

dates and that all information obtained will be kept strictly confidential.

Before talking to your buaines manager, I would like to ask you some questions about the survey and

how a survey of this nature would be received by your hospiral IF it were to be conducted on a

continuing baais for a small sampLing of dischmges per month.

As we mentioned earlier and as you can see from the abstxact form, we are interested in obtaining

information from patient ledgers on Total, Room and Board, and Other charges and sources of payment

including their dollar amount of responsibility.

1. Can you foresee any objections that hospital’s management might have to releasing tfds

inform ation?

Yes No

If yes, uxplain

Q

-. What would be your feelings about participating in this survey if the work were to be done on a

continuing basis by your business office staff, with the Public Health Service crrn~nsating your

hospital for the rime spent as rhey are now doing with rbe medical records department?

—.

35
Ask this question if the administrator feels that the major cause of concern would be availability of

time in the business office.

3. Would you think it would be better if staff from the Public Health Service were to do the

abstracting instead of your own hospital staff?

Yes NO

4. From your knowledge of your hospital and others, which factors, if any, do you think would

cause the greatest concern about conducting a survey of this nature?

INTERVIEW SCHEDULE WITH BUSINESS MANAGER

The U. S. Public Health Service is interested in collecting information from patient ledgers on charges

and sources of payment and in relating this data to the medical information now being collected by the

medical records department for the Hospital Discharge Survey.

Owing to many differences in hospital systems, records, and policies, it is nece’’sary to obtain the

following inform arion before a procedure can be developed to abstract patient (charge information in a

hospital.

Type of equipment rraed to post and record charge data

Type and amount of information available from a patient’s ledger m equivalent

Filing and coding practices ured by your hospital for patient ledger>

Time require d to com plere records and receive payments from discharged patients

Make-up of Total and Room and Board charges

The purposE of my visit today is to obtain this information abour your hospital and, with your he 1P, to

develop and rest a patienr chsrge abstracting procedure, and to teach one of your em plnyees to use the

developed procedure.

I have a sample of the Hospital Dischstge Survey Iisring and a sample abstract form. If YOUcould

obtain a sample of rhe hospital’s discharge listing and a representative paid patient ledger, I believe

we will have all the documents that are needed for this discussion.

1. One of the major considerations for developing absuacting procedures is the type of equipment

your hospital uses for posting chsrges and payments to a patient’s ledger. Which of the following

is used at your hospital?

For Charges For Payments

1. Computer

2. Tabulating equi pmenl

3. Bookkeeping machines (NCR, etc. )

4. Manual

Does your hospital have any plans to change rbis equipment in the near future?

Yes NO

If yes, explain.

If computer--use Computer Hospital Instruction Manual for developing the abstracting, procedmes.

36
2. As we mentioned earlier, the patient charge information needs to be collected for tie same

patient and hospitalization episode that rhe medical reccrds department is using for patient

medical data absuacting. If the medical records department were to suPPly your office with

the list of patients they have selected, (show sample list), would your office be able to locate

the ledgers for the same patients and hospitalization episodes?

2a.

2b.

Yes No

If item 2 is no, what additional information would your office require?

If item 2 is yes, skip to item 4.

Tbfs list (show list) is prepared by the medical recmds department using the hospital’s daily discharge

listing. Each month, a sample of discharges is selected @sually through a terminal di@t) to be used

for medical da:a abstracting.

3. Can tbe additional information required by your deparment (refer to quesricn 2a. ) be cbtained

from the daily discharge listing?

Yes No

If item 3 is yes, do you think the medical records depararrem would supply this additional

information to your office?

Yes No

If item 3 is not dces your office have access to the daily discharge listing or any other records

which could be used to obtain this additional identifying information?

Yes No

4. If patient charge absuacting were to be done on a regular basis in your hospital, which of she

following methods would you suggest for coordinating patient charge and medical data abstracting?

a. Medical records department will continue to prepare listing but will prepare one extra

copy for the business office, which will add additional data as reqrdred.

b. Business office will select and identify patient ledgers on its own, using the same

procedures now being used by the medical records department for reletting the sample.

c. Medical records department will prepare one extra coPy and will add any additional

inforrpation to the business nffice copy, as required.

d. Other? Explain.

The U. S. Public Health Service is also interested in the tyw of charge system used at each hospital

since it will have a direct effect on the procedures used for absrmcting.

5. Uses your hospital charge any of its patients on an all-inclusive per diem (daily) rate or do

you charge all your patients according ro each service or supply received?

All-inclusive

According 10 service or supply

37
If all-inclusive, is it possible to break down this rate to determine the amount charged for

Room and Board?

Yes No

If~, what figure is supplied to inswance companies that request such a breakdown?

$ per day

6. Now let us consider the information we are trying m obtain. As you can see from the abstract

form, we are interested in obtaining Total Charges. Since The makeup of Total Charges varies

among hospitals, it is necessary to determine what is included in Total Charges in your hospital.

For the purposes of Ibis study, Total Charges are defined ax All charges to the patient that are

posted to the patient’s ledger. 1 will read off a list of services or supplies that may or may not

be included in your hospital’s Total Charge figure. For each service or supply, could you tell

me if the charge for each is:

Professional Fees for

1. Pathology

2. Radiology

3. Anesthesiology

4. Surgery

!.5 Regular physician(s)

visits

F?ofessional Fees for

6. Physical therapy

7. Other professional fees

(explain)

8. Private duty nursing

Services

9. Tr!evision

10. Telephone

11. Local telephone calls

12. Guest Imeals

Supplies

13. Blcod

14. Other

Included

in Your

“Total”

Hospital

L&EL

Billed

Separately

and not

Included in

“Total”

Charge

Not

Render ed

at This

WWQ_

Not

Charged For

38
7. Can you think of any other supplies or services which may be billed separately at youI hospital?

(Billed separately means that the charge is not posted to the patient’s ledger. )

8. Again, looking at the ab,suact form, you can see we are also interested in Room and Board

Charges. We would like to see what is included under Room and Board at your hospiral.

Could you tell me if your hospital includes the following supplies and services under Room

and Board or charges separately for them?

Not Considered

Included Separate in Fisher

Food

Routine diets

Special diets

Rourine ,drugs (aspirin, etc. )

Special drugs

Routine nursing

Private duty nursing

Building and Building Equipment

Maintenance of facility

Depreciation

Heat and light

Air-conditioning

Laundry Services

Overhead

Administration

Supervision

SPcial Equipment and Services

Intensive care

Inuavenous feeding

Recovery mom

Surgical dressings

Oxygen setups

Blood setups

Telephone

Television

Guest meals

Laboratory Services

Urinalysis

Routine blood counts

Biopsies

Basal metabolism

39
9. Are there any other supplies or services not mentioned on the preceding page that your hospital

includes in Room and Board?

Yes —No

QE2. w~in.

The next item to consider is the requirements for completing a patient charge and source of payment

abstract. Based On our experience to date, it has been determined that patient charge and source of

payment abstracting can only be done accurately from a paid or confirmed patient ledger. Assuming

this to be true, and this survey were to be conducted on a continuing basis, we would be interested

in determining whether a system could be worked out in your office so that the selected patient ledgers

would only have to be searched for and located once.

10.

11.

Considering this as an ongoing survey, do you think the procedure to be described in the following

paragraph, or one similm to it, ——could and should be used to conduct this survey at your hospital ?

Obtain (or develop) a list of patients records to be ahsmacted,

Locate the selected patient ledgers in the file.

If the ledger is paid or confirmed, remove from file.

If ledger is unpaid or unconfirmed, identify it for abstracting with a TAB or STAMP, etc.

Ttds would alert the posting clerk to give this ledger TOthe abs~actor once it is paid or

confirmed.

Abstract from all paid or confirmed ledgers removed from file or forwarded by the

posting clerk.

Could this procedure be followed?

Yes No

Should tlds procedure be ‘followed?

Yes No

If no, can you recommend any other procedure that could be uced to eliminate the need for

=ng an unpaid account sevetal times?

Yes No

Paid ledgers are usually necessary to obtain accurate source of payment information. We are

interested in identifying the following sources of payment and the amount for which each source

is responsible. Could you tell us, for each of the follnwing sources of payment, if:

(1) Source and amount can be identified from the paid ledger

(2) Source and amount cannnt be identified from the paid ledger

Yes No Explain

Can Be Cannot Be (Yes--Where and How)

—Identified —Identified (No--Why)

1. Blue Cross and Blue Shield

2. Patient Responsibility

Medical charges

Personal charges

(TV, phone, etc. )
12.

13.

14.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Yes

Can Be

Identified

Commercial Insurance

Social Security Adminismation

(Title XVII Medicare)

Welfare (includes Title XIX

Medicare)

Workmen’s Compensation

Federal Public Service

Programs (V. A. etc. )

Other Service Plans

(Kaiser, CHA, etc. )

Probate Courts

Hospital Discounts and

Allowances

Private Charity

Union Welfare Fund

Other (explain)

No Explain

Cannot Be (Yes--Where and How)

Identified (No--Why)

Since we are interested in abstracting from paid or confirmed led~ers, we would like to get an

idea of how long your hospital requires to collect its bills so we can determine when abstracting

can be done.

For all your patienrs with third-party coverage discharged today, how many days would your

hospital require to receive payment or confirmation from the third parry on 907. of them?

Days

As you know, many patienta who pay their own hospital bills are reimbursed by their commercial

insurance. Have you any way of distinguishing those who are reimbursed frarr those who are not?

❑ Yes ❑ No

WV how and how acc~ate~y?

Would it be possible so make copies of a completed ledger, and also copies of other hospiral

records, if any, which conrain source of payment information rbat is nor on the ledger? The

name of the patient can be blanked out.

❑ Yes ❑ No

This concludes the intetview portion of the study.

To CM plete our study, we would like to develop the abstracting procedure to be used at your hospital.

To save time, an outline has already been developed. From this outline, the procedure can be prepared

,by crossing out any statements that do not relate to your hospital’s system or records. The statements

that remain or are filled in should be the abstracting proceduse.

We would then like to explain the absmacting procedure to the persnn selected by you to do the

abstracting. A few abstracts would be completed to show him (her) what has to be done.

41
We would then leave this list (show list) with you. Within the next couple of weeks (before the week

of December 15th), we would appreciate it if you would complete the abstracting for the patients on

the list. During the week of December 15th, we will return to your hospital and check on the work and

the problems encountered. To save time, it would be very helpful if the ledgers used for abstracting

(or copies thereof) could be kept aside with the completed abstracts for our review so that they would not

have to be locared again when we return.

I believe we are now ready to develop the abstracting procedure from the prepared outline.

INTERVIEWER’S COMMENTS AND ANALYSIS

1. Availability of source documents and information

a. Daily discharge listing Yes No

b. Patient ledgers Yes —No

c, Sources of payment Yes —No

@, why was information NOT available?

2, Problems encountered and other comments

INTERVIEWER’S CHECK LIST

All que srions on questionnaire completed

Abstracting procedure developed

Samples of patient ledgers received

Selection list completed with nece%ary identifying information

Hospital employee instructed on ab:mracting

Time summary explained

Appointment made for follow- up visit

42
APPENDIX D

PATlENT CHARGE ABSTRACT FORM USED IN FINAL TEST HOSPITALS

Form@PIO.,d

I+ud,wtRK,Z,I N.. 6% R620.R>

CONFIDENTIAL. All information which would permit identification of an individual or of an establishment

will be held confidential, will be used only by persons engaged in and for the purposes of the suney, and

will not be disclosed CTreleased to ohm persons or used for any other purpose (22 FR 1687).

PATIENT CHARGE ABSTRACT

I. TO BE COhWKETEDBY ACCOUNTING DEPARTMENTFROM MEDICALRECORDSLISTING.

Patient’s Admission Number

Medical Record Number

Discharge Dare

Admission Date

HDS Number

IL TO BECOMPLSTSD BY ACCOUNTING DEPARTMENT

Total Charges Total Amount Covered

Room and Board Charges

Otier Charges (less Amount

Personal Charges) Sources of Payment Covered

Personal Charges ❑ Blue Cross and Blue Shield

Blue Cross ond Blue Sinield write-off

❑ Patient Raponsibility (Medical Charges) _

❑ Patient Responsibility (Personal Charges,

e.g., TV, Telephor% etc. )

❑ Commercial Insurance

❑ Social Security Adminisuation (Title XVIII

Medicare)

❑ Welfare (includes Title XIX Medicare)

Welfare write-off

❑ Workmen’s Compensation

❑ Federal Public Service Rogram (Veteran’s

Administration, etc. )

a other Service Plans (Kaiser, CHA, etc.) _

❑ Hospital Discounts

❑ Private Charity

❑ Other (expIain)

Total Sources of Paymenr (number of Boxes

Checked)

(Work space for abstracter’s calculation and commerm)

Abstracting Date Absmactor’s Initials

43
APPENDIX E

HOSPITAL INSTRUCTION MANUAL USED IN FIELD ‘TEST HOSPITALS

Form Approved

Budget Bureau No. 68-R620. R2

HOSPITAL INSTRUCTION MA NUALi

f3r

Abstracting Patient Charges and Source-of-Payment Data

for the

U.S. Public Health Service

at

(Name of Hospital)

Mmrua I Completed on

1

The Manual presents alternative methods for handling each step in patient charge abstracting. AH inappropriate alternatives for the individual hospital are to be crossed out on the Manual by the study staff member explaining the Manual

to the hospital. The remaining method(s) for each step in abstracting is the one the hospital is to use for each step in

abstracting.

44
PATl ENT (ACCOUNT) IDENTIFICATION PROCEDURE

Patient charge and source of payment information will be abstracted for the same patient

and hospitalization episode that the medical records department uses for abstracting patient

medical data for the National Center for Health Statistics of the U.S. Public Health Service.

1. Obtain the list of accounts that have been selected for abstracting.

2. Remove ledgers (identified from medical records list) from the file and complete the

following items in Section I of the abstract for each ledger.

. HDS number

. Patient number

. Discharge date

Other

3. Abstract from a paid or confirmed ledger only.~

ABSTRACTING PROCEDURE FOR OBTAINING “TOTAL’ CHARGES

The first item to obtain is total charges (see instruction sheet for location of total charges

on abstract).

4a.

4b.

4C.

5a.

5b.

SC.

5d.

Total charges on a patient’s ledger are for one hospitalization only-proceed to number 4.

Total charges on a patient’s ledger may include a balance from a previous admission.

If so, subtract any previous balances before completing item 4. Proceed to number 4.

(Add any other procedure of choice for the hospital.)

Enter total charges on abstract from the total shown on the ledger. (See 3b if not

crossed off.)

Compute total charges by scanning ledger for all payments (credits) and adding the

total of these payments (credits) to the balance due, if any, (see 3b if not crossed off)

and enter on the abstract.

Compute total charges by adding all subtotals for supplies and services. (See 3b, if

not crossed off.) Then enter on the abstract.

(Add any other procedure of choice for the hospital.)

2For the field ~e~t, ~etum ~11 ~b~trac~ for unpaidand unconfirmed accounts with a statement “account not paid”

instead of completing Section II. Be sure to complete Section I of all abstracts.

45
PROCEDURE FOR OBTAINING “ROOM AND BOARD” CHARGES

The second item to obtain is room and board charges.

This hospital has an “all-inclusive-rate” system.

6a. Use $—..._per day as room and board rate. Then:

Multiply figure in item 5a by the number of days the patient stayed in the hospital. Then:

Enter result of item 5b under room and board charges on the abstract.

This hospital charges according to each supply or service provided the patient.

6b.

6c.

6d.

6e.

The

7a.

7b.

7C.

The

8a.

8b.

Enter total for room and board (as shown on ledger) on the abstract.

Compute room and board by totaling all room and board postings in the room and

board column of the ledger and enter total on abstract.

Compute room and board by scanning entire ledger for all room and board postings

(not in separate column) and total all these postings. Enter this total on abstract.

(Add any other procedure of choice for the hospital.)

PROCEDURE FOR OBTAINING “PERSONAL” CHARGES

third item to obtain is personal charges.

Enter personal charges on abstract, as follows:

Total all charges for telephone, television, and guest meals and enter total on abstract.

Total all charges for codes_, _, and _ and enter on abstract.

(Add any other procedure of choice for the hospital.)

PROCEDURE FOR OBTAINING “OTHER” CHARGES3

last charge item to obtain is other charges.

Calculate other charges as follows:

Total room and board and personal charges and subtract this sum from total charges.

Enter result on abstract for other charges.

(Add any other procedure of choice for the hospital.)

31f necessary, use work space at bottom of abstract to make this calculation.

46
PROCEDURE FOR ABSTRACTING SOURCE OF PAYMENT INFORMATION

9. Start by identifying the source of payment. Shown below is a list of the sources of payment and how they can be identified from the patient’s ledger. (See Definitions of Sources

of Payment for what is included in each source of paym;nt.4 )

Source of Payment Identified on

ledge-r by

Cannot identify

from ledger

14

2,

3.

4.

5.

6.

7.

8.

9.

10.

11.

Blue Cross and Blue Shield

Blue Cross and Blue Shield writeoff

Patient responsibility

- Medical charges

- Personal charges (TV, phone, etc.)

Commercial insurance

Social Security Administration (Title XVIII

Medicare)

Welfare (includes Title XIX Medicare)

Welfare writeoff

Workmen’s Compensations

Federal Public Service Program

(Veterans Administration, etc.)

Other service plans (Kaiser, CHA, etc.)

Hospital discounts and allowances

Private charity

.

Other (explain)

10. Check box (if one exists) on the abstract for each source of payment identified from the

ledger.

11. Enter the amount paid by each source on

stract (column labeled amount covered on

the corresponding line to the right on the ababstract).

4

The member of the study team who is working with hospital personnel is to complete column as to how each source

of payment can be identified from ledgers in the specific hospital.

5Workmen!s Compensation cases (#6) usually cannot be identified from the payment information on the ledger. For

this reason, each ledger heading should be scanned before abstracting to determine if a Workmen’e Compensation cqse

is being abstracted.

47
12.

13.

14.

15.

16.

Total all amounts in amount covered column and enter this total on the total amount

covered line on the abstract.

Compare total amount covered to total charges. If these totals are not equal, determine error and correct.

Total all boxes checked and place total on total sources of payment line on abstract.

PROCEDURE FOR COMPLETING ABSTRACT

Enter abstracting date and abstracter’s initials at bottom of abstract. Place assigned

hospital number on top right-hand corner of the abstract.

Place completed abstracts, with ledgers or copies of ledgers in folder. Section I completed for unpaid and/or unconfirmed ledgers and Sections I and II completed for paid

and/or confirmed ledgers. Hold this folder until the abstracts are picked up and the

work discussed.

DEFINITIONS OF SOURCES OF PAYMENT

1. Blue Cross and Blue Shield

All charges paid for by any Blue Cross and/or Blue Shield plan except fov Title XVIII

Medicwe payments made by a Blue Cross and/or Blue Shield organization acting as fiscal

agent for the Social Security Administration, or for Workmen’s Compensation Federal Government Program, or welfare cases when Blue Cross and/or Blue Shield provides the insurance

coverage or acts as fiscal agent. It makes no difference whether Blue Cross or Blue Shield

insurance premium is paid directly by the patient, by the patient and his employer, or entirely

by the employer, by a union health and welfare plan, or otherwise. Blue Cross and Blue Shield

plans vary in their formal name from region to region but any Blue Cross and/or Blue Shield

plan which is a member of the Blue Cross Commission or Associations of Blue Shield Plans

should be included. It is to be emphasized that in any case where Blue Cross and/or Blue Shield

is acting as the fiscal representative for the Social Security Administration for Title XVIII, the

charges are to be put under Source of Payment— Social Security Administration (Title XVIII

Medicare).

la. Blue Cross and Blue Shield writeoff.— All charges written off the Blue Cross and

Blue Shield payment responsibility by the hospital based on the terms of the Blue

Cross/Blue Shield contract in that region. Such discounts are not required by all plans.

2. Commercial insurance

Any charges paid by commercial insurance companies (Continental Casualty, Aema,

Connecticut General, Liberty Mutual, etc.) should be included in this category, except for

Workmen’s Compensation cases which are to be put under Source of Payment-Workmen’s

Compensation. All commercial insurance payments are included here whether the premiums

are paid for by the individual, by the individual and his employer, or by the employer alone, by

a union health and welfare plan, or otherwise.

48
3. Social Security Administration

Included in this category are all charges paid ultimately for Social Security (Medicare)

beneficiaries by the Social Security Administration, including those payments made by Blue

Cross and/or Blue Shield and commercial insurance companies acting as the fiscal agent for

the Social Security Administration.

4. Welfare

Included are charges paid for by welfare and/or health departments as part of public welfare programs for the aged, aid to families with dependent children, aid to the blind, aid to the

permanently and totally disabled, medical assistance to the aged, independent State and local

welfare programs and Title XIX Medicaid programs which have replaced any of the foregoing

public assistance categories. This category includes any charges paid by Blue Cross and/or

Blue Shield in those cases where welfare and/or health departments pay the Blue Cross and/or

Blue Shield premiums, provide the funds to public assistance beneficiaries to pay such premiums, or where Blue Cross and/or Blue Shield act as the fiscal agent for the welfare and/or

health department.

This category includes the Title XIX Medicaid programs which exist in some States.

4a. Welfare writeoff. —All charges written off by the hospital due to the limits set by

welfare within the region.

5. Patient responsibilities

5a. Patient responsibilities—medical. —This includes charges paid directly by the patient

or his representative for supplies and services received.

5b. Patient responsibility—personal.— All charges paid by the patient for telephone, television, and guest meals.

6. Hospital discounts

Includes charges for which the hospital directly assumes responsibility and requires no

payment from the patient or his representatives. It includes discounts provided hospital employees, members of the medical profession, members of churches or religious organizations

working for the hospital, etc.

7. Federal Public Service programs

Any program under which the Federal Government pays for medical services for a Government employee beneficiary such as the Veterans Administration, military dependents’ medical

care services, etc.

8. Private charity

Any payments for medical services donated or given from any source when no direct responsibility y for payment exists, such as individuals paying bills for others, and voluntary health

agencies, foundations, and church groups, who pay for medical services with no legal responsibility involved. This does not include discounts given by hospitals to their employees, which

should be placed under source of payment—hospital discounts.

49
9. Workmen’s Compensation

These are payments made by any local, State, and Federal Workmen’s Compensation “program for injuries or illness related to the patient’s occupation. It does include Workmen’s

Compensation medical payments made by commercial insurance, Blue Cross, or other third

parties acting as the insuring agent for Workmen’s Compensation coverage.

10. Other service programs

Payments made by any third-party payment group other than Blue Cross, commercial

insurance, welfare, or Government.

This category includes primarily prepayment insurance plans such as Kaiser Foundation

Health Plans, Community Health Associates, and Group Health Association.

000

50
APPENDIX F

SUGGESTED PATlENT CHARGE ABSTRACT FORM FOR FUTURE USE

Form Appr. ved

Budget Bureau No. 68- R620. R2

CONFIDENTIAL. All information which would permit identification of an individual or of an

establishment will be held confidential, will be used only by persons engaged in and for tie

purposes of the survey and will not be disclosed or released to odrer persons or used for any other

prupose (22 FR 1687).

PATIENT CHARGEABSTRACT

I. TO BE COMPLETED BY THE ACCOUNnNG DEPARTMENTFROM

LIST OF PATIENTS SELECTEDFOR ABSTRACTING

Patient’s Admission Number

Patient’s Admission Date

Patient’s Discharge Date

Patient’s Hospital Discharge Survey Number

Patient’s hiedical Record Number (if other than Admission Number)

Total Charges

Room and Board Charges

Personal (Nonmedical)

Charges

Other Charges (Total charges

less Room and Board

Oharges and Personal

Charges)

Total Amount Covered

Amount

Covered

Sources of Payment

❑ Blue Cross and Blue Shield

Blue Cross and Blue

Shield write-off

❑ Commercial Insurance

❑ Welfare (includes Title X2X Medicare)

Welfare write-off

❑ Social Security Administration

(Title XVIII hledicare)

❑ Patient Responsibility (hiedical Charges)

•1 other

Check Source of Payment

1. Private charity

2. Hospital Discounts

3. Federal Public Service Programs

4. Other Service Programs

5. Workmen’s Compensation

6. Odrer

Total Sources of Payment

— (Number of Boxes Checked)

Comments and Work Space

Abstracting Date Abstractorrs Initials

51
APPENDIX G

ALTERNATIVE METHODS FOR SELECTING AND RELATING

PATlENT CHARGE LEDGERS AND MEDICAL RECORDS

FOR ABSTRACTING IN A CONTINUING ABSTRACTING PROGRAM

ALTERNATE 1: INITIAL SELECTION OF PATl ENT SAMPLE BY ACCOUNTING DEPARTMENT

WITH REFERRAL TO MEDICAL RECORDS DEPARTMENT

Assumptions

1. The hospital’s admission list is an

2. The accounting department would

appropriate instrument for sample selection.

be willing to select the patient sample for patient charge

and medical data abstracting from the hospital’s admission list,

Procedure

1. Accounting Department —ledger preparation clerk

(1)

(2)

(3)

(4)

Obtains instructions from National Center for Health Statistics for selecting the sample.

Stamps or tabs each ledger selected for abstracting as it is prepared.

Stamps additional pages of ledgers selected for abstracting since each new page becomes the face page.

Prepares in quadruplicate a list of patients selected for abstracting for use as follows:

Two copies to medical records department (one for files and one to be sent to

NCHS with medical records abstracts)

Two copies for accounting department employee designated for abstracting (one

for files and one to be sent to NCHS with patient charge abstracts)

2. Accounting Department—file clerk

(1)

(2)

Removes each ledger identified by the ledger preparation clerk by a tab or stamp before filing in the closed file.

Gives completed ledgers to the accounting department employee designated for abstracting.

52
3. Accounting Department— employee designated for abstracting

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Receives two copies of list of patients selected for abstracting from the ledger preparation clerk.

Receives completed ledgers identified for abstracting from the accounting department

file clerk.

Completes abstract for each ledger received.

Checks off name of patient in both copies of list of patients selected for abstracting as

abstract is completed.

Indicates on ledger that abstracting was completed and returns ledgers to file clerk

for refiling.

Sends monthly to NCHS completed abstracts for that month, abstracts for prior months

clipped separately, list of patients selected for abstracting, and completed statement

on changes in accounting system and participating personnel (transmittal sheet).

o

Audits periodically the list of patients’ ledgers selected and not checked off (abstracted)

and attempts to find absent ledgers.

Files the completed list of patients for sample when all abstracts are completed and

uses it annually to check NCHS reimbursement.

Evaluation

1. Advantages

(1)

(2)

(3)

(4)

Costs hospital less than other alternatives since ledger is identified by accounting department at time of original preparation of ledger and constant searching of files is

avoided.

Requires NCHS to monitor sample selection of only one hospital department.

Minimizes problems of matching patient charge and medical record abstract since the

HDS abstract number is assigned by only one hospital department.

Eliminates need for using patient’s name to find patient charge ledgers for abstracting.

2. Disadvantages

(1)

(2)

(3)

Requires training accounting department ledger preparation clerk to select the sample

from the hospital’s admission list. -’

Creates possibility of ledger tampering since ledger is identified before charges are

posted.

Necessitates use of hospital admission rather than discharge list which is usual basis

for sample selection of hospital patient studies.

53
ALTERNATE 2: INITIAL SELECTION OF

MEDICAL RECORDS DEPARTMENT WITH REFERRAL

Assumptions

PATl ENT SAMPLE BY

TO ACCOUNTING DEPARTMENT

1.

2.

3.

The medical records librarian will consent to send a copy of the list of patients selected for

abstracting, including the names of patients, to the accounting department.

The accounting department will be willing to cooperate with the medical records department

in permitting the medical records department to prepare the list of patients whose ledgers

will be abstracted.

The ledgers selected for abstracting are accessible after they are paid.

Procedure

1. Medical records librarian

(1) Selects patients for medical record and patient charge abstracting from the hospital’s

daily discharge listing in accordance with NCHS instructions.

(2) Prepares in quadruplicate a list of patients selected for abstracting for use as follows:

Two copies to accounting department file clerk with the patient’s name since the

name is necessary to find the ledgers in the accounting department (one for files

and one to be sent to NCHS with patient charge abstracts)

Two copies for medical records department employee designated for abstracting

(one for files and one to be sent to NCHS with medical record abstracts)

2. Accounting Department—file clerk

(1)

(2)

(3)

(4)

(5)

(6)

Receives two copies of the list of patients selected for abstracting with name of each

patient from the medical records department.

Places list from medical records in a follow-up file since most patient charge ledgers

will not have been paid and therefore will not be ready for abstracting.

Removes list of patients selected for abstracting from follow-up file after sufficient

time has elapsed to allow most of the ledgers to be paid.

Uses the list of patients selected for abstracting, after sufficient time has elapsed for

the majority of ledgers to be completed:

. Locates all selected ledgers

. Removes completed ledgers

. Stamps or tabs incomplete ledgers

Gives completed ledgers to the accounting department employee designated for abstracting with two copies of list of patients selected for abstracting.

Forwards all stamped or tabbed ledgers to the employee designated for abstracting as

they are closed out.

54
3. Accounting Department—employee designated for abstracting ●

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Receives completed ledgers and both copies of list of patients selected for abstracting

from accounting department file clerk.

Completes abstract for each ledger received.

Checks off names of patients as abstracted on both copies of list of patients selected

for abstracting.

Indicates on ledger that abstracting was completed and returns ledgers to file clerk

for refiling.

Sends monthly to NCHS completed abstracts for that month, abstracts for prior months

clipped separately, list of patients selected for abstracting, and completed statement

on changes in accounting system and participating personnel.

Audits periodically the list of patient ledgers selected and not checked off (abstracted)

and attempts to find absent ledgers.

Files the completed list of patients selected for abstracting when all abstracts are

completed and uses it annually to check NCHS reimbursement.

Evaluation

1. Advantages

(1)

(2)

(3)

Maintains most consistency with present Hospital Discharge Survey since medical

records department is already designated for selecting the patient sample for abstracting.

Requires NCHS to monitor sample selection of only one-hospital department.

Minimizes problems of matching patient charge and medical record abstracts since

the HDS number is assigned by only one hospital department.

2. Disadvantages

(1)

(2)

Costs more than sample selection by accounting department since each ledger selected

for abstracting by medical records department must be located and removed from files

in the accounting department.

Medical records department must write the patients’ names on the list of patients

selected for abstracting before forwarding to the accounting department.

55
ALTERNATE 3: ‘INDEPENDENT SAMPLE SELECTIONS BY

RECORDS DEPARTMENTS

Assumptions

ACCOUNTING AND MEDICAL

1. Identical patient numbers will be used on the hospital’s daily admission and discharge lists.

(Required because accounting department will select sample from the admission list and

medical record department from the discharge list.)

Procedure

1. Accounting Department—ledger preparation clerk

(1)

(2)

(3)

(4)

Obtains instructions from National Center for Health Statistics for selecting the sample.

Stamps or tabs each ledger selected for abstracting as it is prepared.

Stamps additional pages of ledgers selected for abstracting since each new page becomes the face page.

Prepares in duplicate a list of patients selected for abstracting for use by accounting

department employee designated for abstracting, who retains one copy for files and one

to be sent to NCHS with patient charge abstracts.

2. Accounting Department —file clerk

(1) Removes each ledger identified by the ledger preparation clerk by a tab or stamp before filing in the closed file.

(2) Gives completed Iedgers to the accounting department employee designated for abstracting.

3. Accounting Department—employee designated for abstracting

(1)

(2)

(3)

(4)

(5)

Receives two copies of list of patients selected for abstracting from the ledger preparation clerk.

Receives completed ledgers identified for abstracting from the accounting department

file clerk.

Completes abstract for each ledger received.

Checks off name of patient in both copies of list of patients selected for abstracting as

abstract is completed.

Indicates on ledger that abstracting was completed and returns ledgers to file clerk

for refiling.

56
(6)

(7)

(8)

Sends monthly to NCHS completed abstracts

clipped separately, list of patients selected

for thatmonth, abstracts for prior months

for abstracting, and completed statements

on changes in accounting system and participating personnel (transmittal sheet).

Audits periodically list of patients’ ledgers selected andnotchecked off (abstracted)

and attempts to find absent ledgers.

Files the completed list of patients for sample when all abstracts are completed and

uses it annually to check NCHS reimbursement.

Evaluation

1. Advantages

(1)

(2)

(3)

Costs only slightly more than sample selection by accounting department alone (only

additional cost is preparation of separate listing of patients selected for abstracting by

the medical records department). Low cost because ledger is identified by accounting

department at time of original preparation of ledger and constant searching of files is ~

avoided.

Requires no contact between medical records and accounting department in hospitals.

Eliminates need for using patient’s name to find patient charge ledgers for abstracting.

2. Disadvantages

(1) Requires NCHS to monitor sample selection of two departments.

(2) Increases problems of matching patient charge and medical record abstracts because

common HDS numbers will not exist.

ALTERNATE 4: REFERRAL BY NCHS TO HOSPITAL ACCOUNTING DEPARTMENT AFTER

RECEIPT OF HOSPITAL MEDICAL RECORDS ABSTRACTS

Assumptions

1. NCHS will find it advantageous to designate the patients for patient charge abstracting by

using the same sample listing prepared by the medical records department for medical data

abstracting.

2. The accounting department will be willing to cooperate with NCHS, permitting NCHS to

designate the patients for patient charge abstracting.

3. The ledgers selected for patient charge abstracting are accessible after they are paid.

57
Procedure

1. Medical records department

(1) Completes medical records abstracts and forwards abstracts with list of patients

selected for abstracting to NCHS.

2. NCHS

(1) Receives medical records abstracts andlist ofpatients selected for abstracting from

the hospital’s medical records department.

(2) Uses list of patients selected for medical record abstracting to designate patients for

patient charge abstracting.

(3) Prepares list ofpatients designated forpatient charge abstracting intriplicate for use

as follows:

. Two copies to accounting department file clerk

One copy for NCHS file

3. Accounting Department—file clerk

(1) Receives two copies of list of patients for patient charge abstracting from NICHS.

(2) Obtains patient names from medical records department in cross-reference file and

writes name on list. (Some hospitals will require names of patients to locate ledgers.)

(3) Using the list of selected patients:

Locates all patient ledgers.

. Removes completed ledgers and forwards to accounting department employee

designated for abstracting.

Stamps or tabs all selected ledgers that are not complete.

(4) Gives both copies of list to employee designated for abstracting.

(5) Forwards all stamped or tabbed ledgers to employee designated for abstracting as they

are completed.

4. Accounting Department-employee designated for abstracting

(1) Receives completed ledgers and both copies of list of patients selected for abstracting,

(2) Completes abstract for each ledger received.

(3) Checks off name of patient on both copies of list of patients selected for abstracting as

abstract is completed.

(4) Indicates on ledger that abstracting was completed and returns ledgers to file clerk

for refiling.

58
(5)

(6)

(7)

Sends monthly to NCHS completed abstracts for that month, abstracts for prior months

clipped separately, list of patients selected for abstracting, and completed statement

on changes in accounting system and participating personnel.

Audits periodically the list of patients’ ledgers selected and not checked off (abstracted)

and attempts to find absent ledgers.

Files the completed list of patients for sample when all abstracts are completed and

uses it annually to check NCHS reimbursement.

Evaluation

1. Advantages

(1)

(2)

(3)

Maintains most consistency with present Hospital Discharge Survey since medical

records department is already designated for selecting the patient sample for abstracting.

Requires NCHS to monitor sample selection of only one hospital department.

Minimizes problems of matching patient charge and medical record abstracts sitice the

HDS number is assigned by only one hospital department.

2. Disadvantages

(1) Costs more than sample selection by accounting department since each ledger selected

for abstracting by medical records department must be located and removed from files

in the accounting department.

(2) Medical records department must write the patients’ names on the list of patients

selected for abstracting before forwarding to the accounting department.

~ 00

59
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS

Public Health Service Publication No. 1000

Series 1. Pvograms and collection pvocedures.— Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions,

and other material necessary for understanding the data.

Series 2. Data evaluation and methods research. —Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

techniques, objective evaluations of reliability of collected data, contributions to statistical theory.

Series 3. Analytical studies. — Reports presenting analytical or interpretive studies based on vital and health

statistics, carrying the analysis further than the expositor-y types of reports in the other series.

Series 4. Documents and committee reports. — Final reports of major committees concerned with vital and

health statistics, and documents such as recommended model vital registration laws and revised birth

and death certificates.

Series 10. Data from the Health Interview Survey. —Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and otier health-related toPics >based ‘n ‘ata cO1lected

in a continuing national household interview survey.

Series 11. Data fyom the Health Examination Srwvey. —Data from direct examination, testing, and measurement of national samples of the population provide the basis for two types of reports: (1) estimates

of the medically defined prevalence of specific diseases in the United States and the distributions of

the population with respect to physical, physiological, and psychological characteristics; and (2)

analysis of relationships among the various measurements without reference to an explicit finite

universe of persons.

Series 12. Data from the Institutional Population SuYveys.— Statistics relating to the health characteristics of

persons in institutions, and on medical, nursing, and personal care received, based on national

samples of establishments providing these services and samples of the residents or patients.

Series 13. Data from the Hospital Discharge SWvey. —Statistics relating to discharged patients in short-stay

hospitals, based on a sample of patient records in a national samPle of hospitals.

Series 20. Data on mortality .—Various statistics on mortality other than as included in annual or monthly

reports— special analyses by cause of death, age, and other demographic variables, also geographic

and time series analyses.

Series 21. Data on natality, marviage, and divorce. —Various statistics on natality, marriage, and divorce other

than as included in annual or monthly reports— special analyses by demographic variables, also

geographic and time series analyses, studies of fertility.

SeYies 22. Data from the National Nutality and MoYtality surveYs. —Statistics on characteristics of births and

deaths not available from the vital records, based on sample surveys stemming from these records,

including such topics as mortality by socioeconomic class, medical experience in ?he last year of

life, characteristics of pregnancy, etc.

For a list of titles of reports published in these series, write to: Office of Information

National Center for Health Statistics

U.S. Public Health Service

Washington, D.C. 20201