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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Calculating Patient Volume

2013 Reporting Period and Beyond

Prior to 2013, a Medicaid encounter only included Medicaid paid claims, with a look-back period limited to being within a 90-day period in the previous calendar year. Beginning with CY/FY 2013, however, the look-back period has been redefined to include two options:

  • Across a 90-day period in the previous calendar year; or
  • Across a 90-day period in the last 12 months preceding the provider's attestation

Note that, for the 12-month look-back, the 90-day period may span multiple calendar or fiscal years. However, for the qualification year (the previous calendar year), the 90-day period may not span multiple calendar or fiscal years.

The definition of a Medicaid encounter has also changed effective as of CY/FY 2013. A Medicaid encounter now consists of service rendered on any one day to a Medicaid-enrolled individual regardless of payment liability. The expanded definition of Medicaid encounters include:

  • Medicaid paid claims
  • Zero-paid claims
  • Medicaid patients enrolled at the time of service
  • CHIP encounters for patients in Title 19 and Title 21 Medicaid expansion programs (still cannot include CHIP stand-alone Title 21 encounters)

The specific patient volume calculations for EPs are listed below.

Medicaid Expansion State (Federal Site)
Numerator - Medicaid Paid Claims + Zero Paid Claims + CHIP + Medicaid Enrolled
Denominator - All patient encounters

Non-Medicaid Expansion State (Federal Site)
Numerator - Medicaid Paid Claims + Zero Paid Claims + Medicaid Enrolled
Denominator - All patient encounters

Needy Individual (Tribal/Urban/FQHC/RHC)
Numerator - Medicaid Paid Claims + Zero Paid Claims + CHIP + Medicaid Enrolled + Uncompensated Care
Denominator - All patient encounters

The specific patient volume calculations for EHs are listed below.

Medicaid Expansion State (Federal Site)
Numerator - All Medicaid inpatient discharges and ER encounters (Medicaid Paid Claims + Zero Paid Claims + CHIP + Medicaid Enrolled)
Denominator - All inpatient discharges and ER encounters

Non-Medicaid Expansion State (Federal Site)
Numerator - All Medicaid inpatient discharges and ER encounters (Medicaid Paid Claims + Zero Paid Claims + Medicaid Enrolled)
Denominator - All inpatient discharges and ER encounters

The patient volume report based on the 2013 calculations is now available by installing the Third Party Billing Version 2.6 Patch 12. EPs and EHs using the Third-Party Billing Package will be able to run this report to calculate their thresholds. Although the report will not be available for COTS users, the logic will be shared upon request.

For more information about the Patient Volume Report and patient volume calculation workaround, review the documents below.

Addendum [PDF - 913 KB] (Version 2.6 Patch 12) - This includes 2013 patient volume logic and how to generate the report.
Summarize a Patient List [PDF - 841 KB] - Learn how to calculate patient volume using patient lists.

To learn more, see the attached presentation [PDF - 433 KB] or read the FAQs about patient volume.