Total Medicare Payment Amount ($)

SAS Name
MDCR_PMT_AMT

Amount of payment made from the Medicare trust fund for the services covered by the claim record.

For hospital services, this amount does not include the claim pass-through per diem payments made by Medicare.

To obtain the total amount paid by Medicare for the stay, the pass-through amount (which is the daily per diem amount; field called PASSTHRU) must be added to this field.

Comments

This field is derived by accumulating the payment amount that is present on all the claim records included in the stay (i.e., the sum of payment [reimbursement] reported on the claims that comprise the stay).

In some situations, a negative claim payment amount may be present. For example:

1. when a beneficiary is charged the full deductible during a short stay and the deductible exceeded the amount Medicare pays; or

2. when a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount exceeds the amount Medicare pays (most prevalent situation involves psych hospitals who are paid a daily per diem rate no matter what the charges are.)

Under IP PPS, Inpatient hospital services are paid based on a predetermined rate per discharge, using the DRG. On the IP PPS claim, the payment amount includes the DRG outlier approved payment amount, disproportionate share (DSH), in-direct medical education (IME), and total PPS capital.

It does not include the pass thru per diem amounts (i.e., capital-related direct medical education costs, kidney acquisition deductibles and coinsurance), or any other payer reimbursement.

Under SNF PPS, services are paid using the patient classification system known as RUGs III.

For the SNF PPS claim, the rate for each revenue center line item with revenue center code = '0022' is used; MEDPAR multiplies the rate times the units count; and then sums the amount payable for all lines with revenue center code '0022' to determine the total Medicare payment amount.

For demo ids '01','02','03','04' — claims contain amount paid to the provider, except that special 'differentials' paid outside the normal payment system are not included.

For demo ids '05','15' — encounter data 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the MCO.

For demo ids '06','07','08' — claims contain actual provider payment but represent a special negotiated bundled payment for both part A and part B services. To identify what the conventional provider part a payment would have been, check value code = 'y4'.

For BBA encounter data (non-demo) — 'claims' contain amount Medicare would have paid under FFS, instead of the actual payment to the BBA plan.

Source: MedPAR (derived)