Transcript The Dynamics of Implementing HIPAA in the AR

ER & Hospital-Based
Clinics
Challenges & Hidden
Revenue Strategies
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Special Olympic’s Oath:
Let me win,
But if I cannot win,
Let me be brave in the
attempt.
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A Positive Approach
Keith Harrell:
Attitude is Everything.
Your Attitude in Life
directly affects your
Altitude in Life…
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2014 Outpt Perspective Payment
major changes/proposed
CMS is looking at OPPS more like a
DRG payment environment.
ADD on CPTs are now no longer paid
separately, ever. (N status)
EX) Drug adm additional hrs =
packaged into the primary CPT
Q1 CPTS = when on the claim with
another CPT that is a ancillary,
significant procedure or visit (STV)
= no separate payment .
Q2 CPTS = when on the clam with
surgical (T)= no separate payment.
Q3 payment for composite CPTS.
(EX: OBS 8009 )
CAH – more clarity to come on as not
paid on CPT code..
E&M payment and claim submission .
Eliminate 5 levels/CPT for Type A
ER, Type B ER, and hospital based
clinics/HBC.
Eliminate the problems with new vs
established for HBC
99281-85 –submit with
GxxxxA/ER/HELD
99201-99215 – submit with GxxxxC/
hospital based clinic
G0380-G0384 – submit with
GxxxxB.
Payment will be a single payment –
mean average.
NON-MEDICARE PAYERS ARE
NOT USING G codes. Still need
9xxxx codes.
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What is a Hospital-Based Clinic?
An outpt department of the hospital –
just like lab, x-ray, hospital-based
clinic.
Examples of HBC: IV therapy Clinic,
Wound Clinic, Pain Clinic, Ostomy Clinic, Oncology
Clinic, MNT Clinic for non-covered Dx, ambulatory
outpt clinic, transfusion clinic, OB, anticoagulation, scheduled visits in the ER
Example Hospital-Owned Physician
Directed Clinic: Physician does own E&M,
hospital uses own criteria for their E&M. Two
different sets of criteria; two different E&Ms.
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Hospital owned/physician
directed challenges
Non-Medicare payer does not want to pay 2
charges for 1 visit (1500/doc; UB/facility)
Correct claim submission: Physician bills as
hospital based and will receive a reduced fee
schedule payment as the administrative fees are
covered by the facility.
Idea: Request to bill place of service as office/11
and receive the full schedule payment in lieu of
the reduced payment. This will ensure the full fee
schedule is received in 1 1500 form claim.
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Understanding the E&M process
E&M = facility/Hospital-based clinic/ER
visit charge
510/99201-99205/99211-99215/HBC/dept of the hospital
450/99281-99285/ER
APC regulations:
“As long as the services furnished are documented
and medically necessary and the facility is
following its own system, which reasonably relates
intensity of hospital resources to the different
levels of HCPC’ codes, we will assume that it is in
compliance with these reporting requirements as
they relate to clinic/emergency department visit
codes reported on the bill.”
(Federal Register vol 65, #68, April 7, 2000,
Page 18451)
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No Mandated E&M Leveling Yet
Revised draft available on CMS’s web site
Five levels for ER and hospital based clinics
Critical Care has it’s own criteria
CMS committed to have to facilities 6-12 months
prior to implementation. (unknown if going live)
Pilot still in effect, expect completion in 07
Full interventional system with contributory
factors (allows movement)
www.cms.hhs.gov/hospitaloutpatientpps/downloads/cms1506p_draf
t_aha_ahima_guildelines.pdf or
www.cms.hhs.gov/hospitaloutpatientPPS/HORD/list.asp#TopOfPage
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Golden Rules: ER & HBC
Always, always bill
what was done
first, i.e actual
procedure: Injection,
IV infusion,
lacerations.
Then evaluate
earning the E&M –
as a separately
identifiable service
Each visit – look
for three unique
billable services:
Nursing
procedure/CPT
Surgical/interventio
nal procedure/CPT
E&M.
Not always done,
but look for them!
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Evaluate 3 Billable Services:
E&M, Nursing & Surgical
Procedures
ER & HBC Billing:
E&M
Nursing
Procedures/CPT
Interventional/Surg
ical Procedures/CPT
Know what costs
are being billed
that relate to the
above charges.
Physician Billing:
E&M
Interventional/Surg
ical Procedures/CPT
E&M levels can be
different, but CPT4 surgical code
should be the same.
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What costs are covered?
Nursing Procedure
Nurse doing the
injection
Risk of giving the
injection
Cost of routine
supplies
Separate identifable
from the E&M
Surgical Procedure
Nurse in assistance
Set up, clean up
Routine supplies
Sterilization/tools
Overhead of room
Separate identifable
from the E&M
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2007 Forward Final Regs
Outline:
CMS offers 11 guiding principles:
1) The coding guidelines should follow
the intent of CPT code descriptor in
that the guidelines should be
designed to reasonably relate the
intensity of hospital resources to the
different level of effort represented
by the codes.
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More Guidelines
2) The coding
guidelines should
be based on
hospital facility
resources. The
guidelines should
be not be based on
physician
resources.
3) ..should be clear
to facilitate
accurate payments
and be usable for
compliance
purposes and
audits.
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More Guidelines
4) …should meet
the HIPAA
requirements.
5) …should only
require
documentation that
is clinically
necessary for
patient care.
6) …should not
facilitate upcoding
or gaming.
7) …should be
written or
recorded, well –
documented, and
provide the basis
for selection of a
code.
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More Guidelines
8) …should be
applied consistently
across patients in
the clinic or
emergency dept.
9) …should not
change with great
frequency.
10) …should be
readily available
for fiscal
intermediary
review.
11) …should result
in coding decision
that could be
verified by staff &
outside.
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Other Golden Rules
New vs established. UPDATE: Final regs
11/24/06 pg 68128 “if a patient has a
medical record that was created in the last
3 years, that patient is considered
established.” (No $ differential/2014)
If hospital-based physician, physician’s
payment will be reduced as no overhead,
etc. Hospital to bill their E&M to make
whole. (Hint: pt has 2 copays)
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Specifics of Current E&M Guidelines
Facility and physician levels are not the
same.
Create facility-specific leveling system.
As long as the facility follows it’s own
guidelines –that includes documentation
of the E&M elements = compliance.
HOLD on any mandated E&M leveling
system. Continue to use internal,
auditing, resource based system.
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Understanding the G codes.
Type A ERs – Paid with new G codes with each G code having it’s
own payment. (APC 609,613,614,615,616,617/CC)
Open 24/7 and staffed as an ER plus meets licensure issues as an dedicated
ER plus EMTALA (pg 335, CMS 1506) ---NOT IMPLEMENTED
Type B ERs – Paid with new G codes; included in HBC payment
groupers (lesser payment; APC 604-608)
Not open 24/7 / meets licensure issues / EMTALA
/ during previous calendar year, it provides at least 1/3 of
all of its outpt visits for the treatment of emergency
medical conditions on an urgent basis without requiring a
previously scheduled appointment. (pg 332, CMS 1506) IMPLEMENTED
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New G codes…urgent focus
ER will have a new G code: Type B
with 5 level G codes (CMS only)
The G codes will have their own payment for all 5
levels:G0380-G0385
Intended for Urgent Care distinction …but…
Existing 9xxxx codes for ER and HBCs will remain.
However, each level will have it’s own separate
payment.
Commercial payers likely won’t accept G codes, so
use 9xxx codes.
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Payment Analysis for new G codes
Payments are lower than ER CPTs
G0380 $50.66
99281 $50.01
G0381 $60.48
99282 $82.96
G0382 $83.88 99283 $130.06
G0383 $105.09 99284 $209.99
G0385 $133.96 99285 $325.26
More in line with HBC $s than ER $
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More ER Changes
G0390/trauma team activate/$495.
Must have trauma designation
Can be billed with 99291/critical care
Must document pre-hospital
notification of the trauma
Must document patient was triaged
by hospital caregivers prior to arrival
in the ER
Hint: revenue vs cash if DRG vs CAH (Many end up as inpts)
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Building E&M Criteria
Working with the care team, brainstorm the
detailed services for each main category:
Triage/medical screening/EMTALA (ER only)
Assessment
Emotional Support
Teaching
Discharge Planning/Status
Interventions (= no CPT-4 code)
Remember – until mandated system, the E&M is
whatever the facility says it is, with nursing’s
documentation.
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Sample of E&M Creation Process
Assessment
Reassess, vital check, visual
acuity, reassess post meds
Emotional Support
Patient, family, prolonged
Teaching
Crutch training, infection
guidelines, walker, new
meds, sling
Discharge Status
To nursing home, f/u,
physician, by ambulance
Interventions-no CPT
Enema, observation post
med, IV attempts, IV more
than 2 lines, Admit, rape,
wound cleansing, ring
removal, restraint, rectal
exam, 2 nurses, flushes,
care coordination
Miscellaneous
Language barrier, behavior
issues, coordination of
care, holding/waiting bed;
holding/waiting for a ride
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Sample Acuity Resource E&M
Assessment
Reassessment after meds-10
Repeat vital signs – 5 pts
Visual Acuity – 5 points
Teaching
Ed requiring demonst –20
Ed w/2 or more meds –10
Crutch training – 5
Post wound care – 20
Sling, ace wrap-minor -5
Emotional Support
Discharge Status
Interventions
Continue brainstorming
services, assigning points
based on risk, acuity and
resource consumption.
Each visit, the E&M leveling
form is used to determine
level of E&M to bill.
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Getting the E&M Done
Add points and assign to
level based on totals.
All elements of the E&M
must be charted.
Hint: Explore dating and
signing the E&M leveling
sheet and making it part of
the permanent medical
record.
Match charting to
E&M form as much as
possible.
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Nursing Procedure Opportunities
RT done by an RN – billable as an outpt
only; part of the R&B inpt/Nonbillable (MIM
Section RT 3101.10 B #2, #6-check with FI/MAC too)
Separately billable CPTs should be billed
separately –not included in the E&M
Look for ways to ‘capture nursing
component automatically’. (EX) lab draw
auto charges with associated lab test
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Billing Services in Addition
to the E&M
Program Memorandum A-00-40 & A-01-80 = 25
modifier = separate identifiable services.
Golden rule: Always get the CPT-4 procedure
code. Earn the E&M as the separate service.
Inherent nursing in all procedures/CPT-4 codes
ER = Triage = separate identifiable = add E&M
HBC = procedure + unplanned outcome of
treatment or other medical condition = E&M
Ensure the E&M criteria is well charted in addition
to the Procedure Code. (separate identifiable
E&M)
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False Claims and Kickback Lawsuits Involving
Hospitals and Health Systems” –Becker’s
Hospital Review, 7-11
“Louisville, KY based Norton Healthcare agreed to pay the
federal govt $782,842 in March to settle allegations that it
overbilled Medicare for wound care, infusion and cancer
radiation services by adding a separate E&M charge that
should have been included in the basic rate. The alleged
overbilling, which occurred between Jan 2005-Feb 2010
involved outpt care. The settlement is twice the amt Norton
allegedly overbilled.”
ISSUE:
Transmittal A-00-40, A-01-81 indicate that
there is inherent nursing in all CPT codes. Therefore, the
facility must ‘earn an E&M when done with a procedure.’
Unlikely events, other medical conditions being treated, new
pt=examples.
RAC 2011
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More on Inherent Nursing
Each CPT has ‘inherent nursing’ as part of
each CPT code.
Inherent nursing, PM A-00-40 is ‘hi, how
are you, simple admit, simple discharge.’
These are part of each CPT code and not
separately billable as an E&M.
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Golden Rules for HBC E&M
If no procedure,
always look for an
E&M (99211-15)
If there is a
procedure, the
E&M must be
‘earned’
E&M MUST be a
separate,
identifiable service
Inherent nursing in
all procedures (PM A00-40)
Examples of
‘earning’ E&M in
addition to the
procedure:
Unplanned
outcome/event
New dx, tx, meds
Other medical cond
Initial treatment
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Helpful hints for “inherent”
Using the HBC E&M leveling form, identify
the points for:
Simple assessment
Simple discharge
EX: If total is 30 points, then create a
notation that indicates: If points 5-30 and
done with a procedure, indicates inherent. NO
E&M. 35-50 = 99211
EX: If no CPT procedure, E&M begins at 5
points.
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Creating the Charge
Capture Tool
Create 2 charging
columns:
1 w/o procedures; 1 w/
procedures
EX) W/Procedures
5-30 = noE&M/inherent
35-50 =
55-70 =
Level 1, HBC E&M
Level 2, HBC E&M
IF Nursing/CPT
procedures charged -Go to w/proc)
EX) W/O Procedures
5-15 = Level 1, HBC E&M
20-35 = Level 2, HBC
E&M (up to 5 levels)
(up to 5 levels)
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ER Bell Curve Statistics
Independent firm - outpt
99281
9%
99282
32%
99283
39%
99284
15%
99285
5%
Due diligence – make changes, analyze
appropriateness/like dx, revise again.
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Last Thoughts on E&M
No separate billable services should be part of
the E&M. (CPT-4 = separate)
Critical care (99291) = must level to a level 6
thru the facility’s own system, plus be in
compliance with the CPT-4 guidelines, i.e.
system failure, etc. If not, move back to 5
TEST and TEST SOME MORE any changes
to the E&M leveling system.
Pull historical utilization, develop bell system sorted by like
diagnoses. Compare against new proposed leveling system.
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OPPS July 2011, CR 7443 –
Critical Care
“Beginning Jan 2011, under revised AMA CPT editorial panel guidance,
hospitals that report in accordance with the CPT guidelines will begin
reporting all of the ancillary services and their associated charges
separately when they are provided in conjunction with critical care (9929192). CMS continues to recognize the existing CPT codes for CC services
and has established a payment rate based on its historical data, into which
the cost of the ancillary services is intrinsically packaged. The OCE logic
conditionally packages payment for the ancillary services that are reported
on the same date of service as CC services in order to avoid overpayment.
The payment status of the ancillary services does not change when they are
not provided in conjunction with CC services.
Hospitals may use modifier 59 to indicate when an ancillary procedure or
service is distinct or indept from CC when performed on the same day but in
a different encounter.”
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Sample Nursing Procedure
Charge Ticket
Separately billable
Adm of Influ vaccine IM
(Gxxxx)
Adm of Pneum Vac IM
(Gxxxx)
Adm of Immunization
(90471) + med
CPR (92950)
Monitored/Conscious
Sedation (9914x)
Lab Draw (36415)
Blood Adm (36430) + blood
IV Infusion Therapy (9xxxx)
Injections:
IM, Sub
96xxx
IV
96xxx
Antibody
9xxxx (each)
These are generally hard coded
in the CDM. 1 to 1
relationship.. Only one code
for the service.
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2008 Drug Administration Chgs
Charge by time, chart
by time. Start and
stop times are critical.
Can’t bill the next
billable unit until 31
minutes has passed.
Separate time
charting for hydration
vs
infusion/therapeutic/
medicated.
When billing infusion,
bill the type of
infusion that best
describes the
primary, most
significant service
being provided.
1 hr 30 min = 1 billable
hr; 1 hr 31 mins = 2
billable hrs.
Ensure staff
understand guidelines
Ref: Trans 785; 557
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2008 Drug Administration
Uglies
Initial/primary reason
for visit”
Use 9xxxx codes for
all payers. Only C
code for
Pumps/Medicare
Once determined,
initial/primary visit
code (hydration,
therapeutic, chemo)then use subsequent
CPTs for additional
services
All outpt areas are
impacted: ER,
observation, Hospital
based clinics
May be unrealistic for
nursing/care areas to
chart and charge.
IDEA: Nursing takes
ownership for charting
‘stop and stop’ times
per CPT.
IDEA: Create charge
Capture Analyst
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position
2008/09 Drug Administration
News
Still no payment for
concurrent/96368
96369/70/71 = Subcutaneous
Infusion Therapy
96376/sequential IV Push of the
same substance/drug –watch for
clarity as it indicates
providers/physician only. No payment
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“Time” Charting Ideas
Create a stamp for Drug adm start and stop times.
(Could do recovery & 02 as they are timed
charges)
Use the stamp for billable time
IV Hydration Infusion
______ _______ ______ _____ ______ (multiple lines)
Start
Stop
Date
Dept Initials
IV Therapeutic Infusion
_____ ________ _______ ______ ______ (multiple lines)
Start
Stop
Date
Dept Initials
Remember – time continues from ER to observation/outpt
areas
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Role of Charge Capture
Analyst
Daily, takes Obs, ER, HBC records
Completes the charge ticket for all drug adm
charges: Infusion & Injections (+ Rev)
Completes a daily log of all documentation
‘challenges’ where charges could not occur. (- lost
revenue)
Skill set: Clinical in nature. Must be “heard.”
GOAL -Creates charges and educates on
lost revenue to dept head with objective
of reducing/eliminating losses.
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Sample Surgical/Interventional
Charge Ticket
Separately billable/charging options:
1: Build each CPT-4 code in the CDM. Nurse
assigns charges/codes. (0-69999 CPT)
2: #1 –but only charge description/$ is build
in the CDM with HIM assigning CPT-4 codes.
3: Pre-determine ‘like procedures’ into levels.
Assign pricing to levels with HIM CPT coding.
Ensure that pricing is above Addendum B
CPT-4 coding is done from physician documentation
with supporting nursing documentation.
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Hot Spots
Poor documentation
for E&M criteria –
especially in HBC
Double dipping –
separate CPT-4
items on the E&M
+billed separately
Lost revenue - #2,
but not billed
separately.
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And then there was Audit
Internal self-auditing
External assessment
Ensure E&M criteria is
understood by staff and charted.
Can the record support the procedure
AND the separate identifiable E&M?
Note dates of ‘improvement/changes” as
part of due diligence process.
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AR Systems’ Contact Info
Day Egusquiza, President
AR Systems, Inc
Box 2521
Twin Falls, Id 83303
208 423 9036
[email protected]
www.arsystemsdayegusquiza.com
Thanks for joining us!
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