1. Point-of-care Point of Care Billing: Yes You Can! Christopher FETTERS
Senior Technical Manager, Connectivity Solutions
© All Rights Reserved. Unauthorized duplication is a violation of applicable laws.

2. Goal Goal in Point of Care? Goal in the Laboratory?
Goal in the Hospital?
Golden Rule: Do unto others as you would
have them do unto your mother.

3. 44,000 – 98,000 patients killed each year by medical mistakes
To Err is Human - Building a Safer Health System A Report From The National Academies of Science, Institute of Medicine
44,000 – 98,000 patients killed each year by medical mistakes
Key Recommendations
Center for patient safety
National mandatory reporting
Peer review protections
Focus greater attention on patient safety
FDA should increase attention to safe use of drugs

4. It is necessary to create a culture of change that embraces patient safety through shared accountability within a blameless culture.
Rosina Jones, LHRM, CHRM

5. Causes of Medical Mistakes
15-20% is mechanical failure
60-80% is human error
Active errors
Latent errors

7. Three approaches to quality
Remedial
Alleviate the symptoms of the existing problem
Corrective
Eliminate the cause of existing problems or undesirable situation to prevent recurrence
Preventative
Eliminate the cause of potential problems

8. IDIOT Not this one Changing the process “er” – Season finale
Romano’s accident
Not this one
IDIOT

9. hile point-of-care testing (POCT) has significantly improved the timely delivery of diagnostic information for clinical decision making, the wide range of settings and operators involved in POCT add a layer of complexity to an institution’s effort to ensure consistently high-quality results.” W
Gerald J. Kost, MD, PhD. “Using operator lockout to improve the performance of point-of-care blood glucose monitoring.”

10. Is 99.9% Good Enough? 1 hour of unsafe drinking water every month;
There will be no telephone, electricity or television for 15 minutes each day.
315 entries in Webster's Dictionary will be misspelled
114,500 mismatched pairs of shoes will be shipped/year
811,000 faulty rolls of 35MM film will be purchased this year.
880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips
2,488,200 books will be shipped in the next 12 months with the wrong cover.
5,517,200 cases of soft drinks produced in the next year will be flatter than a bad tire.
1,314 phone calls will be misplaced by telecommunications services every minute.
18,322 pieces of mail will be mishandled/hour
22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes.
2,000,000 documents will be lost by the IRS this year
Your heart fails to beat 32,000 times each year.
Twelve babies will be given to the wrong parents each day.
2,500 newborn babies will be dropped in the next month.
107 incorrect medical procedures will be performed by the end of the day today.
500 incorrect surgical operations each week;
200,000 drug prescriptions will be filled incorrectly in the next 12 months.
A typical day would be 24 hours long (give or take 86.4 seconds)
Jeff Dewar

11. Quality
Our healthcare delivery system is NOT safe for the patient
Safety is part of quality
Process changes ensure long-term benefit
Labs have opportunity because of attention to quality issues
Examine pre-analytical processes first
Use technology to improve processes, address quality & examine data

12. 82% of Patient Data Still Manually Recorded
Source: 1999 EAC US Hospital POC Survey

13. Point of Care Errors Sensa v. Non-sensa Documentation of ACT Results
MD Pocket Developer (distilled water)
Timing urine dipsticks
Bad Patient ID’s
CHANGE THE PROCESS

14. You can’t manage
what you can’t measure.
Bill Hewlett

15. Three things you MUST DO!
Christopher Fetters:
Video of barcoding a patient. Video of instrument download, data management station, computer room, Bills printing off, money falling, patient accounting department
Graphics with poof on previous, then diminishing graphic of current one
Find a bite mark for these…
Three things you MUST DO!
Barcode your patients & operators
2. Install Connectivity
3. Bill for point of care testing

16. Objectives
You should bill for point of care testing!
Point of care billing is profitable!
Billing for point of care improves patient care!

17. Why bill? Gives credit among admin to program Count workload
(You get what you pay for)
Count workload
Ought to be paid for services
Recoup costs
Continue to upgrade technology
Add FTE’s to improve control
Good for patient care

18. We S-H-O-U-L-D bill for Point of Care Testing

19. We should bill for point of care testing.
HOW?
Q. WHY?
The same way we do for all other laboratory testing.
A. Because it is laboratory testing.

20. Point of Care Testing is Lab Testing
Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88)
American Medical Association (AMA)
Medicare

21. CLIA ‘88 Certifies testing Human specimens
• Based on complexity, not setting
• Agents of the laboratory

22. CLIA’s View of In Vitro Testing
CLIA requires all entities that perform even one test, including waived test on ‘... materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings’ to meet certain Federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory and must register with the CLIA program.”

23. AMA’s CPT Codes Defines code for medical procedures
Laboratory testing in the range: to 89399
CPT Codes for POC
Waived Glucose – 82962
Urine dipstick – 81002
ACT – 85347
Fecal occult blood
• • •

24. Medicare Medicare Part A Medicare Part B Inpatient
Reimbursed by Fiscal Intermediary
Medicare Part B
Outpatient/POL’s
Reimbursed by Carrier
Florida (Regional Office: Atlanta)
Part A - First Coast Service Options, Inc Mutual of Omaha Insurance Company
Part B - First Coast Service Options, Inc.

25. Inpatient Medicare Billing Process
Christopher Fetters:
Set this up as an animation or video
Inpatient Medicare Billing Process
Patient discharged
Physician discharge summary and diagnoses
- 30,000 codes
Standardized codes for diagnosis
Formulated by the World Health Organization (WHO)
ICD-10CM is coming…
Medical Records
Coder  ICD-9 codes
- 500 codes
- Clinically cohesive groups
Similar consumption of hospital resources
Similar length of stay patterns
Grouper  DRG code
Upload to Medicare
Payment under Prospective Payment System (PPS)
Upload hospital cost report

26. Use of the cost report Globally Locally PPS based on averages
Christopher Fetters:
Illustrate the averages going down because point of care testing is absent.
Illustrate the cost to charge ratio
Illustrate the lump sum payment at the end of the year.
Illustrate the Part A to Part B Rollover
Use of the cost report
Globally
PPS based on averages
Set next year’s DRG reimbursement schedule
Locally
Cost to charge ratio

27. Example DRG Primary Diagnosis: Secondary Diagnoses:
Christopher Fetters:
Set this up as a flow chart. Get video of medical records, picture of discharge notes, doctor writing discharge notes
Example DRG
Primary Diagnosis:
ICD – “Bypass, aortocoronary”
ICD-9
Secondary Diagnoses:
Valvuloplasty, Atherectomy, Catheterization, Angiocardiogram, or Arteriogram
ICD-9
DRG 106: “Coronary Bypass with Cardiac Catheterization”
DRG
Medicare Average Reimbursement:
$37,000 $$

28. Medicare contractors 12 TRAILBLAZER CHISOLM BCBS “Waived Test”
QUESTION
Part A - Coverage
Is CPT a covered service for inpatients?
ANSWER
Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [
QUESTION
Part A - Coverage
Is CPT a covered service for inpatients?
ANSWER
Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [
QUESTION
Part A - Coverage
Is CPT a covered service for inpatients?
ANSWER
Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [
“Waived
Test”
TRAILBLAZER
QUESTION
Is CPT a covered service for inpatient claims?
ANSWER
Inpatient claims submitted for Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use, is a covered procedure and reimbursed as a portion of the Prospective Payment System for Hospital and Skilled Nursing care inpatient services. [
CHISOLM BCBS 12

29. Medicare Clinical Laboratory Fee Schedule
Covers procedures in CPT Range
Set reimbursement rate (Medicare Part B)
Update yearly by Medicare (

30. Setting charges for analytesX
Using the Clinical Lab Fee Schedule
DON’T
Glucose (82962) $3.03
Use lab/hospital Charge Master
Suggest NCCLS GP-11A
“Basic Cost Accounting for Laboratories”
Calculate using worksheets
(Direct cost + Indirect cost) X Hospital multiplier

31. Medicare Payment Policies
Local
LMRP (Local Medical Review Policy)
Administered by Carrier
National
National Coverage Decisions
23 lab analytes
In effect Nov, 2002
Final Rule: Federal Register 11/23/2001
Administered by Federal Law

32. Medicare National Coverage Decision
Christopher Fetters:
Picture of someone putting a grey top on a core lab instrument
Medicare National Coverage Decision
Specifically addresses glucose testing
Lists ICD-9 for medical necessity
Lists reasons for denial
Also covers CPT 82947

33. Who says I can bill for POCT?
Christopher Fetters:
Gradient picture of Consultant, Government building, Hospital
Who says I can bill for POCT?
Medicare
• Compliance Consultants
• Other hospitals

34. What hospitals?
Cedars-Sinai, Mayo Clinic, Wellspan Health, Baystate Medical, Mercy Health, Henry Ford Hospital, Bay Medical Center (Panama City, FL), Merle West Medical Center, Emory University Hospital, Providence Alaska Medical Center, Hershey Medical Center, Methodist Medical Center, Geisinger Health System, Mobile Infirmary, Lancaster General, SSM Health Care, Lakeland Regional Medical Center, MCCG (Macon, GA), St. Vincent Hospital Santa Fe Regional Medical Center, Mercy Health Partners, Presbyterian Hospital of Plano, Concord Hospital (Concord, NH), PinnacleHealth System…
Just to name a few!

35. AACC Conference Call Poll (2003)
Q: For which POCT procedures does your institution receive reimbursement?
Glucose only (22%)
Coagulation (PT/INR) only (30%)
Glucose and coagulation only (22%)
All POCT charges are billed (26%)

37. What is required to bill lab tests?
CLIA Number
Physician order
Reasonable and necessary (SSA 1862(a)(1)(A))
Physician must use to manage pt care (42 CFR , )
Result to physician promptly (implicit)

38. Medicare National Coverage Decision
Specifically addresses glucose testing
CPT Codes
ICD-9 for medical necessity
Reasons for denial
Absence of signs or symptoms
Routine physical (such as employee physical or community health fair)
Failure to provide medical necessity
Not ordered by physician
Failure to have CLIA certificate
Testing performed on device not FDA approved

39. 100% How do I bill? Manual Billing Data management
Christopher Fetters:
Video of someone filling out a lab card, video of someone docking each type of instrument, video of nurse with stickers on uniform, video of using a pyxis, video of using a data management workstation – Add slide to show increased revenue with data management.
How do I bill?
Manual Billing
20-40% Missed charges
Data management
100%

40. AACC Conference Call Poll (2003)
Q: What are your major stumbling blocks to POC billing?
Too great an investment to set up infrastructure (24%)
The lab director or finance department has told us we cannot bill (34%)
Consultant told us we cannot bill (8%)
We are waiting for connectivity (34%)

41. Why don’t hospitals bill?
How did we get here?
15 years ago…
1988
1992
1995

42. “If you don’t do it excellently, don’t do it at all.
Because if it’s not excellent, it won’t be profitable.
If it is not excellent, it won’t be fun and if you’re not in business for fun or profit, what the hell are you doing here?”
Robert Townsend

43. PROFITABLE! PROFITABLE! Point of Care Billing Point of Care Billing is
Christopher Fetters:
Add spice to all three major points… maybe Flash-animate these three screens
Point of Care Billing is
PROFITABLE!
Point of Care Billing is
PROFITABLE!

44. Laboratory Trends
Profits
Costs

45. Where have all the grey tubes gone?
Christopher Fetters:
Movie of racks of grey top tubes, putting grey tubes on core instrument. Poof
Money leaves as point of care instruments are introduced.
Lined up instruments on table being linearitead.
Training nurses to perform point of care testing.
Flash through glucose, ACT, urine dipstick, hemoccult and all other point of care testing.
Where have all the grey tubes gone?
Dade Behring
Roche

46. Payor mix (typical) Medicare / Medicaid (45-60%) Managed care (20-40%)
Fee for Service (15-25%)
Other (remaining)

47. Billing can improve Patient Care!
Christopher Fetters:
Improve this with a sexy picture collage of nursing, operating room, etc…
Billing can improve Patient Care!
Billing can improve Patient Care!

48. Billing can improve patient care
Christopher Fetters:
Picture of a discontented nurse with her arms crossed.
Picture of doctor signing patient chart.
Illustrate data management
Show form with clinical and financial justification request.
Billing can improve patient care
More FTE’s = Better quality
More leverage with physicians and nurses
Show ROI on Data Management
Financial and clinical justification for new point of care analytes
POC Billing creates more nursing positions

49. Your mission… POC Committee Create an impact worksheet
Pt volumes X Charges = Gross Charges
Gross Charges X Fee for service % = Net Revenue Potential
Billing investigation committee (Ad hoc)
POC Coordinator (& Staff)
Medical Director
Lab Manager / Administrative Director
Lab Business Operations Mgr
LIS Supervisor
Patient Accounting
Nursing Admin
Managed Care Contracts
Potential

50. You should bill for point of care testing!
Christopher Fetters:
Include montage of point of care, data management, money, instruments, downloading, nurse taking care of patients. Build the montage with lots of dissolved shots…
Needs to create a picture of something as it builds. Like a dollar sign or fade into the face of a patient or something…
Conclusion
You should bill for point of care testing!
Point of care billing is profitable!
Billing for point of care improves patient care!

51. Questions? Christopher Fetters Christopher Fetters:
Include stylized Nextivity Logo, Picture of me…etc.
Questions?
Christopher Fetters
Nova Biomedical
(781) x293
(781) Fax

52. Frequently asked questions
1. DRG = No money \ Why bill?
Medicare cost report
Other payors
2. What CPT code for glucose? or 82948
82962: Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use
510K approval by the FDA
3. Venipuncture charge G0001?
Example:
4. “This procedure is just part of the nursing room charge”
5. Repeat testing? 22

53. FAQ – Nursing Room Charge
"Routine services" as defined in Medicare regulations found at 42CFR (B) are: "Routine services means the regular room, dietary and nursing services, minor medical equipment and surgical supplies and the use of equipment and facilities for which a separate charge is not customarily made.“
The Provider Reimbursement Manual also defines routine services at section "Inpatient routine services in a hospital...generally are those services included by the provider in a daily service charge – sometimes referred to as the room and board charge. Routine services are composed of two broad components:
(1) general routine services and
(2) special care units, including coronary care units and intensive care units. Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services and the use of certain equipment and facilities for which a separate charge is not customarily made."
The Provider Reimbursement Manual defines Ancillary Services at section as follows: "Ancillary services in a hospital...include laboratory, radiology, drugs, delivery room, operating room and therapy services. Ancillary services may also include other special items and services for which charges are customarily made in addition to a routine service charge." 23

54. FAQ – Repeat Glucose testing
Question from ASF (AdminaStar Federal, Inc.) to CMS (Centers for Medicare and Medicaid Services, formerly HCFA)
In November we spoke of CMS’s requirement that to be deemed “reasonable and necessary” a physician must use the result of a test in the management of a beneficiary’s specific problem (Program Memorandum AB ). In the instance where a physician has ordered repeated tests—such as a glucose test ordered every half hour—we asked if ASF interprets the requirement to mean a lab or hospital must contact a physician with the results of each test and request another before a repeat test can be performed. ASF replied with a statement from its Local Medical Review Policy (LMRP) on glucose monitoring: “For purposes of this policy prompt physician notification means prior to the next blood glucose test or within eight hours, whichever is sooner”.
We accept ASF’s assurance that this requirement is only applied to the outpatient setting, but there is still a problem with outpatient observation and emergency services, where the physician is often quite specific with his/her plan of care, and will order a series of glucose tests with precise instructions on how to proceed based on their results. Does ASF’s opinion about the need to personally contact a physician with the results of a repeat test before another test can be performed extend to emergency patients or to those who have been admitted to outpatient observation?.
Answer from CMS:
The intent of the policy was not that it be applied to Emergency Department patients or those in observation status, who would be receiving frequent attendance by the physician. [ 24

55. Medicare Intermediary Manual
All laboratory testing must be reimbursed under the Clinical Laboratory Fee Schedule
Laboratory testing is an ancillary service (415.5)
Laboratory services are covered under Medicare as a payable service (210.5)
Transmittal AB & AB-00-99
Laboratory test charges must be reflected on the cost report
Laboratory test charges must be uploaded with department code 30x

56. Payment for glucose testing (Outpatient)
Medicare Transmittal AB CR 1362 (Dec 2000)
When glucose meets the criteria… payment must be made.
“Denial of payment for Part B covered laboratory service cannot be made on the basis that the service is routine care.”

57. Point of Care Billing Impact
Christopher Fetters:
Worksheet with places to fill in numbers and calculate impact for point of care program.
Point of Care Billing Impact
Glucose:
Yearly Total Volume: 300,000
Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)
(Inpatient)
Inpatient volume: 100,000
Charge per test: $ (avg. $12-25)
Yearly charges: $1.5 M
REVENUE FROM PAYORS:
Medicare/Medicaid (55%): $0
Managed Care (30%): $0
Fee-for-Service (15%): $219,000
TOTAL IP REVENUE: $219,000

58. Point of Care Billing Impact
Christopher Fetters:
Worksheet with places to fill in numbers and calculate impact for point of care program.
Point of Care Billing Impact
Glucose:
Yearly Total Volume: 300,000
Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)
(Outpatient)
Outpatient volume: 100,000
Charge per test: $ (avg. $12-25)
Yearly charges: $1.5 M
REVENUE FROM PAYORS:
Medicare/Medicaid (55%): $177,650 ($3.23 CLFS on 55,000 tests)
Managed Care (30%): $0
Fee-for-Service (15%): $219,000
TOTAL IP REVENUE: $396,650

59. Point of Care Billing Impact
Glucose:
Inpatient: $219,000
Outpatient: $396,650
Revenue: $615,650
ACT:
Volume: 48,000 pt tests
Charge: $28.00
Billables: $1.3M
Revenue: $195,000
Urine dipstick:
Volume: 35,000 pt tests
Charge: $9.00
Billables: $315,000
Revenue: $47,250
ABG:
Volume: 11,000 pt tests
Charge: $55.00
Billables: $605,000
Revenue: $90,750
Only 4 analytes:
Hemoccult, Strep-A, Urine Pregnancy, Cardiac Markers, Drug Screens, h. pylori, Gastroccult, PT, pH, Hemoglobin, HbA1C, Provider Performed Microscopy

60. Total Impact (VERY CONSERVATIVE)
Test
Billables
Revenue
Glucose
2,900,000
615,650
ACT
1,300,000
195,000
Urine dip
315,000
47,250
ABG
605,000
90,750
Total
5,120,000
948,650

61. Profit Strip usage: 300,000 (total) Revenue: $615,650 Vial cost: $25
Strip cost: $.50
Total strip cost: $150,000
Gloves, gauze, alcohol, lancet: $.50
Total disposables: $150,000
FTE (POCC): $45,000
Data Management: $75,000

62. Payment for glucose testing (Outpatient)
Medicare Transmittal AB CR 1362 (Dec 2000)
When glucose meets the criteria… payment must be made.
“Denial of payment for Part B covered laboratory service cannot be made on the basis that the service is routine care.”