1. ER & Hospital-Based Clinics
Challenges & Hidden Revenue Strategies

2. Special Olympic’s Oath:
Let me win,
But if I cannot win,
Let me be brave in the attempt.

3. Attitude is Everything.
A Positive Approach
Keith Harrell:
Attitude is Everything.
Your Attitude in Life directly affects your Altitude in Life…

4. 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 )
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
–submit with GxxxxA/ER/HELD
– 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.

5. 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, anti-coagulation, 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.

6. 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 form claim.

7. Understanding the E&M process
E&M = facility/Hospital-based clinic/ER visit charge
510/ / /HBC/dept of the hospital
450/ /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)

8. 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) or

9. 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/interventional procedure/CPT
E&M.
Not always done, but look for them!

10. Evaluate 3 Billable Services: E&M, Nursing & Surgical Procedures
ER & HBC Billing:
E&M
Nursing Procedures/CPT
Interventional/Surgical Procedures/CPT
Know what costs are being billed that relate to the above charges.
Physician Billing:
E&M
Interventional/Surgical Procedures/CPT
E&M levels can be different, but CPT-4 surgical code should be the same.

11. What costs are covered? Nursing Procedure Surgical 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

12. 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.

13. 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.

14. 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.

15. 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.

16. Other Golden Rules
New vs established. UPDATE: Final regs 11/24/06 pg “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)

17. 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.

18. 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 )
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

19. 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.

20. Payment Analysis for new G codes
Payments are lower than ER CPTs
G0380 $ $50.01
G $ $82.96
G $ $130.06
G $ $209.99
G $ $325.26
More in line with HBC $s than ER $

21. 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)

22. 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.

23. 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

24. 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.

25. 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.

27. Nursing Procedure Opportunities
RT done by an RN – billable as an outpt only; part of the R&B inpt/Nonbillable (MIM Section RT 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

28. Billing Services in Addition to the E&M
Program Memorandum A & A = 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)

29. 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 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

30. More on Inherent Nursing
Each CPT has ‘inherent nursing’ as part of each CPT code.
Inherent nursing, PM A is ‘hi, how are you, simple admit, simple discharge.’ These are part of each CPT code and not separately billable as an E&M.

31. Golden Rules for HBC E&M
If no procedure, always look for an E&M ( )
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 A-00-40)
Examples of ‘earning’ E&M in addition to the procedure:
Unplanned outcome/event
New dx, tx, meds
Other medical cond
Initial treatment

32. 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 =
EX: If no CPT procedure, E&M begins at 5 points.

33. 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 = Level 1, HBC E&M
55-70 = Level 2, HBC E&M
(up to 5 levels)
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)

34. ER Bell Curve Statistics
Independent firm - outpt % % % % %
Due diligence – make changes, analyze appropriateness/like dx, revise again.

35. 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.

36. 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 ( ). 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.”

37. 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.

38. 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

39. 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 position

40. 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

41. “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

42. 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.

43. Sample Surgical/Interventional Charge Ticket
Separately billable/charging options:
1: Build each CPT-4 code in the CDM. Nurse assigns charges/codes. ( 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.

44. 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.

45. 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.

46. AR Systems’ Contact Info
Day Egusquiza, President
AR Systems, Inc
Box 2521
Twin Falls, Id
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