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Navigating Coding & Billing Compliance in Outpatient Departments WVHFMA Fall Revenue Cycle November 27, 2012 Jill Newberry, CPA, CPC Arnett Foster Toothman,

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Presentation on theme: "Navigating Coding & Billing Compliance in Outpatient Departments WVHFMA Fall Revenue Cycle November 27, 2012 Jill Newberry, CPA, CPC Arnett Foster Toothman,"— Presentation transcript:

1 Navigating Coding & Billing Compliance in Outpatient Departments WVHFMA Fall Revenue Cycle November 27, 2012 Jill Newberry, CPA, CPC Arnett Foster Toothman, PLLC

2 OPPS Coding and Billing Hot Topics 2013 Proposed OPPS Rule October, 2012 APC Charge Edit Physician Supervision Coding for Clinic and ED Facility E&M Services Emergency Department Services EHR Dangers for E&M Professional Codes Observation Services Injections & Infusions Wound Care 2

3 What is a HOT Topic and Why is it Hot? Something that puts the institution at risk Regulatory risk Financial risk Recent audit activity, increased regulatory review Recovery Audit Contractors (RAC) Office of Inspector General (OIG) 3

4 Background Billing and coding compliance is dynamic with constant changes to regulations and interpretations and/or "clarifications" of long standing rules Individual organizations will experience different hot topics based on service lines, internal systems and controls and methods of communication involved in generating a clean claim Not intended to be an all inclusive list of hot topics (i.e. high risk) billing and coding issues 4

5 How Do Billing and Coding Issues Become Hot Topics? New requirement New interpretation of long standing practice or policy Requires coordination -> 1 group involved Issue under investigation or review by external agencies ex: OIG, RAC etc 5

6 2013 OPPS Final Rule Approximately half the size of the 2012 rule Proposing two major changes: CMS proposes to change the way it calculates APC relative weights Has used median cost data since inception to create APC weights Suggesting using the geometric mean cost to create APC weights CMS released a file so hospitals can look at impact 2013 Geometric Mean Median Change (different view of addendum B 6

7 2013 OPPS Final Rule Proposing two major changes (Cont): Separately payable drugs CMS Proposes to reimburse hospitals for separately payable drugs and biologicals without pass-through status at average sales price (ASP) plus 6%, a 2% increase from No policy changes No additional composite APCs No changes to drug administration Hospitals should take a note of the payment rate shifts due to proposed new process for weighting of APCs 7

8 October 1, 2012 APC Edit Transmittal 2463, May 4, 2012 SUMMARY OF CHANGES: Effective for claims received on or after October 1, 2012, contractors shall verify claims with OPPS Payments that meet a reimbursement amount greater than submitted charges. Background: The U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG), recently issued several final audit reports regarding the Review of Medicare Payments Exceeding Charges for Outpatient Services Processed to various A/B Medicare Administrative Contractors (A/B MACs). Audit findings in these reports include: providers reporting incorrect units of service and/ or incorrect HCPCS codes, or use of HCPCS codes that do not reflect the procedures performed. Based on findings in these reports, the Center for Medicare & Medicaid Services (CMS) is implementing a verification policy when the Outpatient Prospective Payment System (OPPS) payment is greater than the billed charges. 8

9 October 1, 2012 APC Edit Policy: When the OPPS reimbursement is greater than the claim charges, verification will be needed to ensure that a billing error has not caused this situation. Effective for claims received on or after October 1, 2012, FISS shall install a verification edit for claims with OPPS Payments that meet a reimbursement amount greater than submitted charges. The edit shall be applied to the following providers and bill types: Provider Type Types of Bills Hospitals 12X, 13X, 14X Contractors shall suspend those claims receiving the verification edit for development and contact providers to resolve billing errors. If the contractor determines that the reimbursement is excessive and claim corrections are required, the contractor shall return the claim to the provider. If the contractor determines that the billing is accurate and the reimbursement is not excessive, the contractor shall override the FISS edit and submit the claim to the Common Working File (CWF). 9

10 Physician Supervision - Review Many hospital outpatient therapeutic services are covered under the incident to a physicians service provision of the SSA. Physician incident to provisions are contained at SSA §1861 (a)(2)(A) This provision does not apply to services covered under other benefit categories. 72 Fed. Reg , (November 27, 2007) Supervision assumed for on-campus hospital departments per CMS language in the April 2000 OPPS final rule CMS issued a restatement and clarification in the 2009 OPPS final rule that its always expected direct supervision for incident-to outpatient therapeutic services in both on- and off- campus departments Providers raised concerns regarding the CMS clarification during 2009 and 2010 CMS will not withdraw what it considers longstanding physician supervision policies for hospital outpatient services, but has acknowledged that there has been some confusion prior to January 1, 2009 CMS finalized physician supervision requirements for 2010 but in March 2010, agreed to non- enforcement for CAHs. 10

11 2011 Physician Supervision - Review CAHs and rural hospitals commented that the direct supervision requirements conflicted with CAHs CoPs CMS argued there is a difference between CoPs and payment policy However – CMS then announced that physician supervision requirements would not be enforced for CAHs and also for small rural hospitals with less than 100 beds in CY 2011 & also 2012 CMS continues to emphasize need for consistent quality and safety for outpatient services provided all facilities CMS likely to revise supervision rules for all facilities to include CAHs and small rural hospitals 11

12 2011 Physician Supervision - Review CMS designated 16 services as non-surgical extended duration services where direct supervision is required for the initiation of the service followed by minimum standard of general supervision for the duration of the service CMS revised the definition of direct supervision by removing all references to on the same campus or in the off-campus provider-based department of the hospital or in the hospital or CAH By removing specific boundaries, CMS provided flexibility while holding the facility and practitioner accountable for determining how to be physically and immediately available when supervising services provided incident to a physicians service in the outpatient setting The new definition applies equally in the hospital or in an outpatient department of the hospital both on-and off- campus The new definition of direct supervision simply requires immediate availability which means physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure 12

13 2011 Physician Supervision - Review Supervisory practitioner must be immediately available to furnish assistance and direction throughout the procedure Temporal requirement, no specific physical boundary requirement Supervisory practitioner cannot be so physically distant that he/she could not intervene right away Supervisory practitioner cannot be performing another procedure or service that he/she could not interrupt Supervisory practitioner must have within his/her State scope of practice and hospital granted privileges the knowledge, skills, ability, and privileges to perform the service Supervisory practitioner must be clinically able to furnish the service himself/herself Supervisory responsibility is more than the capacity to respond to an emergency and includes the ability to take over the performance of the procedure or provide additional orders 13

14 2011 Physician Supervision - Review Supervision may be performed by a physician or by a certain non-physician practitioner (clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife) Hospital should have in place credentialing procedures, bylaws and other policies to ensure that outpatient services furnished to beneficiaries are provided only by qualified practitioners For therapeutic services furnished under arrangement outside the hospital to patients, CMS expects that the services are being supervised appropriately 14

15 2011 Physician Supervision - Review Direct supervision – immediately available to furnish assistance and direction throughout the procedure. Does not mean in the room; but CMS makes it clear must be physically present. Available thru phone does not meet the requirement. In a clinic within close proximity, is considered to be immediately available. General supervision – services are furnished under the overall direction and control of the physician but his presence is not required during the procedure. Personal supervision – physician is present in the room when procedure is performed. 15

16 2012 Physician Supervision During the 2012 OPPS rulemaking cycle, CMS finalized plans to augment the scope and membership of the APC Advisory Panel to include supervision levels and members of rural and CAH providers, respectively Evaluation Criteria: Complexity of the service; Acuity of the patients receiving the service; Probability of unexpected or adverse patient event; Expectation of rapid clinical changes during the therapeutic service or procedure; and Recent changes in technology or practice patterns that affect a procedures safety. CMS will prioritize requests based on: service volume, total expenditures for the service, and frequency of requests. Priority to services that the public has requested for evaluation in the CY 2010 through CY 2012 OPPS/ASC rules & to services not previously been evaluated by the Panel. Baseline supervision level is direct & requests require justification for change in supervision level, supported with clinical evidence and at the CPT/HCPCS code level. 16

17 2013 Physician Supervision – Proposed Rule Enforcement Instruction for the Supervision of Outpatient Therapeutic Services in CAHs and Small Rural Hospitals: In this proposed rule, we are requesting that CAHs and small rural hospitals submit to CMS for potential evaluation by the Panel at the summer meeting any services for which they anticipate difficulty complying with the direct supervision standard in CY In developing evaluation requests, hospitals should refer to the evaluation criteria that we finalized in the CY 2012 OPPS/ASC final rule with comment period. We recognize that hospitals have had little experience in submitting evaluation requests to CMS for consideration by the Panel. In order to give hospitals additional opportunity this year to become familiar with the submission and review process at the summer Panel meeting, and to allow hospitals time to meet the required supervision levels for services that may be considered for CY 2013, we anticipate extending the non-enforcement instruction one additional year through CY We expect that this will be the final year for the instruction, regardless of the services reviewed by the Panel during its summer meeting. 17

18 2013 Physician Supervision – Sept 24 Preliminary Decisions on Recommendations Hospital OP Payment Panel meeting August 27-28, 2012 Decisions are preliminary and were open to public comment through October 24, 2012 Final decisions will be posted after considering any comments and those decisions will be effective on January 1, 2013 Panel recommended change from direct supervision to general supervision for the following services: G0008 – flu G0009 – pneumoncoccal vaccine G0010 – Hepatitis B vaccine G0127 – Trimming of dystrophic nails – Timming of nondystrophic nails – Introduction of needle or intracatheter, vein – Collection of blood specimen from a completely implantable venous access device – Collection of blood specimen using established central or peripheral cathether, venous – Insertion of temporary indwelling bladder catheter; simple – Change of cystostomy tube; simple – Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging 18

19 2013 Physician Supervision – Sept 24 Preliminary Decisions on Recommendations Panel recommended change from direct supervision to general supervision for the following services (Cont): – IV infusion, hydration; initial – IV infusion, hydration; each additional hour – Refilling and maintenance of portable pump – Irrigation of implanted venous access device for drug delivery systems G0379 – Direct Admit for hospital observation care The following codes remain extended duration meaning general after the initiation of service under direct supervision: G0378 Hospital observation services per hour G9141 – Infuenza A – Strapping, unna boot – Application of multi-layer compression system, leg (below knee) – – IV infusion, therapy codes – – Therapeutic or diagnostic injections 19

20 Physician Supervision – CMS - FAQs FAQ #5 – Can an emergency department physician or NPP directly supervise therapeutic outpatient services while in the emergency department? In most cases the emergency physician or NPP can directly supervise outpatient services so long as the emergency physician in the ED of the campus is immediately available, meaning that, if needed, he or she could reasonably be interrupted to furnish assistance and direction in the delivery of therapeutic services provided elsewhere in the hospital…We believe that most emergency physicians can appropriately supervise many services within the scope of their knowledge, skills, licensure, and hospital-granted privileges… 20

21 Physician Supervision – CMS - FAQs FAQ #6 – Does a physician need to directly supervise therapeutic services delivered to hospital outpatients or can other NPPs directly supervise as well? Beginning in CY2010, NPPs, including nurse practitioners, physician assistants, clinical nurse specialists, certified nurse-midwives, and licensed clinical social workers may directly supervise the provision of all hospital therapeutic services that they may perform themselves within their state scope of practice and hospital-granted privileges, provided that they continue to meet all the requirements for directly providing services, including any collaboration or supervision requirements… 21

22 Physician Supervision – Enforcement If you are audited by any government agency who is questioning physician supervision at your hospital, the first step is to figure out what period is under review in order to determine what the rule was at the time! Be sure to get policies in place for provider based locations as well as any other departments where you perform these services. 22

23 Coding for Clinic and ED facility E&M Services Technical Component Coding – Hospital level of care provided. Hospital must have a policy for determining level of care. Time Staff intervention Point system Professional Component Coding – Based on E&M rules History Exam Medical Decision Making Both technical and professional coding should be monitored by reviewing frequency and distribution of codes. 23

24 Emergency Department Facility E&M Determination Five levels – CPT – Critical care – CPT – code also any procedures performed Third party payers may not pay additional ½ hours of critical care on the facility side All procedures performed by physicians and ancillary staff must be coded Review nursing notes for procedures performed 24

25 Clinic Departments Facility E&M Determination New Patient CPT – Established Patient – CPT – All procedures performed by physicians and ancillary staff must be coded – ancillary staff services determine facility level E&M Review nursing notes for procedures and E&M services performed 25

26 Coding for Clinic and ED facility E&M Services Evaluation and Management (E&M) services are coded on the technical (hospital) component side based on resources utilized CMS states in several OPPS rules that they do not intend to tell us how to code these levels, in fact, in the 2009 OPPS final rule, they state that hospitals are doing well by using their own policies Most hospitals use a scorecard approach to determine the correct level Be careful not to include separately billable services on the scorecard to prevent duplication 26

27 Coding for Clinic and ED facility E&M Services Methodologies for Determining E&M Level (Scorecard type) Staff time – based on the time staff spent with the patient. Higher levels are reported based on increments of time beyond baseline care. Staff intervention – based on the number or type of staff interventions performed by nursing or ancillary staff. Higher levels are reported based on the number and/or complexity of staff interventions. Resource intensity point scoring – based on points assigned to each staff intervention based on time, intensity and staff type required. The service level is determined by the sum of the points for all services provided. 27

28 ED & OP Visit Coding (Facility) CMS E&M Facility Guidelines Based on hospital facility resources Clear and usable for compliance purposes and audits Meet the HIPAA requirements Require documentation that is clinically necessary for patient care Should not facilitate upcoding or gaming Written or recorded, well-documented, and provides the basis for selection of a specific code Applied consistently across patients in the clinic or ED to which they apply Should not change with great frequency Readily available for fiscal intermediary (or, if applicable, Medicare Administrative Contractor) review Should result in coding decisions that could be verified by other hospital staff members, as well as outside sources. 28

29 ED & OP Visit Coding (Facility) 2013 Proposed Rule …we are continuing to instruct hospitals to report facility resources for clinic and emergency department hospital outpatient visits using the CPT E/M codes and to develop internal hospital guidelines for reporting the appropriate visit level. We note that our continued expectation is that hospitals' internal guidelines will comport with the principles listed in the CY 2008 OPPS/ASC final rule with comment period (72 FR 66805). We encourage hospitals with specific questions related to the creation of internal guidelines to contact their servicing fiscal intermediary or MAC. We refer readers to the CY 2012 OPPS/ASC final rule with comment period (76 FR through 74346) for a full historical discussion of these longstanding policies.72 FR FR

30 Emergency Department ED Treatment Rooms Do not bill E/M with drug administration charge when an infusion is the sole reason for the visit 2007 OPPS Final Rule – Providers should bill a low-level visit code in such circumstances only if the hospital provides a significant, separately identifiable low level visit in association with the packaged service. 30

31 Medical Necessity Medically Necessary means that a service, supply or medicine is necessary and appropriate and meets the standards of good medical practice in the medical community for the diagnosis or treatment of a covered illness or injury, as determined by the insurance company Review National Coverage Decisions (NCD) Review Local Medical Review Policies (LMRP) NCDs take precedence over LMRPs 31

32 Medical Necessity - ED Code Signs and Symptoms to support test May code diagnoses from the Radiology Report Rule out or probable diagnose not acceptable May not code results from Lab tests 32

33 Split/Shared Visit Qualified Non Physician Providers (NPPs) who are permitted to assist a physician during a shared visit are: Nurse practitioners Physician assistants Clinical nurse specialists Certified nurse midwife Medicare reimburses services provided by an NPP alone at 85% of the rate it reimburses physicians. However, CMS reimburses visits shared between the physician and the NPP at 100% of the allowed amount to the physician. To obtain the full reimbursement allowed, the physician must document his or her participation in the care of the patient along with the NPPs documentation of his or her portion of the care. If the documentation does not support the physicians presence and the portion of work the physician performed, the NPP should report the care alone. 33

34 Reporting Split/Shared Visits to Medicare The split/shared visit rules state that both the NPP and the physician must have a face-to-face encounter with the patient on the day the facility or practice reports the service. (The Handshake Rule) Both the physician and the NPP should document their own participation in the medical record. The physician practice employs the NPP. Warning - do not report a shared visit when a hospital facility or other entity employs the NPP. The physician cannot simply co-sign the chart and state reviewed and agree in the record without seeing the patient personally. The physician must perform and document at least some of the three key components of E/M services (i.e., the history, the exam, and the medical decision-making) https://www.cms.gov/transmittals/downloads/R178CP.pdf 34

35 OIG Report: Coding Trends of Medicare E&M Services Similar trends held true across 13 different categories of E/M services. The jump from to yielded a handsome increase in compensation. In 2010, Medicare paid on average $97.35 for a visit, which is 50% more than the $64.80 for a As a result of this study, OIG turned the names of 1,700 physicians over to CMS and suggested review. The OIG states that it did not determine whether physicians who chose more 99214s and other higher-level E/M codes in 2010 billed Medicare inappropriately or fraudulently. That line of inquiry, it says, will be the focus of future reports. The following month (June 2012) the OIG issued a Memorandum Report – Use of Electronic Health Record Systems in 2011: Among Medicare Physicians Providing Evaluation and Management Services.Memorandum Report – Use of Electronic Health Record Systems in 2011: Among Medicare Physicians Providing Evaluation and Management Services The survey concluded that physicians do not trust their EHRs to assign billing codes. Of the 2,000 physicians surveyed, 88% manually assign the codes for E&M services and the remaining 12% use professional billers to do so. The message is crystal-clear, OIG has specifically targeted billing fraud perpetuated by reliance on EHR coding/documentation. 35

36 OIG Memorandum Report: Use of EHR Systems in 2011 Among Medicare Physicians Providing Evaluation and Management services 36 This memorandum report responds to a request from officials of the Office of the National Coordinator for Health Information Technology (ONC), who expressed interest in information about physicians reported use of electronic health record (EHR) systems ONC officials made this request in connection with an ongoing evaluation on the extent of documentation vulnerabilities of evaluation and management services using EHR systems

37 OIG Memorandum Report: Use of EHR Systems in 2011 Among Medicare Physicians Providing Evaluation and Management services OIG Findings: 57% of Medicare Physicians used EHR at primary practice location in % of physicians who used EHR for E&M began between 2001 and 2011 Of these physicians, 22% began using EHR in 2011, the year CMS commenced the incentive program 3 of every 4 Medicare physicians with an EHR system used a certified system to document E&M services Although many EHR systems can assist physicians in assigning codes for E&M services, we found that most Medicare physicians manually assigned E&M codes 37

38 NY Times: Medicare Bills Rise as Records Turn Electronic New York Times Article September 21, 2012 the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care. one contractor, National Government Services, recently warned doctors that it would refuse to pay them if they submitted cloned documentation. Trailblazer Health Enterprises in Texas found that 45 out of 100 claims from Texas and Oklahoma emergency department doctors were paid in error. Patterns of over-coding E.D. services were found in template-generated records. One patient came to Virginia hospital ED with kidney stones. When he received the bill from the ED doctor, his medical record, produced electronically, reflected a complete physical exam that never happened. Record showed his extremities had been examined, however patients legs were wrapped in a blanket. Patient alleges most logical conclusion was [the doctor] went to a menu and clinked standard exam and the software filled in a examination of all of his system. After he complained, the physician group reduced his bill. 38

39 Letter From US AG and US DHHS Secretary Dated September 24, 2012 to 5 Trade Associations. 55% of hospitals have already qualified for incentive payments authorized by Congress for adopting and meaningfully using electronic health records. Used appropriately, electronic health records have the potential to save money and save lives. Troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. These indications include potential cloning of medical records in order to inflate what providers get paid. There are some reports that hospitals may be using electronic health records to facilitate up- coding of the intensity of care or severity of patients condition as a means to profit with no commensurate improvement in the quality of care. A patients care information must be verified individually to ensure accuracy: it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments. CMS is initiating more extensive medical reviews to ensure that providers are coding evaluation and management services accurately. This includes comparative billing reports that identify outlier facilities. 39

40 The Dangers of Copy and Paste The practice goes by several names: Copy and paste Cloning Carrying forward Carrying forward information without careful review can cause contradictions in a patients chief compliant documentation or history of present illness. If a clinician is carrying forward information unless they read the information word for word, line for line and re-evaluate, the information carried forward may be inaccurate. Documentation may show physicians performing services they only performed once in the past, leading to over reimbursement. Documentation must be recorded for each specific encounter Once copy and paste gets in to the record, its credibility may be compromised Copying forward a previous review of systems without reviewing changes in the patients health status is noncompliant. Many MACs are now requesting multiple visits of the same patients E&M record and reviewing for cloning, upon finding it, the entire amount of payment is rescinded. 40

41 CMS Allows RAC to Add E&M Services to Approved List In September, 2012, CMS made the decision to allow RACs to begin reviewing the billing codes for office visits for healthcare providers. Specifically the codes at issue are evaluation and management codes (E&M). These claims had previously been off-limits to RACs. Connolly, Inc., the contractor for RAC audit services in 15 states (including WV) will sort through claims filed by doctors and hospitals from as far back as October 1, The plan is to conduct limited reviews using statistical sampling to project how many physician claims that used the high level, established patient E&M code were paid correctly. Other RACs are expected to follow Connollys lead. 41

42 Steps to Take Now to Lower Your Risk Profile Be Proactive – Start Now! Compliance Program – if you dont have an effective compliance program, get one now. If you have not already purchased an EHR, shop carefully and be wary of vendors who promise your patient encounters will come out at a higher level after you adopt their system. Run a baseline CPT frequency report of your E&M services for each provider before you implement EHR. Continue to monitor the frequency of the distribution of E&M code levels after implementation and look for significant changes. Understand EHR functionality – determine where in workflow cloning can occur. Provider regular consistent training to physicians regarding the appropriate use of EHR. 42

43 Steps to Take Now to Lower Your Risk Profile If you have already implemented an EHR, calculate any improved net revenue directly associated with higher E&M coding levels. Review any variations among providers (i.e., some physicians billing mostly level 4 or 5). Perform a documentation review to look for evidence of cloning or carrying forward notes on history, exam or medical decision making. Review current documentation policies and consider turning off ability to cut and paste. Consider not allowing EHR to select level; either move that practice back to the physician or to certified coders. 43

44 Method II Billing – CAHs DEFINED: An increased payment to a Critical Access Hospital for outpatient physician services Attributes of Method II Billing: Must be elected by a CAH within 30 days of start of fiscal year Once elected it remains in effect until CAH cancels Physicians can be employed or contracted by hospital Any outpatient hospital department qualifies: ED, Radiology, Laboratory, Hospital-based physician clinics, etc. Method II Clinic = (Hospital-based clinic) + 15% increase for physician services Increased payment = 15% increase to the physician payment for a hospital-based clinic (see next slide) Physician Prof. Fees are billed on a UB…NOT on a

45 Method II Billing – CAH s Method II Payment Formula (Physician Services): CPT – Medicare Facility Payment (SOS 22)$41.31 Reduce for Patient Coinsurance x 80% Net Medicare Facility Payment$33.05 Increase for Method IIx 1.15 Medicare Facility Payment – Method II$38.01 CPT – Medicare Phys. Office Payment(SOS 11)$57.96 Reduce for Patient Coinsurance x 80% Medicare Phys. Office Payment$

46 Method II Billing – CAHs The Medicare Internet Only Manual (IOM) , Chapter 4, Section 250 states that a CAH billing for the non-physician practitioner (NPP) services under Option II must report a CPT modifier describing the credentials of the performing practitioner. This reference further explains that payment for non-physician practitioners will be made at 115 percent of the allowable amount payable under the Medicare physician fee schedule; in other words at a reduced rate of 115% of the 85% (NPP rate). The non-physician practitioner professional services require one of the following modifiers: GF – Service rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA). SB - Services rendered in a CAH by a nurse midwife. AH - Services rendered in a CAH by a clinical psychologist. AE - Services rendered in a CAH by a nutrition professional/registered dietitian 46

47 Observation Definition has not changed since Day 1 Observation services are those services furnished on a hospitals premises, including use of a bed and periodic monitoring by nursing or other staff, which are reasonable and necessary to evaluate an outpatients condition or determine the need for a possible admission as an inpatient. APC regulation (FR 11/30/01, pg 59881) Observation is an active treatment to determine if a patients condition is going to require that he or she be admitted as an inpatient or if it resolves itself so that the patient may be discharged. Expanded 2006 Federal Register Information Observation is a well defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment, before a decision can be made regarding whether a pt will require further treatment as hospital inpts or if they are able to be discharged from the hospital. Note: No significant 2007, 08,09, 10, 11, 12 reg changes 47

48 Observation Other 2006 Federal Register info: Pt must be under the care of a physician….as documented in the medical record by admission, discharge and other appropriate progress notes that are timed, written and signed by the physician. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care. (pg 68694) 48

49 Transmittal 1745/1760 July 2009 Meant to clarify OBS language on patient status. However, nothing changed regarding active physician involvement, assessment and reassessment to determine if the patient needs admitted or safely discharged home = Billable hour. 49

50 Transmittal 1745/1760 July 2009 Editorial change to remove references to admission and observation status in relation to outpt observation services and direct referrals for observation services. These terms may have been confusing to hospitals. The term admission is typically used to denote an inpt admission and inpt hospital services. For payment purposes, there is no payment status called observation Observation care is an outpt service, ordered by a physician and billed with a HCPCS code. Revenue code 762 or 760 is acceptable. Rounding of hrs. Hospitals should round to the nearest hr. (EX 3:03 to 9:45 = 7 hrs) Standing orders for obs services following outpt surgery are not recognized. Recovery room services billed separately (4-6 hrs) References: 290.1; ; / Transmittal 1745 Medicare Claims Processing Manual Chpt 4, 290; Pub Medicare Benefit Policy Manual Chpt 6,

51 Observation When a patient is converted from observation to inpatient, the following is needed: New set of orders New H&P OR New set of orders Copy of observation H&P plus last progress note outlining reason for need to convert to inpatient Inpatient visit must stand along for coding and billing 51

52 Observation When time begins at the clock time documented in the medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physicians order 52

53 Observation Observation time ends at the clock time when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physician that may take place after a physician has ordered that the patient be released or admitted as an inpatient 53

54 Observation 54 In situations where a procedure interrupts observations services, hospitals would record for each period of observation services the beginning and ending times during the hospital encounter and add the length of time for the periods of observation together to reach the total number of units reported on the claim.

55 Observation 55 Patient placed in observation bed following ER visit with diagnosis of GI bleeding at 6:00 a.m. At 10:00 a.m., patient has EGD procedure and finished recovery from EGD at 3:00 p.m. Patient discharged at 10:00 p.m Bill only 11 hours of observation Patient is at the facility for 16 hours, but patient spends 5 hours undergoing procedure in a separate unit and recovering from procedure

56 Observation Continuous Monitoring: May a hospital report drug administration furnished during the time period when obs services are being reported? CMS FAQ Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g colonscopy, chemotherapy). In situations where such a procedure interrupts observation services and results in two of more distinct periods of obs services, hospitals should record for each period of obs services the beginning and ending times during the hospital outpt encounter. Hospitals should add the length of time for the periods of obs services together to determine the total number of units reported on the claims for the hourly obs services under HCPCS code G0378 (hospital obs service, per hr.) Continuous monitoring = billed 1 st, then earn OBS hrs Medicare Claims Processing Manual, Pub Chpt 6, Section

57 Continued answer to CMS FAQ The hospital must determine if active monitoring is a part of all or a portion of the time for the particular drug administration services received by the patient. Whether active monitoring is a part of the drug administration service may depend on the type of drug administration service furnished, the specific drug administered, or the needs of the patient. For example, a complex drug infusion titration to achieve a specified therapeutic response is reported with HCPCS codes for a therapeutic infusion may require constant active monitoring by hospital staff. On the other hand, the routine infusion of an antibiotic, which may be reported with the same HCPCS codes for a therapeutic infusion, may not require significant active monitoring. For concerns about specific clinical situations, hospitals should check with their Medicare contractors for future information. If the hospital determined that active monitoring is part of a drug adm service furnished to a particular patient and separately reported, then OBS services should not be reported with HCPCS G0378 for that portion of the drug adm time when active monitoring is provided. Observation 57

58 FAQ 9974: "It is an unacceptable practice to automatically place a patient in observation for the sole purpose of providing Chemotherapy, or other therapeutic intravenous infusions. If any complex therapeutic intravenous infusions are given during a patients observation hours these service hours must also be deducted. Hydration is not considered as therapeutic active monitoring." An example: a complex drug infusion titration to achieve a specified therapeutic response that is reported with HCPCS codes for a therapeutic infusion may require constant active monitoring by hospital staff. On the other hand, the routine infusion of an antibiotic, which may be reported with the same HCPCS codes for a therapeutic infusion, may not require significant active monitoring. (Source: FAQ 9974 active monitoring and drug administration.htm) Observation 58

59 Observation 59 Report G0379 with revenue code 762 for a direct admit to observation. A direct admit occurs when the admission is NOT related to: An ER visit A hospital outpatient clinic visit Critical Care Hospital outpatient surgical procedure

60 Observation 60 Inappropriate Uses of Observation (non covered) General standing orders following outpatient surgery Postoperative monitoring during a standard recovery period (4-6 hours) Develop a hospital policy regarding # of hours Routine preparation services furnished prior to diagnostic testing and recovery Diagnostic testing services for which active monitoring is part of the service For patient, facility, or physician convenience

61 Condition Code 44 Original transmittal 81 (effective ) Updated transmittal 299, dated (FL 24-30) Further clarity on physician review: Q&A, March Use when the physician ordered inpatient, but upon UR review performed before the claim was originally submitted, the hospital determined that the service did not meet its inpatient criteria. New MLN Matters Q&A – UR must consult with the practitioners responsible for the care of the patient and allow them to present their views BEFORE making the determination Review and final decision must be made while the patient is still in the facility. 61

62 More CMS clarity on CC 44 FAQ (questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_aip Q: May a hospital change a patients status using CC 44 when a physician changes the patients status without UR committee involvement? A: No, the policy for changing a patients status using CC44 requires that the determination to change a pts status be made by the UR committee with physician concurrence. The hospital may not change a pts status from inpt to outpt/OBS without UR committee involvement. The conditions for use of CC 44 require physician concurrence with the UR committee decision. For CC 44 decisions, in accordance with 42 CFR (d 1), one physician member of the UR committee may make the determination for the committee that the inpt admission is not medically necessary. (cont) 62

63 More CMS clarity on CC 44 Cont. (questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_aip This physician member of the UR committee must be a different person than the concurring physician for CC 44 use who is the physician responsible for the care of the pt. Noridan/MAC states in their FAQ: Q37: If the attending physician AGREES with the status change from INPT to Outpt/OBS, do we need to involve the UR physician also? Or is it only required with the attending does not agree? A37: In order to change the beneficiarys status from inpt to outpt/OBS, the attending physician must concur with the UR committee. 63

64 More CMS clarity on CC 44 - Patient (questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_aip Palmetto/MAC, issued Observation and CC 44 Discussion Items. Power Q&A as a result from NC work group, 4 th Q Q: A Medicare pt is admitted as an inpt. Case Mgt/UR does not believe meets inpt/Interqual requirements. The physician agrees. The pt status is changed back to OBS; however, the hospital failed to inform the pt of the status change. How is this situation billed? Should the pt remain an inpt and not be charged OBS? A: Should the pts status change at any time during the hospital stay, it is imperative that the pt be notified of this change in a timely manner (prior to discharge). In this particular situation, this notification should have occurred at the point when the pt was identified as not being eligible.. 64

65 More CMS clarity on CC 44 - Patient (questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_aip..for an inpt stay they could have been entitled to information regarding the change in status and impact to coinsurance. According to Medicare Claims Processing Manual, Publication , Chapter 30, Section 20: When the beneficiary did not know or could not have reasonably expected to know that the items or services were not covered, but the provider knew or could have been expected to know, of the exclusion of the items or services, the liability for the charges for the denied items or services rests with the provider...Because the pt was not notified of his/her change in status, the provider will be required to bill the claim AS AN INPT type of bill (11x) in spite of the fact that the stay does not meet inpt criteria. The claim should be filed as a no pay.. 65

66 More CMS clarity on CC 44 - Patient (questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_aip.. type of bill (110) with all days and charges as non-covered. Since the beneficiary was not given a notice of non-coverage before discharge, the stay should be billed as provider liability using a M1 occurrence span code in form locator 35 or 36. This will cause the claim to process in FISS as non- covered with no payment and no pt liablity reports on the remittance advice or the beneficiarys Medicare Summary Notice (MSN)...After the no pay claim (TOB 110) is processed, you may then file an inpt ancillary claim (TOB 12x) to seek payment for the eligible ancillary provided during the stay. The eligible ancillary services are outlined in Medicare Claims Processing Manual, publication , chapter 4, section

67 Injections & Infusions Whats New/Revised in 2012: Instructional notes revised to clarify when appropriate to report more than one initial service Includes definitions for sequential and concurrent infusions Includes example of infusion crossing calendar days – depends on whether service was continuous or not revised to specify new drug/substance in description 67

68 Injections & Infusions Whats Bundled? If performed to facilitate the infusion or injection, the following services are included and are not reported separately: Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes, and supplies 68

69 Injections & Infusions Whats Not Bundled (CAH cost) Specific materials or drugs (e.g., HCPCs Level II J- codes) Significant, separately identifiable E&M service - append modifier -25 to E&M code 69

70 Injections & Infusions Reporting Hierarchies/Sequencing Non-Facility Report as the initial code that which best describes the key or primary reason for the encounter, irrespective of the order in which the infusions or injections occur Facility Chemo primary to tx/pro/dx Tx/pro/dx primary to hydration Infusions primary to pushes Pushes primary to injections Hierarchy supersedes parenthetical instructions for add-on codes 70

71 Injections & Infusions Multiple Administrations Only one initial service code should be reported for each encounter unless protocol requires that two separate IV sites must be used If injection or infusion is subsequent or concurrent in nature, even if it is the first such service within that group of services, report subsequent or concurrent code from appropriate section 71

72 Injections & Infusions Multiple Administrations More than one initial service appropriate when: Separate Site IV Right Hand IV Left Hand Separate Encounter Visit at 8:00 am Return visit same day at 4:00 pm and new line started Append -59 modifier to 2nd initial code to identify distinct procedural service 72

73 Injections & Infusions Infusion Time Use the actual time over which the infusion is administered if infusion time is a factor Measured when infusate is actually running – do not count pre- and post time Infusion time must be documented (start and stop) If health care professional administering substance/drug is continuously present to administer injection and observe the patient, bill as a Push If infusion time is 15 minutes or less, bill as a Push Infusion intervals of > 30 minutes beyond 1-hour increments required to report additional hour codes 73

74 Injections & Infusions Chemotherapy & Other Highly Complex Drug or Biologic Agent Administration The chemotherapy administration CPT codes (96401–96549): Are used to report the administration of certain non-radionuclide drugs when the infusion requires physician work or clinical staff monitoring well beyond that of therapeutic drug agents (CPT codes 96360–96379). Apply to parenteral administration of non-radionuclide antineoplastic drugs, antineoplastic agents provided for the treatment of non-cancer diagnoses (e.g., cyclophosphamide for autoimmune conditions), substances such as monoclonal antibody agents and other biologic response modifiers. 74

75 Injections & Infusions The chemotherapy administration CPT codes (96401–96549) may not be used to report administration of: Substances used as diagnostic agents such as radio-opaque dyes. Therapeutic radionuclides (use CPT codes 79101, or 79999). Anti-anemia drugs. Anti-emetic drugs. Hydration fluids. Drugs that appear on the usually self-administered drug exclusion list. 75

76 Injections & Infusions Chemo/Complex/Biologic Techniques SQ or IM ( ) Intralesional ( ) IV Push (96409, 96411) IV Infusion (96413, 96415) More than 8 Hours w/portable or implantable pump ( ) IA Push (96420) IA Infusion ( , 96425) 76

77 Injections & Infusions Therapeutic, Biologic, Diagnostic Codes Used for the administration of substances or drugs Not used for administration of vaccines/toxoids, allergen immunotherapy, antineoplastic hormonal or nonhormonal therapy, or hormonal therapy that is not antineoplastic Not used for chemo, highly complex drugs, or highly complex biologic agents 77

78 Injections & Infusions Therapeutic, Biologic, Diagnostic Require direct physician supervision for patient assessment, provision of consent, safety oversight, and intraservice staff supervision Infusions require special consideration to prepare, dose or dispose of Require practice training and competency for staff who administer infusions Periodic patient assessment with vital sign monitoring required during infusions 78

79 Injections & Infusions Therapeutic, Biologic, Diagnostic Intravenous infusion ( ) Subcutaneous infusion ( ) Injection; subcutaneous or intramuscular (96372) Injection; intra-arterial (96373) Injection; intravenous push ( ) 79

80 Injections & Infusions Hydration (Codes ) Used to report a hydration IV infusion to consist of pre-packaged fluid & electrolytes (eg, normal saline, D5W), but not drugs or other substances Do not report if infusion time is 30 minutes or less Report add on code for hydration intervals of > 30 minutes beyond 1 hour increments Report if hydration provided as secondary or subsequent service after a different initial service administered through same IV access. Can also be performed prior to another infusion Do not report if performed concurrently with other infusion services or to keep open line between infusions or when freeflowing during chemo or tx/pro/dx infusions Hydration separately reportable if medically necessary (e.g. dehydration, N/V) and not part of regular infusion protocol 80

81 Wound Care Billing Guidelines Wound Care (CPT Codes 97597, and ) Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. CPT and/or CPT are typically used for recurrent wound debridements. CPT and/or CPT are not limited to any specialty. 81

82 Wound Care Coding Guidelines Active wound care, performed with minimal anesthesia is billed with either CPT code or Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes CPT code 11043, and 11044, may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC). 82

83 Wound Care Coding Guidelines The following HCPCS codes are considered a dressing and therefore bundled into the procedure. Q4104 Integra BMWD skin sub Q4105 Integra DRT skin sub Q4107 Graftjacket skin sub Q4108 Integra matrix skin sub Q4110 Primatrix skin sub Q4111 Gammagraft skin sub Q4112 Cymetra allograft Q4113 Graftjacket express allograf Q4114 Integra flowable wound matri Q4115 Alloskin, per square centimeter Q4116 Alloderm, per square centimeter Q4117 Hyalomatrix, per square centimeter Q4118 Matristem micromatrix, 1 mg Q4119 Matristem wound matrix, per square centimeter Q4120 Matristem burn matrix, per square centimeter Q4121 Theraskin, per square centimeter 83

84 Wound Care Reasons for Denial Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC Billing of debridement by unqualified personnel 84

85 Wound Care Documentation Requirements The medical record must clearly show that the medical necessity criteria have been met. There must be a documented plan of care with documented goals and documented provider follow- up present in the patient's medical record. Wound healing must be a medically reasonable expectation based on the clinical circumstances documented. Documentation of the progress of the wounds response to treatment must be made for each service billed. At a minimum this must include current wound size, wound depth, presence and extent of or absence of obvious signs of infection, presence and extent of or absence of necrotic, devitalized or non-viable tissue, or other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown. When debridements are performed, the debridement procedure notes must document tissue removal (i.e. skin, full or partial thickness; subcutaneous tissue; muscle; and/or bone), the method used to debride (i.e., hydrostatic versus sharp versus abrasion methods), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. 85

86 Wound Care Can an E&M be billed on the same date as a debridement or other wound care service? Only if there is a separately identifiable and significant service that is performed on the patient can an E&M be billed the same day as a procedure code. This is an OIG, CMS and now RAC Hot Topic Data mine your Wound Care department billing and be sure that any E&M codes billed with a -25 modifier includes documentation to support a significant, separately identifiable service. 86

87 CONTACT INFORMATION Jill Newberry Phone No


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