2 Goal Goal in Point of Care? Goal in the Laboratory? Goal in the Hospital?Golden Rule: Do unto others as you wouldhave 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 Medicine44,000 – 98,000 patients killed each year by medical mistakesKey RecommendationsCenter for patient safetyNational mandatory reportingPeer review protectionsFocus greater attention on patient safetyFDA 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 failure60-80% is human errorActive errorsLatent errors
7 Three approaches to quality RemedialAlleviate the symptoms of the existing problemCorrectiveEliminate the cause of existing problems or undesirable situation to prevent recurrencePreventativeEliminate the cause of potential problems
8 IDIOT Not this one Changing the process “er” – Season finale Romano’s accidentNot this oneIDIOT
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.”WGerald 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 misspelled114,500 mismatched pairs of shoes will be shipped/year811,000 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 strips2,488,200 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/hour22,000 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 yearYour 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 QualityOur healthcare delivery system is NOT safe for the patientSafety is part of qualityProcess changes ensure long-term benefitLabs have opportunity because of attention to quality issuesExamine pre-analytical processes firstUse 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 dipsticksBad Patient ID’sCHANGE THE PROCESS
14 You can’t managewhat 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 departmentGraphics with poof on previous, then diminishing graphic of current oneFind a bite mark for these…Three things you MUST DO!Barcode your patients & operators2. Install Connectivity3. Bill for point of care testing
16 ObjectivesYou 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 workloadOught to be paid for servicesRecoup costsContinue to upgrade technologyAdd FTE’s to improve controlGood for patient care
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 89399CPT Codes for POCWaived Glucose – 82962Urine dipstick – 81002ACT – 85347Fecal occult blood• • •
24 Medicare Medicare Part A Medicare Part B Inpatient Reimbursed by Fiscal IntermediaryMedicare Part BOutpatient/POL’sReimbursed by CarrierFlorida (Regional Office: Atlanta)Part A - First Coast Service Options, Inc Mutual of Omaha Insurance CompanyPart B - First Coast Service Options, Inc.
25 Inpatient Medicare Billing Process Christopher Fetters:Set this up as an animation or videoInpatient Medicare Billing ProcessPatient dischargedPhysician discharge summary and diagnoses- 30,000 codesStandardized codes for diagnosisFormulated by the World Health Organization (WHO)ICD-10CM is coming…Medical RecordsCoder ICD-9 codes- 500 codes- Clinically cohesive groupsSimilar consumption of hospital resourcesSimilar length of stay patternsGrouper DRG codeUpload to MedicarePayment 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 ratioIllustrate the lump sum payment at the end of the year.Illustrate the Part A to Part B RolloverUse of the cost reportGloballyPPS based on averagesSet next year’s DRG reimbursement scheduleLocallyCost 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 notesExample DRGPrimary Diagnosis:ICD – “Bypass, aortocoronary”ICD-9Secondary Diagnoses:Valvuloplasty, Atherectomy, Catheterization, Angiocardiogram, or ArteriogramICD-9DRG 106: “Coronary Bypass with Cardiac Catheterization”DRGMedicare Average Reimbursement:$37,000$$
28 Medicare contractors 12 TRAILBLAZER CHISOLM BCBS “Waived Test” QUESTIONPart A - CoverageIs CPT a covered service for inpatients?ANSWERInpatient 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).[QUESTIONPart A - CoverageIs CPT a covered service for inpatients?ANSWERInpatient 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).[QUESTIONPart A - CoverageIs CPT a covered service for inpatients?ANSWERInpatient 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).[“WaivedTest”TRAILBLAZERQUESTIONIs CPT a covered service for inpatient claims?ANSWERInpatient 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 BCBS12
29 Medicare Clinical Laboratory Fee Schedule Covers procedures in CPT RangeSet reimbursement rate (Medicare Part B)Update yearly by Medicare(
30 Setting charges for analytes XUsing the Clinical Lab Fee ScheduleDON’TGlucose (82962) $3.03Use lab/hospital Charge MasterSuggest NCCLS GP-11A“Basic Cost Accounting for Laboratories”Calculate using worksheets(Direct cost + Indirect cost) X Hospital multiplier
31 Medicare Payment Policies LocalLMRP (Local Medical Review Policy)Administered by CarrierNationalNational Coverage Decisions23 lab analytesIn effect Nov, 2002Final Rule: Federal Register 11/23/2001Administered by Federal Law
32 Medicare National Coverage Decision Christopher Fetters:Picture of someone putting a grey top on a core lab instrumentMedicare National Coverage DecisionSpecifically addresses glucose testingLists ICD-9 for medical necessityLists reasons for denialAlso covers CPT 82947
33 Who says I can bill for POCT? Christopher Fetters:Gradient picture of Consultant, Government building, HospitalWho 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 NumberPhysician orderReasonable 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 testingCPT CodesICD-9 for medical necessityReasons for denialAbsence of signs or symptomsRoutine physical (such as employee physical or community health fair)Failure to provide medical necessityNot ordered by physicianFailure to have CLIA certificateTesting 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 Billing20-40% Missed chargesData management100%
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…198819921995
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 screensPoint of Care BillingisPROFITABLE!Point of Care BillingisPROFITABLE!
45 Where have all the grey tubes gone? Christopher Fetters:Movie of racks of grey top tubes, putting grey tubes on core instrument. PoofMoney 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 BehringRoche
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 managementShow form with clinical and financial justification request.Billing can improve patient careMore FTE’s = Better qualityMore leverage with physicians and nursesShow ROI on Data ManagementFinancial and clinical justification for new point of care analytesPOC Billing creates more nursing positions
49 Your mission… POC Committee Create an impact worksheet Pt volumes X Charges = Gross ChargesGross Charges X Fee for service % = Net Revenue PotentialBilling investigation committee (Ad hoc)POC Coordinator (& Staff)Medical DirectorLab Manager / Administrative DirectorLab Business Operations MgrLIS SupervisorPatient AccountingNursing AdminManaged Care ContractsPotential
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…ConclusionYou 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 FettersNova Biomedical(781) x293(781) Fax
52 Frequently asked questions 1. DRG = No money \ Why bill?Medicare cost reportOther payors2. What CPT code for glucose? or 8294882962: Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use510K approval by the FDA3. 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 ScheduleLaboratory testing is an ancillary service (415.5)Laboratory services are covered under Medicare as a payable service (210.5)Transmittal AB & AB-00-99Laboratory test charges must be reflected on the cost reportLaboratory 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 ImpactGlucose:Yearly Total Volume: 300,000Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)(Inpatient)Inpatient volume: 100,000Charge per test: $ (avg. $12-25)Yearly charges: $1.5 MREVENUE FROM PAYORS:Medicare/Medicaid (55%): $0Managed Care (30%): $0Fee-for-Service (15%): $219,000TOTAL 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 ImpactGlucose:Yearly Total Volume: 300,000Yearly Patient Volume: 200,000 (2/3 of total, waste, QC, repeats)(Outpatient)Outpatient volume: 100,000Charge per test: $ (avg. $12-25)Yearly charges: $1.5 MREVENUE FROM PAYORS:Medicare/Medicaid (55%): $177,650 ($3.23 CLFS on 55,000 tests)Managed Care (30%): $0Fee-for-Service (15%): $219,000TOTAL IP REVENUE: $396,650
59 Point of Care Billing Impact Glucose:Inpatient: $219,000Outpatient: $396,650Revenue: $615,650ACT:Volume: 48,000 pt testsCharge: $28.00Billables: $1.3MRevenue: $195,000Urine dipstick:Volume: 35,000 pt testsCharge: $9.00Billables: $315,000Revenue: $47,250ABG:Volume: 11,000 pt testsCharge: $55.00Billables: $605,000Revenue: $90,750Only 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) TestBillablesRevenueGlucose2,900,000615,650ACT1,300,000195,000Urine dip315,00047,250ABG605,00090,750Total5,120,000948,650
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.”