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 Nurse training Right Patient Right Drug Right Dose Right Route Right Time770,000 untoward drug errors
5 It is necessary to create a culture of change that embraces patient safety through shared accountability within a blameless culture.Rosina Jones, LHRM, CHRM
6 Causes of Medical Mistakes 15-20% is mechanical failure60-80% is human errorActive errorsLatent errors
7 Newsweek Who is the most important person in Media and Entertainment?
8 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
9 IDIOT Not this one Changing the process “er” – Season finale Romano’s accidentNot this oneIDIOT
10 Three phases of laboratory testing Pre-analyticalAnalyticalPost-analytical
11 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.”
12 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
13 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
14 82% of Patient Data Still Manually Recorded Source: 1999 EAC US Hospital POC Survey
15 Point of Care Errors Sensa v. Non-sensa Documentation of ACT Results MD Pocket Developer (distilled water)Documentation of urinesTiming urine dipsticksBad Patient/Operator ID’sTimeliness of data (docking)wirelessCHANGE THE PROCESS
16 Your mission… Risk Analysis Brainstorm What tests? Pre-analytical, analytical, post-analyticalWhat steps?List what could go wrong? (Risk Analyis)Prioritize (Severity)Change the process / re-educateAudit
17 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…operatorsThree things you MUST DO!Barcode your patients & operatorsInstall Connectivity(not just data management)3. Bill for point of care testing
19 Standard Data Management Schema NetworkClinical Data StationPOC DeviceDate/TimeDevice S/NQC Lot#QC LockoutUser IDPatient IDStrip Lot#ResultComment Code
20 Standard Data Management Schema NetworkClinical Data StationPOC Device
21 Standard Data Management Schema DownloadingNetworkClinical Data StationPOC Device
22 Standard Data Management Schema NetworkClinical Data StationPOC DeviceQC in range Valid Patient ID Valid User IDComment CodeFlagged Results
23 Standard Data Management Schema NetworkClinical Data StationPOC DeviceFlagged Results
24 Standard Data Management Schema NetworkClinical Data StationPOC DeviceüQC in range Valid Patient ID Valid User IDComment CodeüüüFlagged Results
25 Standard Data Management Schema Cum ReportHIS TerminalNetworkClinical Data StationPOC DeviceLIS SystemHIS SystemPatient BillingFlagged Results…
26 Benefits Time savings (up to 1/3 of POCC) Ability to bill Results on EMRQC tracking / regulatory viabilityImproved user compliance“What I do matters to somebody”QC/Operator LockoutEarly problem detection (liability)CONCLUSION:1. Ability to bill improves ability to staff to an adequate level and use discretionary time to improve patient care.2. IMPROVED CONTROL = IMPROVED QUALITY = IMPROVED SAFETY = IMPROVED PT CARE
27 Challenges Doesn’t inherently save *nursing* time Timeline Apparent Price (Sticker-shock)Manual testingInterfacesMultiple devices / multiple DM systemsCONCLUSION: Lack of profit, cost of implementation and the challenge of multiple analytes have been a barrier to ubiquitous implementation of connectivity.
28 ObjectivesYou should bill for point of care testing!Point of care billing is profitable!Billing for point of care improves patient care!
29 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
30 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.
31 Point of Care Testing is Lab Testing Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88)American Medical Association (AMA)Medicare
32 CLIA ‘88 Certifies testing Human specimens • Based on complexity, not setting• Agents of the laboratory
33 CLIA’s View of In Vitro Testing One Waived Test = LaboratoryCLIA’s View of In Vitro TestingCLIA 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.”
34 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• • •
35 Medicare Medicare Part A Medicare Part B Inpatient Reimbursed by Fiscal IntermediaryMedicare Part BOutpatient/POL’sReimbursed by CarrierAlabama(Regional Office: Atlanta) Part A - Blue Cross and Blue Shield of Alabama; Mutual of Omaha Insurance Company Part B - Blue Cross and Blue Shield of Alabama
36 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
37 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
38 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$$
39 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
40 Medicare Clinical Laboratory Fee Schedule Covers procedures in CPT RangeSet reimbursement rate (Medicare Part B)Update yearly by Medicare
41 Setting charges for analytes XUsing the Clinical Lab Fee ScheduleDON’TGlucose (82962) $3.27Use lab/hospital Charge MasterSuggest CLSI (NCCLS) GP-11A“Basic Cost Accounting for Clinical Services”Calculate using worksheets(Direct cost + Indirect cost) X Hospital multiplier
42 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
43 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
44 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%)
45 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)
46 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
47 100% 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%
48 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%)
50 US Testing MarketThe US Laboratory testing market totaled ~$35.4 billion (5.63 bn tests) in 2001 (including commercial, hospital, physician office & other labs)Hospitals/IHN’s = > 4.1 bn testsCommercial other & labs = ~ 1.53 bnPOCT is almost $4 billion and GROWING!
51 Payor mix (typical) Medicare / Medicaid (45-60%) Managed care (20-40%) Fee for Service (15-25%)Other (remaining)
52 Healthcare Personnel Shortages Other HospitalProfessions25%Registered Nurses75%As many as 168,000 hospital positions are unfilled in six selected job categories. Three out of four vacancies are nursing positionsNote: Other hospital professions include pharmacists, radiological technologists, laboratory technologists, billing/coders, and housekeeping/maintenance staff.
53 Staff Shortages Continue For U.S. Hospitals A Shortage of Medical TechnologistsNortheastMidwestSouthWestMean Vacancy Rate (in percent)
54 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
55 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
56 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!