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Point-of-care Point of Care Billing: Yes You Can! Christopher FETTERS

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Presentation on theme: "Point-of-care Point of Care Billing: Yes You Can! Christopher FETTERS"— Presentation transcript:

1 Point-of-care Point of Care Billing: Yes You Can! Christopher FETTERS
District Sales Manager © All Rights Reserved. Unauthorized duplication is a violation of applicable laws.

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

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

4 Nurse training Right Patient Right Drug Right Dose Right Route
Right Time 770,000 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 failure 60-80% is human error Active errors Latent errors

7 Newsweek Who is the most important person in Media and Entertainment?

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

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

10 Three phases of laboratory testing
Pre-analytical Analytical Post-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.” W Gerald 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 misspelled 114,500 mismatched pairs of shoes will be shipped/year 811,000 faulty rolls of 35MM film will be purchased this year. 880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips 2,488,200 books will be shipped in the next 12 months with the wrong cover. 5,517,200 cases of soft drinks produced in the next year will be flatter than a bad tire. 1,314 phone calls will be misplaced by telecommunications services every minute. 18,322 pieces of mail will be mishandled/hour 22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes. 2,000,000 documents will be lost by the IRS this year Your heart fails to beat 32,000 times each year. Twelve babies will be given to the wrong parents each day. 2,500 newborn babies will be dropped in the next month. 107 incorrect medical procedures will be performed by the end of the day today. 500 incorrect surgical operations each week; 200,000 drug prescriptions will be filled incorrectly in the next 12 months. A typical day would be 24 hours long (give or take 86.4 seconds) Jeff Dewar

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

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 urines Timing urine dipsticks Bad Patient/Operator ID’s Timeliness of data (docking) wireless CHANGE THE PROCESS

16 Your mission… Risk Analysis Brainstorm What tests?
Pre-analytical, analytical, post-analytical What steps? List what could go wrong? (Risk Analyis) Prioritize (Severity) Change the process / re-educate Audit

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 department Graphics with poof on previous, then diminishing graphic of current one Find a bite mark for these… operators Three things you MUST DO! Barcode your patients & operators Install Connectivity (not just data management) 3. Bill for point of care testing

18 Fetters POC Device Classes
0 – Manual testing i – Marginally Connectable Instruments ii – Batch Download Connectable Instruments iii – Continuous Connected Instruments (Wired) ? iv – Continuous Connected Instruments (Wireless)

19 Standard Data Management Schema
Network Clinical Data Station POC Device Date/Time Device S/N QC Lot# QC Lockout User ID Patient ID Strip Lot# Result Comment Code

20 Standard Data Management Schema
Network Clinical Data Station POC Device

21 Standard Data Management Schema
Downloading Network Clinical Data Station POC Device

22 Standard Data Management Schema
Network Clinical Data Station POC Device QC in range Valid Patient ID Valid User ID Comment Code Flagged Results

23 Standard Data Management Schema
Network Clinical Data Station POC Device Flagged Results

24 Standard Data Management Schema
Network Clinical Data Station POC Device ü QC in range Valid Patient ID Valid User ID Comment Code ü ü ü Flagged Results

25 Standard Data Management Schema
Cum Report HIS Terminal Network Clinical Data Station POC Device LIS System HIS System Patient Billing Flagged Results

26 Benefits Time savings (up to 1/3 of POCC) Ability to bill
Results on EMR QC tracking / regulatory viability Improved user compliance “What I do matters to somebody” QC/Operator Lockout Early 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 testing Interfaces Multiple devices / multiple DM systems CONCLUSION: Lack of profit, cost of implementation and the challenge of multiple analytes have been a barrier to ubiquitous implementation of connectivity.

28 Objectives You 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 workload Ought to be paid for services Recoup costs Continue to upgrade technology Add FTE’s to improve control Good 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 = Laboratory 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.”

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

35 Medicare Medicare Part A Medicare Part B Inpatient
Reimbursed by Fiscal Intermediary Medicare Part B Outpatient/POL’s Reimbursed by Carrier Alabama(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 video Inpatient Medicare Billing Process Patient discharged Physician discharge summary and diagnoses - 30,000 codes Standardized codes for diagnosis Formulated by the World Health Organization (WHO) ICD-10CM is coming… Medical Records Coder  ICD-9 codes - 500 codes - Clinically cohesive groups Similar consumption of hospital resources Similar length of stay patterns Grouper  DRG code Upload to Medicare Payment under Prospective Payment System (PPS) Upload hospital cost report

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 ratio Illustrate the lump sum payment at the end of the year. Illustrate the Part A to Part B Rollover Use of the cost report Globally PPS based on averages Set next year’s DRG reimbursement schedule Locally Cost to charge ratio

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 notes Example DRG Primary Diagnosis: ICD – “Bypass, aortocoronary” ICD-9 Secondary Diagnoses: Valvuloplasty, Atherectomy, Catheterization, Angiocardiogram, or Arteriogram ICD-9 DRG 106: “Coronary Bypass with Cardiac Catheterization” DRG Medicare Average Reimbursement: $37,000 $$

39 Medicare contractors 12 TRAILBLAZER CHISOLM BCBS “Waived Test”
QUESTION Part A - Coverage Is CPT a covered service for inpatients? ANSWER Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] QUESTION Part A - Coverage Is CPT a covered service for inpatients? ANSWER Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] QUESTION Part A - Coverage Is CPT a covered service for inpatients? ANSWER Inpatient claims submitting for Glucose, blood by glucose monitoring device(s) cleared by the FDA (Food and Drug Administration) specifically for home use is a covered procedure and reimbursed DRG for hospitals or RUG for Skilled Nursing Facilities (SNF). [http://www.trailblazerhealth.com/faqs.asp?action=print&id=1561] “Waived Test” TRAILBLAZER QUESTION Is CPT a covered service for inpatient claims? ANSWER Inpatient claims submitted for Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use, is a covered procedure and reimbursed as a portion of the Prospective Payment System for Hospital and Skilled Nursing care inpatient services. [http://www.bcbsok.com/chisholm/frequently_asked_questions.html] CHISOLM BCBS 12

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

41 Setting charges for analytes
X Using the Clinical Lab Fee Schedule DON’T Glucose (82962) $3.27 Use lab/hospital Charge Master Suggest CLSI (NCCLS) GP-11A “Basic Cost Accounting for Clinical Services” Calculate using worksheets (Direct cost + Indirect cost) X Hospital multiplier

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

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

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 Number Physician order Reasonable and necessary (SSA 1862(a)(1)(A)) Physician must use to manage pt care (42 CFR , ) Result to physician promptly (implicit)

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

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 Billing 20-40% Missed charges Data management 100%

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%)

49 Laboratory Trends Profits Costs

50 US Testing Market The 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 tests Commercial other & labs = ~ 1.53 bn POCT 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 Hospital Professions 25% Registered Nurses 75% As many as 168,000 hospital positions are unfilled in six selected job categories. Three out of four vacancies are nursing positions Note: 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 Technologists Northeast Midwest South West Mean 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 management Show form with clinical and financial justification request. Billing can improve patient care More FTE’s = Better quality More leverage with physicians and nurses Show ROI on Data Management Financial and clinical justification for new point of care analytes POC Billing creates more nursing positions

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

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… Conclusion You should bill for point of care testing! Point of care billing is profitable! Billing for point of care improves patient care!

57

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


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