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). [
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). [
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). [
“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. [
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 analytesX
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!

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