Virginia Point of Care Coordinators Point of Care Billing Strategies Christopher FETTERS President & Founder Nextivity

Virginia Point of Care Coordinators Point of Care Billing Strategies Objectives Identify quality issues in healthcare and POCT Identify key requirements to bill for POCT Provide examples of POCT billing impact List reasons why a POCT billing claim will be rejected Review Medicare Fraud & Abuse

Virginia Point of Care Coordinators Point of Care Billing Strategies 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

Virginia Point of Care Coordinators Point of Care Billing Strategies Causes of Medical Mistakes 60-80% is human error Active errors Latent errors 15-20% is mechanical failure

Virginia Point of Care Coordinators Point of Care Billing Strategies Three stages of quality Remedial Corrective Preventative

Virginia Point of Care Coordinators Point of Care Billing Strategies Is 99.9% Good Enough? 1 hour of unsafe drinking water every month. 2 unsafe plane landings per day at O'Hare Airport in Chicago. 12 newborns will be given to the wrong parents daily. 50 babies dropped at birth every day. 291 pacemaker operations will be performed incorrectly each year. 500 incorrect operations each week. 315 entries in Webster's Dictionary will be misspelled. 18,322 pieces of mail will be mishandled/hour. 20,000 incorrect prescriptions every year. 22,000 checks deducted from the wrong bank account each hour. 32,000 missed heartbeats per person each year. 880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips. 2,000,000 documents will be lost by the IRS this year. 2.5 million books will be shipped with the wrong covers each year. 5.5 million cases of soft drinks produced will be flat each year. A typical day would be 24 hours long (give or take 86.4 seconds.) What are your POCT compliance rates? By Jeff Dewar

Virginia Point of Care Coordinators Point of Care Billing Strategies Six Sigma Measures errors per million Focused on Process Improvements Improve quality and reduce errors

Virginia Point of Care Coordinators Point of Care Billing Strategies 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 institutions effort to ensure consistently high-quality results. Gerald J. Kost, MD, PhD. Using operator lockout to improve the performance of point-of-care blood glucose monitoring W

Virginia Point of Care Coordinators Point of Care Billing Strategies Challenges to POC Quality 1.Users not indoctrinated in laboratory medicine 2.Copious data Handwritten (transcription errors) No ref range, incomplete results, no initials 3.Accurate patient ID 4.Regulatory compliance 5.Over-taxed POCC 6.Manual testing / UN-connected instruments 7.Connectivity is not plug n play 8.Testing in the home-setting

Virginia Point of Care Coordinators Point of Care Billing Strategies Technology can benefit quality CBT – Computer based training for nursing Barcoded patients - Mercy Health System, Philadelphia feedback to nursing - UC Davis Intranet policies, procedures, information - UTMB (www2.utmb.edu/poc) Online QC uploading - UTMB Data Management for QC, patient results - PinnacleHealth, Veterans Admin, Samaritan Health, etc

Virginia Point of Care Coordinators Point of Care Billing Strategies Quality conclusions for healthcare Our healthcare delivery system is NOT safe for the patient Quality Safety (for the patient) Process changes ensure long-term benefit Labs have opportunity because of attention to quality issues Examine pre-analytical processes first Use technology to examine data & improve quality

Virginia Point of Care Coordinators Point of Care Billing Strategies Billing terms PPS – Prospective Payor System DRG – Diagnosis Related Groups ICD-9 – Diagnosis Codes Fiscal Intermediary Insurance company Administrates Medicare Part A Carrier Insurance company Administrates Medicare Part B CPT – Current Procedural Terminology Modifier – QW, QR

Virginia Point of Care Coordinators Point of Care Billing Strategies Payor mix (typical) Medicare / Medicaid (45-60%) Managed care (15-25%) Private payor (10-30%) Other (remaining)

Virginia Point of Care Coordinators Point of Care Billing Strategies 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)

Virginia Point of Care Coordinators Point of Care Billing Strategies Are you sure I can bill for POCT? Laboratory services covered Laboratory services ancillary Laboratory testing subject to fee schedule Lab billing should follow Section 450 (1450) Use Revenue code 30x Lab testing MUST be reflected on cost report

Virginia Point of Care Coordinators Point of Care Billing Strategies Medicare National Coverage Policy Federal Register March 10,2000 Vol 65 No. 48. Pp 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

Virginia Point of Care Coordinators Point of Care Billing Strategies Payment for glucose testing 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.

Virginia Point of Care Coordinators Point of Care Billing Strategies Steps to be compliant and bill properly -Check with FI for using Remember your modifiers – repeat and waived -Have a Charge code -Audit the Rev Usage report to make sure the charge is being billed -Must have a Rev code in the 300s to be accepted by Medicare -(EOMB) Remittance advices should be audited to see if they were denied oLab usually gets CPT codes along with the Remittance advices -Make sure that signed order and documented result -Check to see if is carved out in your managed care contracts

Virginia Point of Care Coordinators Point of Care Billing Strategies Medicare Fraud and Abuse Billing for services that were not rendered Misrepresenting medical necessity by reporting covered procedures Signing blank records or falsifying documents Consistently using procedure codes that describe more extensive service than performed

Virginia Point of Care Coordinators Point of Care Billing Strategies Managed care -Could be capitated or lump sum -Check on the carve outs for particular testing Opportunity to negotiate contracts Get it in the CDM Need a rev usage report (shows how many times they billed) Make a financial projection Send a memo to Contracts Officer

Virginia Point of Care Coordinators Point of Care Billing Strategies How do I set my pricing? Lab Director, Lab Operations Mgr 1.5 – 2.0 X Medicare Fee Schedule Pricing Worksheet (Direct cost + Indirect cost) X Hospital markup

Virginia Point of Care Coordinators Point of Care Billing Strategies Steps to charge a POCT Physicians order Test performed Download Auto-verify Interface LIS Nightly billing (charge code) Financial system (convert to CPT) Wait for discharge Discharge notes by physician Coding by medical records (ICD-9) Grouper (figures out DRG) Upload to Medicare or printed bill to Pts Insurance

Virginia Point of Care Coordinators Point of Care Billing Strategies 1. What is the impact of POCT Billing? List tests and volumes Glucose ACT PT Blood gases Hemoglobin Urine dip Gastroccult Hemoccult Rapid Strep Pregnancy

Virginia Point of Care Coordinators Point of Care Billing Strategies 2. What is the impact of POCT Billing? Look up CPT Codes and your core lab pricing OR Use Medicare Fee Schedule avg * 1.5 – 2.0

Virginia Point of Care Coordinators Point of Care Billing Strategies 3. What is the impact of POCT Billing? Find out your payor mix (%) Medicare / Medicaid Managed care Private payor Other

Virginia Point of Care Coordinators Point of Care Billing Strategies 4. What is the impact of POCT Billing Multiply for total charges Volume IP X IP Charge Volume OP X OP Charge Multiply payor mix for draw-down. IP Total charges IP X Private payor OP Total charges OP X Finances factor Add IP + OP = Expected direct revenue OR (more true) 69% of charges = Revenue

Virginia Point of Care Coordinators Point of Care Billing Strategies For more information Christopher Fetters 317 N Newberry St York, PA (717) (801) Fax Presented 14 August 2001 to the Virginia Point of Care Coordinators, Newport News, VA, courtesy of Lifescan