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Billing therapy services in support of comprehensive APC services

Billing therapy services in support of comprehensive APC services

by Valerie A. Rinkle, MPA

CMS’ Transmittal 3523, issued May 13, is the quarterly July 1 OPPS update. In this transmittal, CMS briefly mentions billing physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to comprehensive APC (C-APC) services under revenue code 0940 (general therapeutic services) rather than the National Uniform Billing Committee?defined revenue codes for these services (i.e., 042x, 043x, and 044x, respectively).

CMS refers to these therapy services as "non-therapy outpatient department services." In addition, CMS says that these services should not be reported with therapy CPT® codes.

These therapy services have been packaged into C-APCs since the inception of these per-encounter/per-claim payments in 2015. Initially, CMS implemented 25 C-APCs in 2015 for device-intensive procedures. In 2016, the agency expanded the concept to 33 surgical and procedural C-APCs covering almost 700 CPT/HCPCS procedure codes in nine clinical families. It also added one C-APC to pay for ancillary services in the case of inpatient-only procedures performed on a patient who dies prior to being admitted as an inpatient (billed with modifier ?CA).

Another C-APC is for observation services when billed for eight or more hours, with either ED, clinic, or direct admit codes and no surgery service performed. These C-APCs are defined with status indicators J1 and J2. On these claims, there is one payment associated with one primary CPT/HCPCS regardless of the number of days for the encounter. All of the other charges and codes are billed on the claim. There are a few exceptions, such as non-OPPS services like ambulance and preventive services such as vaccines and mammography.

While the transmittal does not provide much explanation, it is assumed that this instruction follows CMS’ comment in the 2016 OPPS final rule, where CMS stated at 80 FR 70326 (emphasis added):

Payment for these non-therapy outpatient department services that are reported with therapy codes and provided with a comprehensive service is included in the payment for the packaged complete comprehensive service. We note that these services, even though they are reported with therapy codes, are outpatient department services and not therapy services. Therefore, the requirement for functional reporting under the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) does not apply.

 

Therefore, according to this statement in the 2016 OPPS final rule, CMS intended to provide administrative relief to hospitals so that they would no longer have to report functional status HCPCS G codes and modifiers when these therapy services were provided in support of C-APC services and included on the same claim.

However, since January 1, the Integrated Outpatient Code Editor (I/OCE) claim edits continue to require reporting of functional status HCPCS G codes and modifiers if therapy CPT and revenue codes are reported. Changing the reporting of these therapy services from the usual revenue codes and CPT codes to revenue code 0940 and no CPT codes will no longer trigger the claim edits that require the reporting of functional status codes and modifiers. However, there seems to be even more behind this change.

 

Defining therapy services

CMS described these therapy services provided during the perioperative period or in support of observation as not the same therapy services discussed in section 1834(k) of the Social Security Act (SSA). This distinction is an important one, because therapy services that meet the definition of therapy services performed by therapists under a plan of care in accordance with sections 1835(a)(2)(C) and 1835(a)(2)(D) of the SSA are excluded from OPPS by statute and paid under the Medicare physician fee schedule.

CMS implies that therapy services performed during the same encounter as C-APC services, even when performed by licensed and credentialed therapists, do not meet that same statutory definition of therapy, namely due to not being under a plan of care. Therefore, CMS no longer wants these therapy services in support of C-APCs to be reported with the same revenue and CPT codes as that used for therapy provided under a plan of care, which are required to be billed as repetitive services on monthly claims. C-APC services are required to be on an outpatient hospital claim that includes all the other charges and codes for services performed during the same encounter that are supportive or adjunctive to the C-APC service.

The transmittal also refers to the status indicator for this revenue code (0940) being changed from B to N. Status indicator B means codes that are not recognized when submitted on an OPPS claim. One way to remember this is that B stands for "better code." Status indicator N means items unconditionally or always packaged, or stated another way, services never separately paid. Heretofore, status indicators were preserved for CPT/HCPCS codes and APC groupings and not assigned to revenue codes.

However, CMS maintains a list of packaged revenue codes. Previously, revenue code 0940 was not included in the list of packaged revenue codes (Table 4 in the 2016 OPPS final rule at 80 FR 70320). CMS appears to be changing revenue code 0940 to be included in the list of packaged revenue codes.

If the services are no longer to be reported with CPT codes, then this revenue code will become packaged. As is the case with all packaged revenue codes, if the service is defined by a CPT/HCPCS code, and all other CPT/HCPCS coding and NCCI policies are followed, the CPT/HCPCS codes should be reported in addition to the revenue code irrespective of the fact that the revenue code is packaged.

 

Setting a precedent

This transmittal is the first time that CMS appears to suggest that services that meet the definition of CPT/HCPCS codes should not be reported at all, even when all other CPT/HCPCS coding conventions and NCCI policies are followed; it appears to be a precedent for CMS.

Once this change occurs, CMS will not use hospital therapy cost center cost-to-charge ratios from hospital cost reports to reduce the billed charges for therapy under revenue code 0940, but rather hospitals’ "other" cost center cost-to-charge ratios. It will likely result in a mismatch of revenue and expense that could adversely impact future rate setting.

It is interesting to note that rehabilitation services are optional hospital services under CMS’ Conditions of Participation (CoP) at 42 CFR 482.56, which states:

Physical therapy, occupational therapy, speech-language pathology or audiology services, if provided, must be provided by qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists as defined in part 484 of this chapter.

 

There are a few services that CMS defines as "sometimes therapy services" which can either be performed by therapists or nurses, namely wound care services. The CoPs, which are different than conditions of payment, do not require a plan of care, but do require orders. Therefore, it appears that hospital therapy services can be provided without a plan of care, and presumably, these services are now packaged under OPPS and do not qualify for physician fee schedule payment. Requirements for therapy plan of care for coverage can be found at 42 CFR 410.61 and 42 CFR 424.24.

To implement this change, hospitals will likely have to duplicate therapy charges in the chargemaster under the different revenue code that would only be used for Medicare outpatients and not for Medicare inpatients, and commercial or Medicaid accounts that are not likely to follow this billing instruction. This implementation step will likely complicate charge capture and increase the likelihood of errors.

Providers should evaluate this CMS instruction and provide feedback to the agency. Consider the following:

  • Is this proposal more or less burdensome than continuing to report therapy under the current revenue codes and also reporting the functional status codes and modifiers?
  • Do hospitals currently develop plans of care for therapy, whether or not it is in support of a C-APC service?
  • Will it alleviate a different type of burden on therapists if plans of care are not required?

 

Providers should comment to CMS if this solution is more burdensome or creates more confusion. CMS may be able to find other ways to change the I/OCE edits for functional status codes and modifiers and allow therapy services to continue to be reported with the usual revenue codes and CPT codes.

One of the most significant impacts may be to the accuracy of future payment rates. If this instruction continues without change, then a fundamental principle of cost reporting and rate setting seems to have been changed. This new policy may create a critical precedent for future rate setting. If CMS does not hear from many providers, then it is not likely to change the requirement and providers will need to work toward implementation as of July 1.

 

Editor’s note: Rinkle is a lead regulatory specialist and instructor for HCPro’s Medicare Boot Camp®?Hospital Version, Medicare Boot Camp®?Utilization Review Version, and Medicare Boot Camp®?Critical Access Hospital Version. Rinkle is a former hospital revenue cycle director and has over 30 years in the healthcare industry, including over 12 years of consulting experience in which she has spoken and advised on effective operational solutions for compliance with Medicare coverage, payment, and coding regulations.

HCPro.com – Briefings on APCs

Documenting chronic health problems with a comprehensive Preventive medicine visit

I’m wondering if anyone can shed some light or provide direction for me regarding what can or should be addressed during a patients preventative medicine exam
I understand the difference between a Medicare AW exam and the age appropriate exam CPT codes 99381-99387 and 99391-99397
My query lies with the later the none Medicare exam
Components include appropriate history and exam with preventative counseling based on age as well as risk factor reduction,Immunizations and diagnostic’s
Where the water gets muddied for me is when the patient has long term chronic problems which are all brought into the encounter as well.
Is it necessary ? to discuss the pt’s COPD ,NIDDM , sarcoidosis etc during their preventative medicine visit ,assuming all conditions are stable at the time of the visit and if so to what extent
Understanding that if there is a significantly problem or abnormality found or discussed such as an exacerbation of the pt’s COPD that would be addressed with an E&M.
What I want to be sure of is it necessary to address all comorbidities during a preventative visit with a separate assessment and plan for each
Obviously the patients entire health picture is taken into consideration for counseling etc however the focus sometimes shifts from preventative a follow up visit on the chronic problems Not to mention the extra time spent addressing each co morbidity
If anyone can provide insight or recommend literature to research I would appreciate it
Is there a way to bill for extended Preventative visit when the provider addressed several stable chronic medical problems,as they can be quite lengthy

Thank you in advance Cheri

Medical Billing and Coding Forum

Comprehensive EP study/Cath Ablations

Trying to teach myself how to code cardiology procedures, need help coding, any help is greatly appreciated :)

PROCEDURE PERFORMED:
1. Catheter ablation of atrial fibrillation by pulmonary vein isolation.
2. Catheter ablation of complex fractionated electrograms at the left atrial
roof.
3. Comprehensive EP study with left ventricular pacing and recording.
4. Intracardiac electrophysiologic 3D mapping.
5. Intracardiac echo.
6. Transseptal puncture x1.
7. Programmed stimulation and pacing after IV drug infusion isoproterenol.
8. Implantation of St. Jude implantable cardiac memory loop recorder system.

PREOPERATIVE DIAGNOSIS:
Atrial fibrillation.

POSTOPERATIVE DIAGNOSIS:
Paroxysmal atrial fibrillation.

COMPLICATIONS:
None.

SPECIMEN TAKEN:
None.

ESTIMATED BLOOD LOSS:
10 mL.

CONTRAST:
Zero.

SEDATION:
Per general anesthesia.

BRIEF SYNOPSIS:
XXXXXX is a XXXXXX with past medical history of
tachycardia mediated cardiomyopathy, EF 40 to 45%, diastolic heart failure,
hypertensive heart disease, paroxysmal atrial fibrillation on amiodarone
therapy. He is seen and examined, deemed appropriate for atrial fibrillation
for rhythm control.

DESCRIPTION OF PROCEDURE:
The patient was brought to the EP lab in a fasting state whereupon he was
connected to blood pressure, pulse oximetry, and electrocardiographic
monitoring. An anesthesiologist was present and participated in the entire
procedure for administration of sedation and continuous monitoring vitals. He
presented in normal sinus rhythm. After the right groin was prepped and draped
in usual sterile fashion, 3 venous access were obtained in the right femoral
vein. Three J-tipped 0.035 inch guidewires were advanced into the right
femoral vein via modified Seldinger technique. Two SL0 and 1 short 8-French
sheath were advanced over the guidewires into the IVC. At different points in
time, catheters were placed within the high right atrium, His, coronary sinus,
right ventricle, left atrium, left ventricle.

A single transeptal puncture was performed guided by fluoroscopic, hemodynamic,
and intracardiac echo. A BRK needle was advanced into the SL0 sheath. This
was withdrawn to the level of the fossa ovalis. Tenting of the septum was
observed on intracardiac echo. Following this a SafeSept guidewire was
inserted through the BRK needle across the interatrial septum into the left
superior pulmonary vein. The BRK needle, dilator, and sheath were then
advanced into the left atrium. Intravenous heparin was administered to
maintain an ACT of 300 to 350 throughout the course of the procedure.

A Biosense Webster 3.5 mm irrigated tip, J-curve SmartTouch SF ablation
catheter was inserted into the second SL0 sheath and advanced across the
initial transseptal puncture site in the left atrium.

A 3D electroanatomic mapping system (CARTO) and PentaRay catheter were utilized
to recreate geometry of the left atrium and pulmonary veins. The PentaRay
catheter was inserted into the left ventricle and mitral annular points were
marked on CARTO. All 4 pulmonary veins demonstrated potential wide area.

Antral encircling lesions were delivered to isolate all 4 pulmonary veins. An
esophageal probe marked the esophagus and careful attention was paid to avoid
damage to it. At no point in time did the esophageal temperature rise more
than 0.3 degree during ablation. Careful attention was also paid to avoid
damage to the phrenic nerve prior to ablation of the right-sided pulmonary
veins. High-output pacing at 20 milliamps 10 milliseconds was performed at the
ostium of the right-sided pulmonary veins prior to ablation. There was no
evidence of diaphragmatic stimulation over those parts. Following isolation of
all 4 pulmonary veins, I then targeted complex fractionated electrograms at the
left atrial roof between the left and right superior pulmonary veins
effectively creating a roof line. Bidirectional block was achieved across the
roof. 18 mg of adenosine was administered and there was evidence of right-
sided pulmonary vein reconnection. Further ablation was performed around the
roof as around the right inferior pulmonary vein, which subsequently resulted
in re-isolation of those veins. An additional 18 mg of adenosine was
administered and there was no evidence of pulmonary vein reconnection.

Comprehensive EP study was then performed. Sinus cycle length was 720
milliseconds, PR 130, QRS 135, QT 42, AH 85, HV 35, AV block 310, VA block 510,
AV node ERP less than 200 at 500.

Isoproterenol was then initiated up to 10 mcg. On isoproterenol, sinus cycle
length was 680 milliseconds, PR 166, QRS 115, QT 360, AH 73, HV 35, AV block

290, VA block 350, AV node ERP less than 200 at 400. Intracardiac echo post
ablation showed no evidence of pericardial effusion. 50 mg of protamine was
delivered intravenously. All sheaths and catheters removed and hemostasis was
achieved with manual pressure.

Following this, a St. Jude cardiac memory loop recorder system was implanted.
The skin was incised using the implant tool at the fourth intercostal space, 2
cm lateral to the left edge of the sternum. The implant trocar was used to
tunnel into the subcutaneous tissue and the loop recorder was advanced into
place using the plunger tool. The implant tool was removed and pressure was
held. A sterile sleeve was applied and confirmed adequate R-wave measurements.
Pressure was held until there was minimal bleeding and then the wound was
dressed and covered with Dermabond, Telfa, and Tegaderm

Medical Billing and Coding Forum

Your Comprehensive Guide To Hiring A Medical Negligence Lawyer

Since medical negligence cases are often hard to win without any legal help due to the complex nature of these claims many claimants prefer hiring legal help to get maximum compensation. The following paragraphs will elaborate on a few things all claimants should know about hiring a medical negligence lawyer.

Medical negligence solicitors specialize in clinical negligence cases and dental malpractice cases. Usually these lawyers specialize only in 1 field and they do not practice other personal injury cases. These solicitors spend years studying the law applicable to these cases so that they can help claimants get maximum compensation as soon as possible.

A medical negligence solicitor helps claimants get compensation when a medical procedure goes wrong due to which the claimants suffers a personal loss. An instance of such a claim would be a claimant asking for compensation since the dentist he went to did not perform the bridge work properly due to which the claimant not only suffered from pain and misaligned teeth but also had to go to another dentist to clean up the first dentists mess.

Claimants should remember that to get maximum compensation they will need to collect documents that help them prove that the medical procedure had gone wrong due to which they suffered a financial or personal loss. Such documents include but are not limited to previous medical records before the original treatment started, current medical records after the treatment ended, X-rays if any, treatment bills and treatment receipts.

In addition to guiding the claimant and preventing him from making mistakes, the selected medical negligence lawyer will help the claimant complete all the paper work and the solicitor will also take copies of the required documents and give back the originals to the claimant. In addition the medical negligence solicitor will represent the claimant in court, deal with the party at fault and negotiate with the insurance company or adjuster if required.

Claimants should note that no win no fee services do not apply for medical negligence claims since medical negligence solicitors charge a small fee for working on these claims. While the selected solicitor will be helping claimants get maximum compensation, solicitors cannot guarantee that claimants will get 100% compensation due to the nature of medical negligence claims. Claimants should also note that the medical negligence lawyer will be discussing these fees and the amount of compensation that can be got before the claimant signs up with the selected solicitor.

The amount of compensation that claimants can get by taking a medical negligence solicitors help depends on the type of the problem incurred, the severity of the problem and if the claimant plans to claim for additional compensation. Claimants should remember these lawyers can be found online using search engines and these solicitors can also be hired by opting for the services of an accident claim company.

If you want maximum compensation as soon as possible then hire a medical negligence lawyer from this reputable company. Visit their website at http://www.100percent-compensation.co.uk/.

Your Comprehensive Guide To Hiring a Medical Negligence Lawyer

Since medical negligence cases are often hard to win without any legal help due to the complex nature of these claims many claimants prefer hiring legal help to get maximum compensation. The following paragraphs will elaborate on a few things all claimants should know about hiring a medical negligence lawyer.

Medical negligence solicitors specialize in clinical negligence cases and dental malpractice cases. Usually these lawyers specialize only in 1 field and they do not practice other personal injury cases. These solicitors spend years studying the law applicable to these cases so that they can help claimants get maximum compensation as soon as possible.

A medical negligence solicitor helps claimants get compensation when a medical procedure goes wrong due to which the claimants suffers a personal loss. An instance of such a claim would be a claimant asking for compensation since the dentist he went to did not perform the bridge work properly due to which the claimant not only suffered from pain and misaligned teeth but also had to go to another dentist to clean up the first dentist’s mess.

Claimants should remember that to get maximum compensation they will need to collect documents that help them prove that the medical procedure had gone wrong due to which they suffered a financial or personal loss. Such documents include but are not limited to previous medical records before the original treatment started, current medical records after the treatment ended, X-rays if any, treatment bills and treatment receipts.

In addition to guiding the claimant and preventing him from making mistakes, the selected medical negligence lawyer will help the claimant complete all the paper work and the solicitor will also take copies of the required documents and give back the originals to the claimant. In addition the medical negligence solicitor will represent the claimant in court, deal with the party at fault and negotiate with the insurance company or adjuster if required.

Claimants should note that no win no fee services do not apply for medical negligence claims since medical negligence solicitors charge a small fee for working on these claims. While the selected solicitor will be helping claimants get maximum compensation, solicitors cannot guarantee that claimants will get 100% compensation due to the nature of medical negligence claims. Claimants should also note that the medical negligence lawyer will be discussing these fees and the amount of compensation that can be got before the claimant signs up with the selected solicitor.

The amount of compensation that claimants can get by taking a medical negligence solicitor’s help depends on the type of the problem incurred, the severity of the problem and if the claimant plans to claim for additional compensation. Claimants should remember these lawyers can be found online using search engines and these solicitors can also be hired by opting for the services of an accident claim company.

If you want maximum compensation as soon as possible then hire a medical negligence lawyer from this reputable company. Visit their website at http://www.100percent-compensation.co.uk/

More Medical Coding Articles

Comprehensive electrophysiologic evaluation

The EP specialist documents that a comprehensive electrophysiologic evaluation was performed in the hospital, including induction of arrhythmia, right atrial pacing, and bundle of His recording. The specialist documented the study and wrote a report. What CPT® code(s) is/are reported?
Why this 93618-26, 93610-26, 93600-26 is the correct answer?
And Not this 93620-26?
Thank you

Medical Billing and Coding Forum

Overcome billing and coding challenges for comprehensive observation services

Overcome billing and coding challenges for comprehensive observation services

by Janet L. Blondo, LCSW-C, MSW, CMAC, ACM, CCM, C-ASWCM, ACSW

Billing correctly for observation hours is a challenge for many organizations. Getting it right requires knowing how to calculate observation hours for each patient, which is far from straightforward.

According to CMS, observation hours start accruing not when the patient comes into the hospital, but when the physician writes the order for observation. Observation hours end when all medically necessary services related to observation are complete. In some cases, this means that you can still bill for time spent completing the patient’s care after the physician writes the ­discharge order.

For example, a physician comes in to see the patient at 7:30 a.m. and writes the discharge order, which states discharge will occur pending the completion of tasks X, Y, and Z. The nursing staff finishes up those three tasks and the patient is finally ready to leave the hospital at 11 a.m. The hours between 7:30 a.m. and 11 a.m. are potentially billable observation hours because they were used to complete the patient’s medical care. Observation hours therefore end not with the discharge order, but with the completion of medical services.

In addition, because observation services are considered a temporary period to aid in decision-making, CMS states in the Medicare Benefit Policy Manual that only in rare and exceptional cases should observation services last more than 48 hours.

If a case reaches the 48-hour mark and the physician still hasn’t made a decision to discharge or admit the patient for inpatient care due to instability or risk of an adverse event if discharged, nor has any documentation made a compelling case for the need to continue observation, the services no longer meet the definition of observation care and the hospital should not bill for future hours. Hospitals should also not report observation hours after the physician has decided to send the patient home or to a lower level of care if the patient is receiving no active treatment and is just in a holding pattern until he or she moves to the next level of care or goes home.

 

Coding for comprehensive observation services

The 2016 OPPS final rule implemented changes for coding and billing for observation services. Among the changes made by CMS was the creation of a new comprehensive APC (C-APC) for comprehensive observation services.

Specifically, hospitals will now bill all qualifying extended assessment and management encounters, including observation services, through the newly created comprehensive observation services C-APC code 8011. A new status indicator, J2, was also created to specify that more than one service was provided.

CMS now requires hospitals to bundle services provided and previously billed separately?services such as level 3 ED visits, IV infusions, echocardiograms, speech therapy, and similar services. CMS pays a flat rate for the comprehensive observation services, which includes the bundled services.

Hospital staff should bill all hours of observation for a single encounter on one line under revenue code 0762. If the hospital provided observation care to a patient over multiple days, the date of service should be the date that observation care began. Although one rate is now paid for comprehensive observation services, HCPCS code G0378 is still used to bill observation services by the hour. When using this code, the organization should round to the nearest hour. For example, eight hours and 20 minutes in observation would round to eight hours, whereas nine hours and 40 minutes would round to 10 hours. If the hospital ­provided observation care to a patient over multiple days, the date of service should be the date that observation care began.

The second HCPCS level II code for observation is G0379. This code is used for a direct admission or referral for observation care from a physician in the community. Note that this code is not used if an ER physician or a physician from a provider-based department or clinic makes the referral. This code previously allowed hospitals to bill for costs associated with the visit, including registration and collecting clinical information about the patient, but costs are now bundled with the payment for the comprehensive observation services.

Claims that meet the following criteria will be paid under C-APC code 8011:

  • Claims that do not contain a procedure with HCPCS code with status indicator T (indicates a surgical procedure)
  • Must show eight or more hours of service under HCPCS code G0378
  • No other services on the claim must have a status indicator of J1

 

Services must be provided the day of or one day prior to the date of service for the following visit codes:

  • All ED visit levels, CPT codes 99281?99285 or HCPCS codes G0381?G0384 and critical care services CPT code 99291
  • HCPCS code G0463 (hospital outpatient clinic visit)
  • Same date of service for HCPCS code G0379 (referred by physician outside of hospital)

 

Hospitals can no longer bill separately for observation if these services are required after an outpatient surgical procedure. If a patient meets criteria for observation monitoring after the standard surgical recovery period, the hospital can place him or her in outpatient observation, but the cost for the observation care will be bundled into the payment for the surgical procedure.

Although hospitals are not paid separately for ancillary services under C-APC code 8011, all ancillary services received are reported on the claim under their corresponding HCPCS codes. Use the revenue codes corresponding with their related cost center, such as the following:

  • Laboratory, 30X and 31X
  • Radiology, 32X, 35X, and 61X
  • Covered drugs, 25X and 636
  • Noncovered self-administered drugs, 637

 

Under Medicare OPPS policies, outpatient therapeutic services in hospitals and critical access hospitals must meet the following requirements:

  • Provided in a hospital or a provider-based department
  • Ordered by a physician or nonphysician provider
  • Integral although incidental to the services that the facility is providing
  • Provided under the appropriate level of supervision

 

Grasping the complexity of carve-outs

Sometimes, observation billing requires organizations to also have a grasp of what not to bill or, more specifically, how to carve out nonreportable services. This might include time the patient spent in imaging for a CT with contrast when he or she was monitored by other clinical staff. The same would be true for any other service that includes active clinical monitoring, such as chemotherapy or a blood transfusion.

If your organization isn’t clear whether a service falls into this category, ask your Medicare administrator what type of services it considers to be monitored and should thus be subtracted from observation time.

CMS includes the following two options for calculating these carve-outs for observation time:

  • Document the beginning and end of monitored procedures and subtract that time from observation using either a manual or automated process.
  • Subtract the average length of time for a given procedure. This will require the facility to create a policy or procedure to ensure that all calculations include a consistent methodology. For example, the organization might establish a guideline that a transfusion of one unit of blood takes three hours.

 

Whatever process your organization uses, it’s likely that it will be a costly investment because these carve-outs require staff members to look at medical records to calculate this time, adding to the cost of care. With a bundled payment for comprehensive observation services, it may be most cost-effective to adopt a policy of automated calculation of carve-out time for monitored services.

 

Ensuring proper patient status

In addition to ensuring that these requirements are met, it’s also important to ensure that patient status was determined accurately. Sometimes, patient status is not correct, and the problem needs to be addressed using condition codes 44 or W2.

If a patient is insured by Medicare, the hospital will need to file a change of status using condition code 44 if the patient has not yet been discharged from the hospital. However, if the patient’s status was found to be inaccurate after he or she was discharged, the hospital can use condition code W2 to change the patient’s status.

Condition code 44 is most often used when the utilization review (UR) committee determines that a patient wasn’t assigned to the correct status or no longer meets inpatient status criteria. To use the code, the following must be true:

  • The physician has already written an inpatient order
  • The patient has not yet been discharged
  • The claim has not been submitted

 

The UR committee notifies the hospital, the patient, and the attending physician in writing of its decision that the admission does not meet inpatient criteria no later than two days after the determination. Documentation should indicate the reason for the determination, as this information will assist coders. The patient may be placed in outpatient observation with the agreement of the attending physician or with the concurrence of at least two physician members of the UR committee. Physician concurrence of patient status must be documented in the chart along with who was involved with the change in status, why the change was made, and what care was provided to the patient.

The order for outpatient observation cannot be backdated, but the entire episode of care will be billed as an outpatient episode using bill type 13X or 85X, reporting condition code 44 on the UB form in one of the Form Locators 24?30, or electronically in Loop 2300, HI segment, with qualifier BG on the outpatient claim (CMS, Medicare Claims Processing Manual, Section 50.3, Chapter 1, 2015). The hours the patient spent in an inpatient bed prior to the order change to observation can be submitted on the outpatient claim using revenue code 0762.

If not all of the criteria are met to initiate condition code 44, the hospital uses bill type 12X for covered "Part B only" services provided to the patient, such as diagnostic lab tests, radiology services, surgical dressings, and some other services listed in the Medicare Benefit Policy Manual.

If the UR committee determines after the patient has already been discharged from the hospital that the patient’s stay as an inpatient was not medically necessary, it’s important to self-deny the claim and resubmit it for payment under Part B Medicare. If the claim is not self-denied, it is likely that a Medicare Administrative Contractor (MAC) will deny the hospital’s inpatient claim under Medicare Part A as not medically necessary. In this instance, if the hospital agrees and does not plan to appeal the decision of the MAC, it can resubmit the claim for payment of any eligible services under Medicare Part B. This can be done using condition code W2, which may also be referred to as Part A to B rebilling.

Part A to B rebilling must be submitted using a 12X or 13X type of bill within one calendar year of the "through" date of the original Part A medical services. The form must include condition code W2 along with the treatment authorization code A/B rebilling (see MLN Matters MM8445).

The rules regarding observation billing can be complicated, so it’s important to audit and monitor billing regularly to ensure compliance.

 

Editor’s note

Blondo is the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland. This article is an excerpt from HCPro’s Observation Services Training Handbook. For more information, see www.hcmarketplace.com.

HCPro.com – Briefings on APCs

CMS adds new comprehensive APCs in 2016 OPPS final rule

The 2016 OPPS final rule includes the first negative payment update for the system, but CMS also listened to commenters on a variety of proposals to make them less onerous either operationally or financially.
 
“CMS’ language is quite firm in parts of the rule when explaining why some proposals were finalized, but the agency also showed its willingness to listen to providers who submitted detailed comments for other proposals,” says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
 
CMS adds 10 C-APCs
CMS did not change the logic for comprehensive APCs (C-APC) or complexity adjustments in the final rule, but did add 10 new C-APCs for 2016 in addition to the 25 established for the first time for 2015. This is up from the nine CMS proposed, due to the addition of a level 5 for musculoskeletal procedures.
 
CMS finalized C-APC 8011 (comprehensive observation services) to replace the existing extended assessment and management (EAM) composite APC 8009. Payment for C-APC 8011 will be made when a claim contains a specific combination of services performed with each other (similar to the existing EAM), instead of only using a primary service CPT® code assigned to status indicator J1 like other C-APCs. CMS will use status indicator J2, newly introduced for 2016, to identify these combinations of services for the observation C-APC.
 
Providers will need to meet all of the following criteria to qualify for C-APC 8011 payment in 2016:
  • Claims do not contain a procedure with status indicator T (significant procedure subject to multiple procedure discounting)
  • Claims do contain eight or more units of services described by HCPCS code G0378 (observation services, per hour)
  • Claims contain G0378 and any one of the following codes on the same date of service or one day prior:
    • HCPCS code G0379 (direct referral of patient for hospital observation care) on the same date of service as HCPCS code G0378
    • CPT codes 99281–99284 (ED visit for the E/M of a patient [Levels 1-4])
    • CPT code 99285 (ED visit for the E/M of a patient [Level 5]) or HCPCS code G0380 (type B ED visit [Level 1])
    • HCPCS code G0381–G0384 (type B ED visit [Levels 2–5])
    • CPT code 99291 (critical care, E/M of the critically ill or critically injured patient; first 30–74 minutes)
    • HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient)
  • Claims do not contain a J1 service
 
CMS originally proposed to only allow high-level ED visits to help generate the observation C-APC, similar to the current EAM composite APC. But this is one of the proposals that CMS agreed with commenters on and determined the observation C-APC should be expanded to include all visit levels, says Shah.
 
The 2016 national payment rate for C-APC 8011 is $ 2,174.14, and while this payment is significantly higher than the EAM composite APC payment received today, providers should keep in mind that no other services are paid separately under the C-APC logic, says Shah, whereas today other services can, and do, generate separate payment.
 
“Any analysis that is done on separately payable observation services must be done carefully,” she says.
CMS finalized C-APC 5881 (ancillary outpatient services when patient dies) to replace composite APC 0375, which has the same description. The single, comprehensive payment would be applied for all services reported on the same date and on the same claim as an inpatient-only procedure with modifier –CA (procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission).
 
As a result of new C-APCs that are not largely based on previous device-dependent APCs, CMS is expanding the list of add-on codes that are evaluated for a complexity adjustment to include all add-on codes that can be appropriately reported with a base code that describes a primary J1 service.
A list of all packaged CPT add-on codes evaluated for a complexity adjustment is included in Table 8 of the final rule.
 
The other new C-APCs are similar to those established in 2015, assigned to different levels of procedures within similar clinical families.
 
“Providers need let their payment review and denial staff know about the services related to these C-APCs,” says Valerie A. Rinkle, MPA, Medicare regulatory specialist for HCPro, a division of BLR, in Danvers, Massachusetts.
 
With previous bundling that led to certain line items no longer being paid separately, many providers had claims routed to staff as denials, she says. If the billing office is alerted to changes in payment policies, providers can mitigate such delays.

 

Editor’s note: The 2016 OPPS final rule was published in the November 13 issue of the Federal Register. This article was originally published in Briefings on APCs. Email your questions to editor Steven Andrews at [email protected].

 

HCPro.com – JustCoding News: Outpatient

How to Become a Medical Billing Specialist – A Comprehensive Guide to Start the Career of Your Dream

Are you interested in the field of Medicine and have an excellent knowledge of accounts? If yes, then becoming a Billing Specialist is just the right job for you. A Medical Billing Specialist is an individual responsible for maintaining the health and medical records of patients at the medical facility they work at. Since these professionals will always be needed to ensure patients’ medical care, this is one career that’s on the rise and will continue to be stable for a long time. Here’s a comprehensive guide which will tell you all that you need to know about this job. I’m sure that by the time you finish reading it, you’ll be convinced that this really is the right career for you. Duties and Responsibilities If you choose to pursue this career, some of main responsibilities which you will be asked to handle are:

* Maintaining patients’ medical records
* Carrying out a vast array of administrative work/ supervision
* Scheduling and confirming appointments
* Handling medical billing procedures
* Completing claim forms
* Verifying patients’ signatures
* Presenting Insurance benefits to the patients
* Adhering to each insurance carrier’s policies and procedures
* Entering data and bookkeeping
* Billing insurance companies
* Interacting with all healthcare providers (internal and external)
* Documenting the daily activities in proper medical terms

Skills Required Before we discuss the actual educational requirements of a Medical Billing Specialist, here are some primary skills and qualities that you must have in order to excel in this career. Some of these Include:

* Intelligence
* A passion for the medical field
* The ability to multitask and work in a fast paced environment
* The ability to catch the slightest details
* Responsibility
* Good Communication and interpersonal skills
* Knowledge of bookkeeping and accounting
* Knowledge of working with computers
* Patience

Training After attaining your high school degree, you must pursue an associate or bachelor’s degree in business administration or accounting. Many Medical Billing Specialists receive paid training on the job to learn about the different aspects of their careers. Another option is for you to obtain certification from a nationally recognized organization, such as the American Medical Billing Association in the United States, in order to improve their credentials and understand this job more. One of the most interesting aspects of working as a Medical Billing Specialist is that the requirements for the job are never limited or biased by location, gender, race, religion, or physical disabilities.

Lisa Thomas is your guide to medical careers.

Learn about Medical Billing Specialists education, job and salary. Search for health care schools near you and receive free information from Medical Billing Specialists schools at http://www.medicalassistantvacancies.com

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