2011 CDM Updates Day 2

Download 2011 CDM Updates Day 2

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Part 2 of 2 of a workshop presented to the Western New York chapter of HFMA

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  • 1. HFMA Western NY Chapter January 26, 2011 Day 22011 OPPS UPDATES, CODING CHANGES AND CHARGE MASTER APPROACHES
  • 2. CY2011 HCPCS/CPT AND OPPS UPDATES Outline for remainder of work shop: Laboratory (inc. Blood Bank)D Radiology (inc. Nuclear Medicine) Pain ManagementA Interventional RadiologyY Cardiac Catheterization Electrophysiology1 Medical and Surgical Supplies Outpatient Facility E/M Services; Clinic and Emergency ServicesD Outpatient Observation Services Infusions and InjectionsA PharmaceuticalsY Diagnostic Cardiology Respiratory/Pulmonary2 Cardiac and Pulmonary Rehabilitation Radiation Oncology 2
  • 3. CY2011 HCPCS/CPT AND OPPS UPDATES Hospital Facility Chargemaster Reference Guide Includes additional detail for topics discussed today HCPCS/CPT Code to UB04 crosswalk Modifier definitions Greater narrative detail The companion guide provides for quick access to important payment tables and references UB04 claim form UB04 revenue code descriptions CMS Medically Unlikely Edits (MUEs) CY2011 CPT Code Changes CMS OPPS status indicator definitions CMS OPPS comment indicator definitions CY2011 CMS OPPS Final Rule Addendum B 3
  • 4. CLINIC AND EMERGENCY SERVICES Separate HCPCS/CPT codes have yet to be established to describe E/M services provided within a facility. Hospitals are permitted to utilize physician E/M to capture charges for services provided. Physicians expertise Hospitals overhead To determine the appropriate level of service for a patients visit, it is necessary to first determine whether the patient is new or already established. New vs. Established Pertains to whether or not the patient already has a medical record number If patient had use of that medical record number within the past 3 years, the patient is considered an established patient to the hospital The same patient could be new to a physician or department, but established to the hospital 4
  • 5. CLINIC AND EMERGENCY SERVICES CMS Standards for E/M Guidelines for Facilities1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources2. The coding guidelines should be based on hospital facility resources, not physician3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits4. The coding guidelines should meet the HIPAA requirements5. The coding guidelines should only require documentation that is clinically necessary for patient care6. The coding guidelines should not facilitate upcoding or gaming7. The coding guidelines should be written or recorded, well-documented, and provide the basis for selection of a specific code.8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.9. The coding guidelines should not change with great frequency.10. The coding guidelines should be readily available for fiscal intermediary (or if applicable MAC) review.11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.2008, Federal Register Vol. 72, p. 66805 5
  • 6. EMERGENCY SERVICES CY2009 New York State ED Facility Levels 40.00% 35.00% 30.00% 25.00% % Distribution 20.00% 15.00% 10.00% 5.00% 0.00% 1 2 3 4 5 6 New York 3.69% 13.12% 35.69% 34.59% 12.91% 1.00% National 3.40% 12.52% 33.22% 33.00% 17.87% 2.00%
  • 7. CLINIC AND EMERGENCY SERVICES A visit should be charged only when the patient is being seen for such services as to: be diagnosed; obtain a referral; obtain or renew prescriptions; discuss plans for therapy; have a dressing changed; check vital signs, and/or obtain services where the reason for the visit is not for the sole purposes of having a diagnostic test/procedure, injection, surgical procedure or other service that is further defined by a CPT/HCPCS Code. 7
  • 8. CLINIC AND EMERGENCY SERVICES VISIT CHARGE WITH PROCEDURE When the patient meets the visit criteria defined on the previous page, but during the same visit the patient does have a diagnostic test/procedure, injection, surgical procedure or other service, the visit level may still be charged. A modifier -25 must be appended to the visit charge to indicate to the payers that there were separate and distinct procedures performed. Visit with -25 modifier and Procedure Charge Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She is unsure of the origin of her pain and her treatment options. She would like further evaluation. She is greeted in the pain management clinic with a history taken by the hospital nurse before being seen by the physician. The physician reviews her symptoms and history and recommends an epidural injection. The physician performs the epidural injection while the patient is still in the office. 8
  • 9. CLINIC AND EMERGENCY SERVICES PROCEDURE ONLY When the patients reason for coming to the hospital is for a scheduled diagnostic test/procedure, injection, surgical procedure or other service it is not appropriate to also charge for a visit unless the patient presents a new problem or there is some degree of medical decision. Time spent preparing the patient, including any related evaluation prior, is included in the procedure charge. Procedure Charge Only Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She has been scheduled for an epidural injection. The physician performs the epidural injection in the clinic. 9
  • 10. CLINIC AND EMERGENCY SERVICES PROCEDURE ONLY When the patients reason for coming to the hospital is for a scheduled diagnostic test/procedure, injection, surgical procedure or other service it is not appropriate to also charge for a visit unless the patient presents a new problem or there is some degree of medical decision. Time spent preparing the patient, including any related evaluation prior, is included in the procedure charge. Procedure Charge Only Scenario Mrs. Smith is being seen by the pain management specialist at the hospital for her back pain. She has been scheduled for an epidural injection. The physician performs the epidural injection in the clinic. 10
  • 11. CLINIC AND EMERGENCY SERVICES CY2011 OPPS UPDATE CMS has not made revisions regarding the guidelines for clinic and emergency services E/Ms. Continue to utilize internal guidelines. Critical Care in the Facility Setting CMS clarified in the final rule that, consistent with the 2011 CPT guidelines, hospitals may begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. However, hospitals will not receive separate payment for these ancillary services. If code 99291 is present on the claim with any of the specified ancillary procedure codes, the IOCE will change the status indicator of the ancillary procedure code from Q[#] to N for packaging. There is an exception to